Abstract
This essay examines two questions. First, does some list of essential goals of medicine define an internal, or professional, medical ethics? Second, does our medical tradition bar physicians from treatments not aimed at fighting disease or improving health? The answer to the second question seems clear. As a matter of historical fact, not only are many such treatments accepted today, but some have been since the dawn of Western medicine. If our tradition begins with Hippocratic medicine, then from the start it accepted contraception for no health-related purpose. If it begins instead in the second half of the nineteenth century – the only other plausible era of origin – then obstetrical anesthesia is an original treatment not aimed at health. Either way, no historically-based internal morality of medicine can limit physicians’ legitimate uses of biomedical knowledge for patients’ benefit to health promotion. This removes a typical argument against such controversial treatments as assisted suicide, voluntary euthanasia, and human enhancement.
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Notes
- 1.
In this essay, I use ‘fighting disease’ as an abbreviation for any of three things: (1) preventing pathological conditions, (2) reducing their severity, and (3) mitigating their bad effects (cf. 9.5). In line with my (1977), ‘promoting health’ might embrace not only all these, but also creating “positive health,” in the sense of unmixed improvements of normal part-function – one kind of “enhancement.” But for clarity, I ignore the concept of positive health below. It is unnecessary to this paper’s arguments: e.g., both examples in 9.4 (contraception and obstetrical anesthesia), and most of the other examples in 9.1, are outside positive health as well. Still, it is natural to imagine an independent argument, specifically for enhancements, based on positive health. I thank Jean Gayon for alerting me to this connection.
- 2.
- 3.
Wootton (2006, 50) says that the first medical degree was awarded in 1268.
- 4.
As Beauchamp says, “Medicine is a vague and inherently contestable concept” (2001, 604).
- 5.
Later, Wootton makes a stronger claim. The appropriate standard of harm, he says, is this: a harmful treatment is one worse than a placebo, such as a sugar pill, or homeopathic or magical healing. Hence, though he allows that many patients did benefit from Hippocratic therapies like bloodletting, he calls nearly all standard treatments harmful because they also weakened the patient and gave only a placebo benefit.
- 6.
Indeed, one of history’s most celebrated medical treatments was unlawful: Pasteur’s 1885 inoculation with Roux’s anti-rabies vaccine of a boy bitten by a rabid dog.
- 7.
Actually, Veatch does not consistently view medical care and health care as identical in his essay. On the contrary, he allows several times that justified medical treatment might not aim at “health and healing” (639; cf. 633). What is true is that he does not restrict medicine to physicians.
- 8.
Because I am sticking to fairly uncontroversial examples, I omit nontherapeutic abortion. Still, there is at least one case of abortion that only very conservative ethicists would oppose: abortion of an anencephalic fetus, or any other with no chance at sentience. Pregnancy with an anencephalic fetus does not seem to be a pathological condition of the mother; the pregnancy may be perfectly normal. Rather, the defect is in another organism.
- 9.
For the menstrual and sleep-cycle examples, I thank Elselijn Kingma.
- 10.
According to my analysis of health, a functional level typical of an age group cannot be pathological. E.g., after a certain age presbyopia is normal; yet no one objects to its correction as unmedical. Many similar examples could be found. I thank Kate Rogers for the example and the general point. These examples would vanish, however, on a revised analysis that judges all adults by the standards of young ones. For brief discussion, see my (2014), 714.
- 11.
According to Sherry and Wilson (1998), local or intraarticular injections during competition of anti-inflammatory drugs (corticosteroids) or anesthetics (e.g., procaine) are permissible, if reported. I have not yet found evidence of physicians acting as trainers to help athletes achieve peak performance. But if biomedical knowledge were used in this way, would anyone object? In ancient Greece there were two main kinds of trainer, paidotribes and gymnastes, neither of whom was a physician (Kyle 1987, 142). But there was a school of “medical gymnastics,” and the term iatroleiptes may indicate that some practitioners combined medical and athletic roles (Golden 2008, 149 n 83). An early example may be Herodicus, alleged teacher of Hippocrates.
- 12.
It is interesting to note that Nordenfelt assumes medicine to be “a species of health enhancement.”
- 13.
