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Love Thy Patient: Justice, Caring, and the Doctor–Patient Relationship

Published online by Cambridge University Press:  29 July 2009

Rosamond Rhodes
Rosamond Rhodes
Affiliation:
Associate Professor of Medical Education, Mount Sinai School of Medicine, New York.
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Extract

Traditional moral theories of rights and principles have dominated medical ethics discussions for decades. Appeals to utilitarian consequences, as well as the principles of respect for autonomy, beneficence, and justice, have provided the standard vocabulary and filled the literature of the field.

Recently on the bioethics scene, however, there has been some discussion of virtue, and, particularly within the nursing ethics literature, appeals are being made to the feminist ethics of care. This intimation of a shift in the wind may have to do with postmodern doubt, or it may be attributable to the claim that virtue theory and the ethics of care (which focus on the character or feelings of the agent, respectively) are more appropriate to private interaction; theories of rights and justice (which focus on the act rather than the agent) are best applied to the political domain of public policy.

Type
Special Section: Compassion: What Does It Really Mean?
Information
Cambridge Quarterly of Healthcare Ethics , Volume 4 , Issue 4 , Fall 1995 , pp. 434 - 447
Copyright
Copyright © Cambridge University Press 1995

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References

Notes

1. Dancy, J. Caring about justice. Philosophy 1992;67:447–66.CrossRefGoogle Scholar I include utilitarianism, and consequentialism in general, within the broad category of what I want to call principle based theories of justice. The principle they follow is some version of “maximize the desirable consequences (for everyone).” In this classification I follow Dancy, 454–5.

2. Pellegrino, ED. The virtuous physician, and the ethics of medicine. In: Virtue and Medicine: Exploration in the Character of Medicine. Philosophy and Medicine Series, No. 17. New York: D. Reidel Publishing Co., 1985:243–55.Google Scholar

3. Graff, H. Should doctors be more like nurses? Paper presented at the Politically Correct Study Group, Chicago, February 23, 1993.Google Scholar (My thanks to Hollace Graff for bringing this literature to my attention.) Benner, P, Wrubel, J. The Primacy of Caring: Stress and Coping in Health and Illness. Menlo Park, California: Addison–Wesley Publishing Co., 1989Google Scholar; Gadow, S. Nurse and patient: the caring relationship. In: Bishop, AH, Scudder, JR, Eds. Caring, Curing, Coping: Nurse, Physician, Patient Relationships. Birmingham, Alabama: University of Alabama Press, 1985Google Scholar; Watson, J. Nursing: Human Science and Human Care. Norwalk, Connecticut: Appleton-Century-Crofts, 1985Google Scholar; Jecker, NS, Self, DJ. Separating care and cure: an analysis of historical and contemporary images of nursing and medicine. The Journal of Medicine and Philosophy, 1991;16(3):285–306.CrossRefGoogle Scholar

4. This was suggested by Roger Crisp.

5. Salkever, SG. Finding the Mean: Theory and Practice in Aristotelian Political Philosophy. Princeton, New Jersey: Princeton University Press, 1990:120.Google Scholar

6. MacIntyre, A. After Virtue. Notre Dame: University of Notre Dame Press, 1984Google Scholar; Slote, M. Goods and Virtues. Oxford: Oxford University Press, 1983Google Scholar; Midwest Studies in Philosophy, p. 13.Google Scholar

7. Ruddick, S. Justice in families. Paper presented at the APA Eastern Division meetings,Washington, DC,December 1992;Google Scholar also in Gilligan, C. In a Different Voice. Cambridge, MA: Harvard University Press, 1982Google Scholar; and Baier, Annette, cf. note 1. Dancy, . 1992:464.Google Scholar

8. Wong, DB. Comments on Ruddick: Justice in Families. Paper presented at the APA Eastern Division meetings,Washington, DC,December 1992.Google Scholar

9. See note 7. Ruddick, . 1992:2–3.Google Scholar

10. See note 8. Wong, . 1992:17.Google Scholar

11. Baruch Brody has called this “the downwards-up model.” Quality of scholarship in bioethics. The Journal of Medicine and Philosophy 1991;15(2):161–78.Google Scholar

12. The subtle moral problems raised by this case were discussed during rounds by Drs. Irwin Gelernt and Isadore Kreel and the other surgeons of Team V, Mount Sinai School of Medicine, January 1994.

13. McLeod, M. Bad blood. The Orlando Sentinel Florida Magazine 1993; 12 19:10–24. at p. 17.Google Scholar

14. Howard, J. Curzer has argued that care is a vice. Is care a virtue for health care professionals? The Journal of Medicine and Philosophy 1993;18(1):51–70.Google Scholar Curzer has focused on what I would see as an excess of caring and I agree that such an extreme of feeling is vice. In this discussion I am focused on the mean, not the extreme, and I advocate well-regulated feelings of goodwill.

15. See note 7. Ruddick. 1992. Ruddick gives the example of the senior family member who beats a child out of too much love, being deeply concerned about the child's good and wanting to help the child to develop a good character.

16. Case 3 is a simplified version of a case presented by Dr. Manuel Alvarez at a meeting of the Hospi tal Board Ethics Committee, Mount Sinai School of Medicine, January 12, 1994.

