Medical Ethics PHIL 148 @ Binghamton University, Sum 11

5Jun/1129

Lecture 06/06>The Patient-Professional Relationship

The question we are faced with today, and will be faced with throughout the semester, is “what is the object of medicine?” The answer to this question severely impacts what the answer to the various ethical questions we ask will be. Is the purpose of medicine merely to heal physical injury and disease? Or is it meant to aim at something more. Notice the language that all of the articles you read for today use in discussing the various bioethical issues: their main concern is the balance between patient health and patient autonomy. Notice as well that when they discuss health, they are not merely discussing physical well-being, but also mental well-being.  There is an important distinction underlying all of these articles: that between disease and illness.

Disease, injury, whatever word best expresses the point, refers to the underlying physical cause of trouble for an individual. This is the broken bone or the clogged arteries; the damage to the brain, the loss of sight. These are all problems that fall under the category of disease. Illness, on the other hand, refers to the impact of disease on the individual. Illness is a subjective category closely tied to the individual life of the patient and the way they approach their disease or injury.  The readings for today are largely concerned not simply with disease, but with illness--a concern largely represented through the concept of patient autonomy.

These readings frame the object of medicine as restoring the patient to an autonomous state or, where not possible, carrying out the patient’s autonomous wishes. These might be called illness concerns. On the other side of the equation are the disease concerns—the drive to solve the physical malady. The object of medicine might be to solve the illness concerns, but this might only be done by solving the disease concerns. Yet, these two kinds of concerns can conflict and it is not a simple resolution where these conflicts take place.

If the world was absolutely certain and we understood one another perfectly, it is likely that there would be little conflict between illness and disease concerns. However, the world in general and the medical world in particular both operate under the burden of mere probability. Complicating matters, individuals are not transparent to one another.  As Childress and Seigler point out, we have varying different values and these values might not be shared by both the patient and the health care professional.

Autonomy is often treated as if it is an all or nothing concept, but this seems wrong. An individual might be diminished in their autonomy capacity, yet still be able to make certain kinds of decisions. If illness simply robbed an individual of their capacity to act autonomously, then there would be very little to discuss in medical ethics—medical professionals would have the freedom to treat patients in whatever way would best suit the problem. Precisely the fact that medicine does not work in this way demonstrates that autonomy is a continuum on which we all operate at various levels depending on our circumstances. This is true even in our day to day lives. In some situations, we feel completely in control. In others, we feel powerless. In these situations out capacity for autonomous action is operating at different levels. Of course, in these situations medicine does not interfere. Medicine only deals with autonomy problems related to physical ills.

Consider the flu. If you have ever been sick with the flu, you know that it weakens you physically; it drains you of energy; and it makes it difficult to function properly. In a certain sense, you have lost control of your life through the interference of this malady. But the flu is (generally) minor. You are bedridden for a few days and you make a slow recovery. Within a week, you are almost back to normal functioning. The impact of the flu is minimal. It may have some drastic effects immediately, but it’s overall impact on one’s autonomy competency is slim. This is because the flu is a blip on the radar of your life. It is (usually) easily dealt with. Some medication, bed rest, and it passes. The treatment is simple and easy to grasp. The whole medical element of the flu is minimal.

There are, however, two ways in which disease or injury might rob one of autonomy in a more serious way. The first is directly related to the disease. The more pervasive a disease or injury is, the more it dominates one’s identity. The loss of a leg might throw a person of balance, not merely physically, but mentally. Imagine an individual whose identity was closely wrapped up with their physical ability. The loss of a leg would deal a large blow to their ability to make sense of themselves and, through that, their world. The self might be considered a kind of faux stationary point from which one may move the world. It is the strength of one’s self that gives one the competency to be autonomous. This autonomy can be eliminated by a disease that robs an individual of their identity, their stationary point, or which forces them to reconceive of themselves as weak and dependent in some sense.

The second more serious impact of disease on autonomy is only indirectly related to the disease but directly related to the treatment of the disease. Just as disease can throw an individual off balance and so rob them of autonomy competency, being admitted into the medical system can have just as damaging an effect. The medical system operates under the idea that the patient is weak and dependent and, as they serve to overcome this, they reinforce that perception--this is what Ackerman calls the "sick role.' Further, the medical system is alien to the patient in many ways (at least most patients) and this feeling of alienation further reinforces the loss of control. Thus, a patient who was already struggling with autonomy becomes further undermined in their treatment.

Yet, if this diminishing of autonomy can later serve to strengthen and repair autonomy, shouldn’t such a diminishing be allowed?

It is this balancing between diminishing and balancing autonomy that is at stake in the conflict between illness and disease concerns. In order to treat the illness, the disease must be treated. Sometimes treating disease requires taking actions that the patient might not want to consent to. Sometimes treating the disease requires taking actions that the patient is not able to understand. Both of these cases raise issues of competency and to decide them a balance needs to be struck between the patient’s present level of autonomy competency, the potential diminishing of autonomy competency by the treatment, and the desire to increase the patient’s autonomy competency.

Key Concepts:

  • Autonomy
  • Disease
  • Illness
  • Paternalism

Some Questions to Consider:

  • Is the object of medicine really to treat illness and not merely disease?
  • Can we adequately talk about medicine in terms of autonomy? Or is this a misleading conversation?
  • What obligation does the health care professional have to the patient?
  • What obligation does the patient have to herself?

 

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