Wootton’s title, Bad Medicine, coupled with his claim that “real medicine” begins with the germ theory, shows an ambiguity of usage reminiscent of a common fallacy in aesthetics: confusing the questions “What is art?” and “What is good art?”
- 14.
Journal of Medicine and Philosophy 26 (2001). One essay in the symposium (Arras 2001) includes an analytical survey of the full spectrum of views.
- 15.
Pellegrino’s theory applies only to clinical medicine, not to other “branches” such as preventive or social medicine or medical science (2001, 564).
- 16.
Since Pellegrino believes that ‘health’ means “making whole again” (2001, 568), it seems unclear how pain relief, which is merely blocking a sensation, is a case of it, and similarly for suffering in general.
- 17.
For the analogy, see 573–5. It is weakened by the fact that “[e]ach profession operates most directly on one or other of the four levels” (573). E.g., ministry “has its moral dimension most specifically at level four” (574) – not level one, as with medicine.
- 18.
- 19.
Fleischhauer and Hermerén (2006, 11, 427–31) propose a hierarchy of medical goals: intrinsic goals, overarching operational goals, and specific operational goals.
- 20.
The Hastings Center report mentions a “consensus” that it is “not helpful, nor really possible, to set fixed priorities” among medical goals (Callahan 1999, 20). Unfortunately, its own text often uses a distinction between “primary” or “core” goals of medicine and “secondary” ones (11). In an earlier essay, I too used the terminology of core and peripheral medicine (1987, 382–4), though “therapeutic” and “nontherapeutic” might have been better. I was clear that both were permissible, so the present essay changes no doctrine. But in its light, such statements as “Peripheral medical treatment is medical only in that physicians do it” (383) may need revision.
- 21.
- 22.
For Culver, Gert, and Clouser’s original discussions, see Clouser et al. (1981, 1997) and Culver and Gert (1982). For my criticisms of this definition of malady as a general account of medical abnormality, see (1997, 43–4). The Hastings writers make two changes in the Culver-Gert definition. An unimportant one is from “sustaining” cause to “external” cause. The important one is from ‘death’ to ‘untimely death’, a change I criticize below. Obviously, for a person’s death to be an “evil,” it need not be untimely.
- 23.
They write: “[E]very civilized society should guarantee all of its citizens a decent basic level of health care, regardless of their ability to pay for it. Beyond that basic minimum (…) patients should be free to spend their own money to gain additional benefits”. (40) Yet does not this statement contradict the writers’ demand for “an equitable medicine” which is “affordable to all” (51)? Given the patient freedom in the quotation, inequality of wealth guarantees inequality of medical care.
- 24.
For example, their “equitable medicine” will not “continually develop drugs and machines that only the affluent can afford…” (51). Such drugs and machines, of course, are privately funded and so should be acceptable by pages 40 and 28. Regrettably, the Hastings chapter often contradicts itself.
- 25.
This list improves their earlier shorter one: “healing, promoting health, and helping patients achieve a peaceful death” (1995, 12).
- 26.
In a later essay, they also recognize a set of “clinical virtues” (2001, 582). I shall not discuss either of these aspects of their view.
- 27.
Miller and Brody’s original IMM essay (1995) has more on the contrast between VAE and medical execution. They object that in medical execution, (i) the doctor is an agent of the state, not of the patient; (ii) execution does not serve any “medical goals”; (iii) lethal injection is not “a medical treatment or procedure”; (iv) it does not “aim at responding effectively to the patient’s medical condition”; and (v) it is not intended for the benefit of the patient. Therefore even if capital punishment is justified, doctors must not take part in executions (1995, 15–16). Yet consider these writers’ own scenario (16). An inmate asks his own prison doctor for a lethal injection in lieu of electrocution, and the state agrees. It does not seem that Miller and Brody’s reasons can condemn such an action. Contra (ii), as to VAE, Miller and Brody count “peaceful death” as a medical goal sometimes justifying lethal injection (12). Presumably, then, lethal injection can be a “medical procedure,” contra (iii). Contra (i) and (v), in the prison story the doctor does seem to act as the prisoner’s agent, at his request and for his benefit. That leaves only (iv), which seems circular: why isn’t impending painful death a “medical condition,” here as elsewhere? In my view, as noted in 9.5, if a horribly painful death is otherwise inevitable, for a doctor to grant a competent euthanasia request is not just permissible, but obligatory.
