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Medicine, Health Care and Philosophy

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22.11.2018 | Scientific Contribution

The logic of the interaction between beneficence and respect for autonomy

verfasst von: Shlomo Cohen

Erschienen in: Medicine, Health Care and Philosophy | Ausgabe 2/2019

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Abstract

Beneficence and respect for autonomy are two of the most fundamental moral duties in general and in bioethics in particular. Beyond the usual questions of how to resolve conflicts between these duties in particular cases, there are more general questions about the possible forms of the interactions between them. Only recognition of the full spectrum of possible interactions will ensure optimal moral deliberation when duties potentially conflict. This paper has two simultaneous objectives. The first is to suggest a typological scheme of all possible modes of interaction; these will be classified under the “discrete,” “semi-discrete,” and “non-discrete” categories, according to whether the meaning and/or forms of expression of each duty are treated as independent from or rather as constrained by the other. The second objective is to show that all logical possibilities of interaction indeed have real expressions in medical ethics, to provide clear illustrations of each, and in particular to stress those that have usually escaped recognition.

The distinction between the discrete and semi-discrete categories has strong affinity to the distinction between balancing and specifying norms (to resolve conflict). Both distinctions do not neatly overlap, however, as will become clear below. In addition, the typology expounded here encompasses also the non-discrete category, which squarely exceeds the balancing-specifying distinction, and thus provides a more comprehensive typology.

For some important discussions of the balancing-specifying debate see Richardson (1990), Richardson (2000), Smith Iltis (2000), deMarco and Ford (2006), Gordon et al. (2011), Beauchamp and Childress (2013), Paulo (2016).

Two clarifications: (1) In “beneficence” I here include nonmaleficence; there are surely interesting moral differences between these two duties but they are not pertinent to this discussion. (2) RFA here refers to a generic sense of personal autonomy, central to liberal politics as well as biomedical ethics, denoting self-governed individual choice, expressing personal preferences and values. This is not the Kantian conception of autonomy; it is, however, compatible with a wide range of extant definitions of autonomy, among which we need not choose for our present purposes.

For an example of the former see Kass (1981), for an example of the latter see Gillon (2003).

Beauchamp and Childress, ibid.

See e.g. Groll (2012).

Beauchamp and Childress, ibid. p. 20.

The question of the general theoretical framework within which moral justification takes place (e.g. whether we employ reflective equilibrium) is also beyond the scope of this typological discussion of modes of interaction.

See e.g. Dworkin (1972), VanDeVeer (1986).

Feinberg (1986). A classic example already offered by Mill is of paternalistically stopping a person about to cross a bridge in danger of collapsing.

Gert and Culver (1976).

Thaler and Sunstein (2008).

Coons and Weber (2013) suggest that passing from coercive paternalism to libertarian paternalism is not a move from harsher to milder paternalism, but rather the opposite, since the libertarian paternalist attempts not merely to override the preferences of the other but to shape them, and this is a more sinister denial of the other’s agency (ibid. pp. 22–23). This insight surely deserves discussion. I strongly disagree with it, but elaboration remains beyond our scope.

Johnson et al. (2012).

There is a well-known effect of the ordering of options on which option is chosen; see e.g. Carney and Banaji (2012) for recent evidence.

This holds true at least in the eyes of the many who accept that “ought implies can.”

Moreover, attempting in the name of RFA to supplement the choice task with a reflective discussion of all ways in which the form of presentation of the choice set deviates from theoretical objective neutrality would be incompatible with even minimal constraints of practicality in human communication; it would concomitantly be confusing to the chooser to such a degree as to undermine the original motivation of facilitating an aware choice as the expression of RFA.

Conly (2013), see in particular p. 8.

For critical treatments of libertarian paternalism’s more permissive attitude to RFA see for example Hausman and Welch (2010), White (2013).

For challenges that even rational persuasion poses to the anti-paternalist see Tsai (2014).

For some discussion relevant to this point see Cohen (2013).

For a discussion of the multiple ambiguities see e.g. Kleinig (2010).

We are assuming that the treatment’s importance would indeed be endorsed by the patient had she overcome her anxiety, i.e. that the paternalism is soft.

While the behavior of the doctor described here bears affinity to the “subjective standard” of disclosure (see Beauchamp and Childress, ibid. p. 127), that view is conceived as the optimal interpretation of the duty of RFA, not in terms of the semi-discrete model.

With respect to the analysis in this paper there is a further reason why beneficence is not merely an imperfect duty: I defined it above as encompassing the duty of nonmaleficence, which is a perfect duty.

Richardson, “Specifying Norms as a Way to Resolve Concrete Ethical Problems.”

Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” p. 220.

For a systematic founding of bioethics on libertarian principles see Engelhardt (1986).

See e.g. Bayne and Levy (2005).

Justifications that appeal to the semantic reliance between the duties can be open to abuse or self-deception. For instance, a law may allow physician-assisted suicide or even euthanasia, citing beneficence as a ground and relying on a radically subjective understanding of well-being. It may be the case, however, that merely lip service is paid to beneficence, by claiming that only the person herself knows when suffering has become “unbearable” while the true moral motivation behind the law may in fact be RFA. I thank an anonymous reviewer for this insight.

As with the previous mode in this category, a universal dependence of one duty (or value) on the other would have presented the initial semblance of a tension as an unintelligible conceptual confusion that dissolves upon scrutiny, which is highly counterintuitive. Such complete denials of personal autonomy and rejection of RFA are indeed well known—think for instance of B. F. Skinner’s classic Beyond Freedom and Dignity—but are not our interest here. A different sort of candidate for the universal dependence may seem to be the utilitarian view, where RFA is subjugated to a general beneficence of sorts (making the totality of beings with moral status maximally happy). This too is irrelevant here, however, for we are not speaking of subjugating (merely) the justification of RFA to that of beneficence but rather its very meaning.

den Hartogh (2016).

We should note, however, that even emotions that are in themselves irrational can in specific scenarios be used strategically to facilitate rational plans. For insights into relevant ironic mechanisms see Frank (1988).

Interesting insights on this can be gained from Tsai (2018).

The best analysis of respect as emanating from concrete relations between persons is Buss (1999).

I will but mention two theories that exhibit variations on the theme of the dependence of RFA on beneficence, though whose respective structures are too distant from the structure of the present analysis to merit further elaboration here. Dillon (1992) introduced the concept of “care-respect,” where respect is intrinsically intertwined with caring, and so dependent on it. For Edmund Pellegrino the precise meaning of RFA is fixed only within a four level account of the comprehensive (physical, emotional, spiritual) good of the patient, where “beneficence becomes the primum principium of all ethics” (2001).

Chadwick (1997).

Cooper 1998.

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Titel: The logic of the interaction between beneficence and respect for autonomy
verfasst von: Shlomo Cohen
Publikationsdatum: 22.11.2018
Verlag: Springer Netherlands
Erschienen in: Medicine, Health Care and Philosophy / Ausgabe 2/2019
Print ISSN: 1386-7423
Elektronische ISSN: 1572-8633
DOI: https://doi.org/10.1007/s11019-018-9876-4

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