17. This issue has been discussed by Rhodes, R, Miller, C, Schwartz, M. Transplant recipient selection: peacetime vs. wartime triage. Cambridge Quarterly of Healthcare Ethics, 1992;4:327–31.CrossRefGoogle Scholar The authors argue that such allocation violates the principle of justice and that likelihood of success must be factored into organ allocation decisions because of the scarcity of organs.

18. A complicating factor: doctor's feelings as a factor in medical care. A film by Dr. Richard Gorlin and Staff, Mount Sinai School of Medicine, New York, makes this point dramatically. Hohokus, NJ: Transit Media Communications.

19. This is the essence of Kant's categorical imperative, in particular the formulation from the perspective of a legislator in the kingdom of ends. It is also the perspective of citizens in a just and fair society. According to Rawls, “[a]s citizens in society we normally want justice from everybody else.” Rawls, J. Political Liberalism. New York: Columbia University Press, 1993:208.Google Scholar

20. Medical student, Mary Beach, has pointed out that delivering medical care is personally much more rewarding when you care about your patients. See also Devettere, R. Clinical ethics and happiness. The Journal of Medicine and Philosophy 1993;18(1):71–89.CrossRefGoogle ScholarPubMed Aristotle would concur: for him, happiness is the reward of virtue because the virtuous person takes pleasure in virtuous activity.

21. Aristotle, Nichomacean Ethics. Books VIII and IX [Trans Ross, D]. London: Oxford University Press, 1971Google Scholar; There Aristotle's use of “friendship” needs, to be read broadly as something akin to goodwill toward one's fellows, brotherly love, or what Julia Annas has called “civic friendship.” Simi larly, the importance of feeling brotherly love can be noted in Kant, I. The Metaphysics of Morals: Doctrine of Virtue [Trans Gregor, MJ]. Cambridge, UK: Cambridge University Press, 1991:§46–7; 469–74.Google Scholar cf. Guyer, P. Kant and the Experience of Freedom: Essays on Aesthetics and Morality. Cambridge, UK: Cambridge University Press; 1993:392.CrossRefGoogle Scholar

22. Aristotle could say that such a person has achieved the “mean” of loving feelings and that such a person has the virtue of friendship. The person with the virtue of friendship will feel different degrees of loving feelings toward different people depending on the particular history and the kind of relationship. Aristotle maintains that one should feel more for a father than a fellow citizen although one should feel some goodwill toward everyone. On this scheme, a physician should care about a patient somewhat more than for a citizen and somewhat less than for a father.

23. For Aristotle there are six particular kinds of justice all included in the virtue of universal justice. Anyone can do an act of justice, but only those who do just acts with the feeling of friendship have the virtue of justice. And only those with the virtue will reliably do just acts because their judgment will be right and they will not be swayed by inappropriate feelings.

24. This was pointed out by Joe Fitschen in conversation.

25. This paragraph is meant as a response to comments made by Kamm, Frances and Ezorsky, Gertrudewhen I read an earlier draft of this paper at a meeting of the New York Group,Society for Philosophy and Public Affairs,New York University,February 16, 1994.Google Scholar

26. See note 21. Kant, . 1991:Intro XII, c:402.Google Scholar cf. note 21. Guyer, . 1993:366.Google Scholar

27. Arthur Kuflik has objected that this may not always be the case and that particularly, in the law, the judge may be required not to feel. Joe Fitschen pointed out that the accused is presumed innocent before the law and would therefore be owed the same concern that was due anyone else before the judge. Furthermore, because the judge has the special obligation of assuring that the accused is given a fair and just trial, the judge has the special obligation to feel concern for the accused. New York Group, Society for Philosophy and Public Affairs, New York University, February 16, 1994.

28. See note 21. Aristotle, . 1971:Book VIII;10–11.Google Scholar

29. May, WF. The virtues in a professional setting. In: Medicine and Moral Reasoning. Fulford, KWM, Ed. Cambridge, UK: Cambridge University Press, 1994:75–90.CrossRefGoogle Scholar May's theme in this paper is the moral necessity for a physician to develop a virtuous character.

30. Carse, AL. The “voice of care”: implications for bioethical education. The Journal of Medicine and Philosophy 1991;16(1):5–28.CrossRefGoogle ScholarPubMed This feature of medical education is listed among her recommendations (#7, on pp. 22–3).

31. This seems to be the essence of the AMA's criticism of some managed care plans. American Medi cal Association Council of Ethical and Judicial Affairs, Code of medical ethics report #60. 1994;V. Designing reimbursement plans to encourage ethical behavior has been discussed in the litera ture, e.g., Erde, E. Economic incentives for ethical and courteous behavior in medicine: a proposal. Annals of Internal Medicine 1990; 113(10):790–3CrossRefGoogle ScholarPubMed; Arnold, RM, Forrow, L. Rewarding medicine: good doctors and good behavior. Annals of Internal Medicine 1990;113(10):794–8CrossRefGoogle ScholarPubMed; Prospective payment: DRGs and ethics. Spicker, SF, Ed. The Journal of Medicine and Philosophy 1987;12 (Spec Iss).Google Scholar

32. See note 7. Ruddick, . 1992:2.Google Scholar “Justice and Care each offer a ‘point of view from which alone a certain sort of understanding of human life is possible.’ That is to say, each orientation is genuinely moral; neither can be replaced by or subsumed under the other; and there is no third, ‘mature,’ single integrative moral perspective within which each orientation has its place.”

33. See note 8. Wong, . 1992:17.Google Scholar