- 28.
Miller and Brody had already stated that the IMM creates only prima facie duties in their original essay (1995, 16). But only in 2001 are they clear about how this view of disputable cases differs from a “borderline” view of them. The borderline view is that such cases do not clearly violate IMM. On the prima-facie duty view, IMM is clearly violated, but overruled by external morality.
- 29.
The rest of the quoted paragraph raises further questions. The authors say that female contraception differs from vasectomy because “[u]nwanted paternity, unlike unwanted pregnancy, does not qualify as a medical condition to be prevented” (357). What makes pregnancy a “medical condition” is apparently that it “brings women under medical attention” (356). But so, for vasectomy patients, does male fertility. Moreover, the “disability” argument cannot excuse vasectomy, so it seems to be outside even their newly expanded list of the goals of medicine. Still, the authors consider it “an acceptable peripheral medical practice that does not threaten or violate professional integrity” (357). Yet three pages later, they say: “All peripheral medical procedures and practices challenge professional integrity, since they are at best weakly supported by the goals of medicine” (360).
- 30.
- 31.
The efficacy of ancient contraceptives, while fascinating, is irrelevant to my argument. If we are to use historic physicians as moral exemplars, what matters is not so much what they were doing, but what they thought they were doing. Also of interest is what canonical doctors would have done if they had thought that they could. E.g., during much of medical history, physicians might well have done cosmetic surgery if it had been feasible at the time. That is especially plausible for eras, including classical Greece, when ideals of health and beauty were closely linked. Chapters 185–191 of the Hippocratic work Diseases of Women II are, in fact, cosmetic recipes (Totelin 2009, 11).
- 32.
See Plato, Laws, 5.740; Aristotle, Politics 7.16.15.1335b19-26 (cited by Riddle 1997, 14).
- 33.
Riddle finds these Christian views “not much different from prevailing Judaic, Hellenic, and Roman values (1997, 82), which would mean that by then a large change had occurred in the attitudes of the ancient world at large.
- 34.
On the Nature of Women, ch. 98. I quote from Riddle (1992), 74. An almost identical passage, with the heading “Contraceptive” [atokion], appears in Diseases of Women (I, ch. 76).
- 35.
On the Nature of the Child, ch. 2 (Littré 1962, 490–1). Another reference to birth control by hetairai is in On Fleshes, 19, though no doctor is mentioned there.
- 36.
There is no textual basis for John of Alexandria’s fantasy that this doctor (whom John believes to be Hippocrates himself) prescribed abortion to keep the woman from suicide after losing her looks (Commentary on Hippocrates’ “On the Nature of the Child” 18 [2, 216], quoted by Kapparis 2002, 79). John suggests the idea only to resolve the clash between this story and a corrupt version of the Hippocratic Oath that bans all abortion (see note 38, infra).
- 37.
This conclusion of Edelstein’s famous essay (1967, 3–63) seems to be the dominant current view (Riddle 1997, 38–9), though Edelstein’s claim that the oath is wholly Pythagorean is rejected. The oath may have been written long after the classical period (von Staden 2007, 427). Leven states flatly that it “was unknown to Greek physicians of the classical age and cited only rarely in later antiquity” (1998, 15). On one of several conflicts (ibid., 11) between the oath and the Hippocratic corpus, see note 38.
- 38.
