Abstract
There are ethical guidelines that form the foundation of the traditional doctor–patient relationship in medicine. Health care providers are under special obligations to their patients. These include obligations to disclose information, to propose alternative treatments that allow patients to make decisions based on their own values, and to have special concern for patients’ best interests. Furthermore, patients know that these obligations exist and so come to their physicians with a significant level of trust. In this sense, therapeutic medicine significantly differs from straightforward business practices such as the buying and selling of houses, cars, cell phones, etc. However, we argue that this relationship differs when medicine is used for enhancement rather than therapy. When patients seek enhancements they are not as vulnerable as when they are ill. And in an enhancement setting, physicians have little role outside of medical risks to discuss motivation and alternatives. Therefore, we conclude that a more reasonable alternative may be for doctors and patients to use ethical norms associated more with straightforward business practices, specifically sales. We believe that full disclosure of this different set of norms will benefit both physicians and patients.
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Notes
We use the term “practice” very generally. A practice is any activity in which rational agents engage that gives rise to expectations. These expectations are normatively significant, and provide a framework through which we can understand obligations.
Additionally, see Beauchamp (2010).
There are some exceptions. Patients in medical emergency situations cannot shop around. While these cases are important, they do not constitute the majority of doctor–patient interaction.
We should clarify that what we are calling the “unique position of need” refers to just one species of need. We believe that there are other needs that are not related to defects or malfunctions. One might need money for example, but not in virtue of some defect. Of course such needs can often be quite serious.
We do not wish to say which theory of well-being is correct. The standard candidates are usually taken to be hedonism, desire fulfillment, objective list theories, or some sort of hybrid. While the goods we list here are usually associated with the objective list theories, we make no claims about whether they are good in themselves or good with respect to the fact that they normally produce pleasure or fulfill desires. For discussions of these theories of well-being, see Parfit (1984) and Griffin (1986).
Part of Beauchamp and Childress’ goal is to give an account that renders the normal everyday actions of autonomous people. They can accomplish this using different cutoff points in different practices. That is, the amount of understanding one needs to act autonomously in say, buying a television, is a lower cutoff point than what one needs to autonomously consent to a medical procedure. We see the advantage of such a view, but one could also make autonomous choice non-context specific. Acting autonomously would simply require some baseline level of understanding. On this alternative model, we could still justify a unique set of norms in medicine by saying that it is more important to ensure that choices are autonomous than in other practices.
Autonomy is the most common answer to the question of why informed consent is necessary. In addition to Beachamp and Childress, see also Faden and Beachamp (1986). However, other authors give alternative or at least additional groundings of informed consent in medicine. Some, following John Stuart Mill’s arguments against paternalism, believe it is based on patient protection. Others believe informed consent ensures against patient abuse in the form of coercion, deceit, and exploitation. See Manson and O’Neill (2007). Still others ground informed consent in trust. This could be forward looking in the sense that informed consent helps patients to trust medical professionals, see O’Neill (2002). Or trust could be understood in a backward-looking sense, in that honoring the trust the patient has put in the doctor. See Joffe and Truog (2010, p. 352) and Pellgrino and Thomasana (1993). Finally, some argue that informed consent in medicine should be seen in the context of a more general model of valid consent transactions. See Miller and Wertheimer (2010). For a more detailed overview of these and some additional approaches, see Eval (2011).
In a well-known paper, Robert Veatch (1995) actually challenges this idea on the grounds that doctors are not in a position to know what is in the best interest of their patients. For this reason he recommends replacing the informed consent model with a system of pairing doctors and patients on the basis of deeply held shared values. While we are more optimistic about informed consent in therapeutic medicine, we share some of Veatch’s concerns when it comes to enhancement medicine. We will discuss this in the following section.
Joffe and Truog (2010) similarly point to the difficulty of physicians being able to know how to distinguish means from ends and patients’ values. Like us, however, they believe that while this poses pragmatic difficulties, it is not sufficient reason to transition out of the informed consent model altogether.
We recognize that this claim needs a great deal more support if we are to sufficiently meet Veatch’s criticisms. For the purposes of this paper, we are assuming that the informed consent model works at least sufficiently well in therapeutic medicine.
There are some exceptions. Physicians might, for moral reasons, refuse to perform abortions or engage in the practice of physician-assisted suicide.
We should also note that we are not arguing that the use of medicine for enhancement is itself morally wrong. Some enhancements might be wrong of course, but that does not mean enhancement is wrong per se. For an argument against the moral relevance of the therapy-enhancement distinction in medicine, see Resnik (2000).
If we had universally agreed upon concepts of health and disease, we might simply say that therapies are medical interventions that treat diseases, whereas enhancements are medical interventions that produce a desired effect in a subject that is already healthy in the relevant way. However, there is no such agreement over these concepts. The broadest debate is whether health and disease are value-laden terms. Naturalists argue that health and disease are value neutral. Diseases are biological dysfunctions. The most prominent account is Boorse (1977, 1997, 2011), though other naturalists disagree about the best account proper function. Normativists argue that health and disease are value-laden concepts, so a disease must be disvalued or in some other sense “bad” for the one who has it. See Engelhardt (1972). Others, most prominently Wakefield (1992) argue for a hybrid account in which diseases must be both dysfunctional and as well as bad for the one who has it.
For example, human growth hormone could be used to treat children who were abnormally short or it could be used to make average sized children taller. One would be a therapy and the other an enhancement, so we cannot categorize the use of human growth hormone itself as one or the other.
We thank an anonymous reviewer for this example.
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Delaney, J.J., Martin, D. Therapy, Enhancement, and Medicine: Challenges for the Doctor–Patient Relationship and Patient Safety. J Bus Ethics 146, 831–844 (2017). https://doi.org/10.1007/s10551-016-3042-9
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DOI: https://doi.org/10.1007/s10551-016-3042-9