Abstract
Physicians frequently ask whether they should give patients what they want, usually when there are considerations pointing against doing so, such as medicine’s values and physicians’ obligations. It has been argued that the source of medicine’s values and physicians’ obligations lies in what has been dubbed “the internal morality of medicine”: medicine is a practice with an end and norms that are definitive of this practice and that determine what physicians ought to do qua physicians. In this paper, I defend the claim that medicine requires a morality that is internal to its practice, while rejecting the prevalent characterization of this morality and offering an alternative one. My approach to the internal morality of medicine is constructivist in nature: the norms of medicine are constructed by medical professionals, other professionals, and patients, given medicine’s end of “benefitting patients in need of prima facie medical treatment and care.” I make the case that patients should be involved in the construction of medicine’s morality not only because they have knowledge that is relevant to the internal morality of medicine—namely, their own values and preferences—but also because medicine is an inherently relational enterprise: in medicine the relationship between physician and patient is a constitutive component of the craft itself. The framework I propose provides an authoritative morality for medicine, while allowing for the incorporation, into that very morality, of qualified deference to patient values.
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Notes
I am indebted to Daniel Brudney for this example.
There are variations on these models in the literature. For example, Savulescu (1995) argues that physicians should make all-things-considered value judgments: physicians form a conception of what is best for their patients and rationally argue with them (without coercing patients). He calls this “rational non-interventional paternalism.”
In debates about medicine’s morality, the term “morality” does not denote specifically “moral imperatives” that command categorically. Moreover, physician obligations are broadly-construed professional obligations rather than distinctively moral obligations. Therefore, following Williams’s (1985, pp. 174–196) distinction between “morality” and “ethics,” the name “the internal ethics of medicine” would have been a more appropriate title for the project. This would have had the virtue of not suggesting a closed “morality system.” However, since the project is known as “the internal morality of medicine” in the literature, I will use this language throughout the current paper.
Versions of this position are defended by both Beauchamp (2001) and Veatch (2000, 2001). However, Veatch does sometimes slide into talking about mere societal and cultural norms. For example, Veatch (2001, pp. 632, 636, 639) argues that knowing what constitutes the ends and norms of medicine “requires turning outside of medicine to the basic religious, philosophical, and cultural norms,” as well as to “broader societal norms,” which provide “the ends of life and the moral norms that structure that life” needed for deriving medicine’s ends and norms.
Veatch bases this distinction on MacIntyre’s (2007, pp. 188–189) two reasons for Xs counting as internal goods: (a) “we can only specify them in terms of chess or some other game of that specific kind and by means of examples from such games”; (b) “they can only be identified and recognized by the experience of participating in the practice in question. Those who lack the relevant experience are incompetent thereby as judges of internal goods.”
Pellegrino (2001b, p. 565) is not clear about what he means by an “objective order of morality,” adding: “An internal morality of medicine [...] is not a morality divorced from all ethical theories. [...] It is not closed to insights from other ethical methodologies [nor to] insights from literature, history, or the social and physical sciences. [...] It looks, however, beyond cultural and historical contexts to what is common to the human predicament of being ill and being healed.” However, the ways in which a common human predicament gives rise to an “objective order of morality” and the ways in which this objective order interacts with other methodologies are left unexplained.
Brody and Miller (1998, pp. 386–387) argue that “healing” is too narrow to act as medicine’s end. Instead, they suggest that medicine has multiple goals, such as “diagnosing the disease or injury,” “preventing disease or injury,” “curing the disease or repairing the injury,” “lessening the pain [...] caused by the disease or injury,” and “helping the patient to die with dignity.” They note that these multiple goals are unified by the fact that the physician is dedicated to “benefitting patients in need of medical treatment and care,” but do not postulate this as the end of medicine.
This suggestion could be implemented vis-à-vis other medical professionals, for example, nurses and pharmacists.
My aim is not to defend constructivism as a meta-ethical view. Rather, I am defending a version of what Street (2010, p. 367) has called “restricted constructivist views in ethics.” Such views “specify some restricted set of normative claims and say that the truth of a claim falling within that set consists in that claim’s being entailed from within the practical point of view, where the practical point of view is given some substantive characterization.” In other words, instead of accounting for the correctness of all normative claims, I am accounting for a subset of such claims (those that pertain to medicine) in terms of further normative claims, such as assumptions that are embedded in the constructivist procedure (unforced general agreement, justifying one’s claims to relevant others, and so on).
Pellegrino (2001b, pp. 569–571) adds two more components to the two listed above, which together constitute the good of the patient: the good for humans and the spiritual good. However, these additional components do not make things better. Indeed, when considering these four components together, it is far from clear how they are supposed to track an objective normative order and be internal to medicine: the patient’s perception of the good is subjective (in contrast to the alleged mind-independent objectivity of medicine’s morality) and the good for humans and the spiritual good are broader than the goods of medicine (in contrast to the alleged internality of medicine’s morality).
For a defense of this type of position, see, for example, Kipnis (2006). As for the legal status of such positions, the law actually varies across different countries, states, and cities: some places, but not others, have laws that do authorize (or even obligate) HIV-positive patients’ health care providers to inform known partners of these patients.
Some of these roles are mentioned in Emanuel and Emanuel (1992).
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Acknowledgements
I am very grateful to my former teacher Daniel Brudney, as well as to the graduate students at a work-in-progress workshop at the University of Chicago, for giving me detailed feedback on an early draft of this paper. I would also like to thank audiences at the following conferences—and Eric Kraemer in particular—for feedback on drafts of this paper: Medical Knowledge in a Social World Conference at UC, Irvine (2016), ASBH Annual Meeting (2016), and APA Central Division Meeting (2017). I am also grateful to my colleagues—Jochen Bojanowski, Ben Bryan, Dan Korman, Jonathan Livengood, Ben Miller, and David Sussman—for their comments on the penultimate draft of this paper. Finally, I would like to thank two anonymous referees for Synthese, whose comments were invaluable in improving this paper.
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Ben-Moshe, N. The internal morality of medicine: a constructivist approach. Synthese 196, 4449–4467 (2019). https://doi.org/10.1007/s11229-017-1466-0
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DOI: https://doi.org/10.1007/s11229-017-1466-0