In the first century A.D. (four centuries after Hippocrates), Scribonius Largus sees the oath as prohibiting all abortion, and possibly contraception too. He says that Hippocratic medicine had the goal of “healing [sanandi], not doing harm [nocendi],” and therefore that it protected even potential persons (Riddle 1992, 8). A bit later, Soranus reports two schools of moral thought about abortion and contraception, endorsing the more liberal one. “For one party banishes abortives, citing the testimony of Hippocrates who says: ‘I will give to no one an abortive,’ moreover, because it is the specific task of medicine to guard and preserve what has been engendered by nature. The other party prescribes abortives, but with discrimination, that is, they do not prescribe them when a person wishes to destroy the embryo because of adultery or out of consideration for youthful beauty; but only to prevent subsequent danger in parturition if the uterus is small and not capable of accommodating the complete development, or if the uterus at its orifice has knobby swellings and fissures, or if some similar difficulty is involved. And they say the same about contraceptives as well, and we too agree with them.” [Gynaeciorum libri IV, ch. 60] (Jütte 2008, 35). Three points can be made about these passages. First, contraception is not “harm,” nor does it destroy anything already “engendered by nature.” So these writers mention no objection of principle to medical contraception except that it is not “healing.” Second, both writers are working from a corrupted text, since it is now clear that the original oath explicitly bans only abortion by pessary (Riddle 1992, 7–8; 1995, 38). (But see Kapparis 2002, 71–75, for arguments that a general ban was intended.) Third, since the Hippocratic corpus contains books like Diseases of Women with many recipes for abortive pessaries (Riddle 1992, 76–7), either the oath or these books are inauthentic. The most likely conclusion is that the oath is atypical of Hippocratic medicine. Note, too, that once we reject the oath’s authority, physician-assisted suicide is a second example, besides contraception, of an accepted ancient treatment by physicians not aimed at health. I thank John Riddle for this point.
- 39.
O’Brien and Cefalo (1996) describe these mechanisms as “changes in position of the fetal head during passage through the birth canal. Because of the asymmetry of the shape of both the fetal head and the maternal bony pelvis, such rotations are required for the average size fetus to accomplish passage through the birth canal.” The classical stages are (1) engagement, (2) descent, (3) flexion, (4) internal rotation, (5) extension, (6) external rotation, and (7) expulsion (1996, 372–3).
- 40.
- 41.
- 42.
Rosenberg and Trevathan (2001, 2002) note a beneficial effect of pain in discouraging women from the anatomically difficult task of giving birth alone, though they do not claim it evolved for this purpose. Psychoanalytic writers have seen labor pain as aiding the mother’s emotional bonding with her baby. During the Victorian controversies, W. Tyler Smith, a prominent obstetrician, claimed a number of physiological benefits of pain in assisting labor – though he conceded that anesthetized women could give birth, or even be “ecstatic” (1847, 595).
- 43.
A very detailed account of the history of anesthesia is Duncum (1947). Poovey’s chapter (1988, 24–50) also has a wealth of historical information, though thickly encrusted with feminist and postmodernist claptrap. One might expect a feminist writer to give some credit to pioneers in relieving women of agonizing pain. But since men always act from the worst motives, Poovey is unsparing in her criticism.
- 44.
Some quotations collected by Simpson (1849, 38) are as follows. In the opinion of the famous physiologist Magendie, “pain always has its usefulness.” A Mr. Nunn says: “Pain should be considered as a healthy indication, and as an essential concomitant with surgical operations, and … it is amply compensated by the effects it produces on the system, as the natural incentive to reparative action.” A Dr. Pickford believes that “pain during operations is, in the majority of cases, even desirable, and its prevention or annihilation is, for the most part, hazardous to the patient.” Simpson (39) calls these views “eccentric” since both doctors and laymen had earlier agreed unanimously with Galen: Dolor dolentibus inutilis est (pain is useless to the pained).
- 45.
Victoria also took chloroform for her last baby, Princess Beatrice, in 1857 (21).
- 46.
In brief, Simpson argues that (1) in Eve’s curse (“In sorrow thou shalt bring forth children”), the Hebrew word etzebh, translated in Victorian Bibles as “sorrow,” actually means work or effort throughout the Old Testament, which uses other words for pain (hhil, hhebel); (2) anesthesia blocks only the pain of labor, not the muscular effort; (3) in the same passage Adam too is cursed, with arduous farming and eating, yet no one makes religious objections to farm implements, draft animals, and cooking; (4) Jesus died for our sins, including original sin; and (5) God himself was the first anesthetist, when he put Adam to sleep to extract a rib to make Eve. Simpson also recalls religious objections to previous medical discoveries like vaccination. The fourth objection in his 1849 list was that it is always wrong to destroy consciousness. Simpson replies that no one considers it immoral deliberately to go back to sleep. W. Tyler Smith and others vocally made one more criticism to which Simpson later replied: that anesthesia during birth evokes signs of sexual arousal in women, like those seen in animals (Poovey 1988, 30–33, 38ff). Smith suggested that labor pain has the natural benefit of “neutraliz[ing]” any such “sexual emotions” aroused by birth, and he believed that Englishwomen would prefer even the worst pain to exhibiting lewd behavior (31). As for Simpson, he denied having ever seen such a phenomenon, saying that the sexual excitement was probably “in the minds of the practitioners” (33).
- 47.
Another critic who, like Meigs, calls labor pain “physiological” is Robert Barnes, in contrasting surgical with obstetrical anesthesia: “The pathological pain of surgical operations is not to be compared, in its effects, to the physiological pain inherent to parturition” (1847, 678). I would emphasize, however, that pain in surgery is normal, not pathological. The surgical wound is pathology; the pain reaction to it is a normal defense mechanism.
- 48.
Miller, Brody, and Chung claim that “The central goal of relief of pain and suffering is confined to conditions that qualify as “maladies.” … [I]t is not within the purview of physicians to attempt to relieve any and all pain and suffering that may afflict human beings” (2000, 354). But since, as we saw in 9.4, pregnancy for them is not a malady (356), this rule bars obstetrical anesthesia. Moreover, they offer no authority for the restriction of medicine to maladies except the Hastings Center panel, nor any definition of the term, since that panel’s own definition of ‘malady’ covers pregnancy.
- 49.
Miller and Brody (2001, 583) view this limitation as part of physicians’ duties, not the goals of medicine.
- 50.
Bengt Brülde seems to reach a similar conclusion, in an essay (2001) that I discovered too late to include in 9.3. I am puzzled by his claim that his seven goals of medicine (5–6) are “irreducible” to one another (1,5,8), since five of them are only “instrumental” (6) to the “final” two: “a long life and a good life” (7). Then it would seem that those five can be eliminated, as he earlier suggested about the goal of health for just that reason (4). Moreover, since a long life is valuable only insofar as it is also good (9), Brülde seems in the end to be left with only one goal of medicine: total well-being, or my goal IV. He does not use his framework to draw conclusions about controversial practices, such as VAE or enhancements.
- 51.
Actually, for any medical practices requested by patients in their interest, there are two views worth distinguishing: that they are (1) permissible, or (2) obligatory, to the ethical physician. As to enhancements, like most of the literature, I concentrate on (1), but my arguments for it may support (2) just as strongly. I thank Jodi Arias for calling my attention to the distinction in this area.
- 52.
These duties are not limited to medicine. In all fiduciary relationships, as opposed to “arm’s-length” transactions, the professional has a moral and legal duty to act in the client’s interest, consistently with his own best judgment. Thus, if the client demands an action that the professional is sure will damage him – a terrible investment, the amputation of two healthy legs – he must refuse. As Miller and Brody say in the medical case: “The physician is an independent moral agent, committed to the internal morality of medicine, not a tool at the command of the autonomous patient” (1995, 14). To forestall confusion: I have argued in unpublished work that there is no such thing as pure exploitation, i.e., exploitation without deception or coercion. All consensual, mutually beneficial exchanges are moral. As for a consensual exchange in which A harms B, a libertarian may say that A cannot suffer legal punishment for it. But political libertarianism still allows moral condemnation of A for profiting by hurting others, even with their consent. And that is uncontroversially wrong in a fiduciary relationship.
- 53.
For many useful ideas I thank my University of Delaware colleagues, especially Mark Greene, and audience members at Hamburg in September 2012. For much help with contraception and ancient medicine, thanks to John M. Riddle, Karl-Heinz Leven, Robert Jütte, Ralph Rosen, and Annette Giesecke. I am also grateful to Jefferson Medical College in general, and to Dr. Gonzalo Aponte and Dr. Steven Herrine specifically, for letting me attend classes in pathology and clinical medicine, first in the 1980s and then again in 2012. Most of what I know about medicine I learned beneath Jefferson’s winged ox.
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Boorse, C. (2016). Goals of Medicine. In: Giroux, É. (eds) Naturalism in the Philosophy of Health. History, Philosophy and Theory of the Life Sciences. Springer, Cham. https://doi.org/10.1007/978-3-319-29091-1_9
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DOI: https://doi.org/10.1007/978-3-319-29091-1_9
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