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Neither Freedom nor Autonomy Without Beneficence

Neither Freedom nor Autonomy Without Beneficence Varma and Wendler1 recently focused on the medical ethical challenge represented by the treatment for people lacking advanced directives or designated surrogates. They argue that it is fundamental to give them the same level of respect afforded those with surrogates. The clear identification of instruments to help physicians make treatment decisions consistent with the patient's preferences is mandatory. They propose a “population-based treatment indicator,” a computer-based tool that should be able to unravel a patient's choice by relying on the treatment preference of comparable individuals. The data to be implemented into the decisional algorithm are mainly based on “age and sex, and features of the patient's clinical situation, such as diagnosis.”1(p1712) We all know that the patient-physician relationship underwent an in-depth transformation over the last 50 years. The main achievement was the awareness that physicians cannot heal a person just by curing the disease, while ignoring or disregarding the patient's view. Subsequently, the patient's autonomy gained a leading position in the hierarchy of values entangled in the relationship. We believe, however, that the deepest ethical principle mastering the physician behavior has to be the good of the patient rather than his or her autonomy or freedom.2 Therefore, beneficence is paramount. This statement could seem out of fashion if not backed with the firm belief that it is impossible to truly achieve what is for a patient's good without respecting the patient's wishes. In this way “the principle of beneficence joined concern for the best interest of patients with concern for their autonomy.”3 Pellegrino and Thomasma named this approach “beneficence in trust.”3 Respecting patients’ wishes is an essential feature of acting for their good, but patients' preferences could not be consistent with the best medical knowledge (eg, if they want to undergo chemotherapy, although the treatment is an ineffective procedure because of the disease stage). In this scenario, the physician has the right not to carry out what the patient wills. In other situations, the patient is unable to give directives anymore. In such cases, a physician has a duty to do everything possible to give the best care to the patient. If uniqueness is a cornerstone of a patient's autonomy, to let a computerized flowchart decide what is good on the basis of the most frequent choice has to be considered a denial of the patient's freedom. To delegate to a computer the physician's responsibility, besides being an illusion, is a perilously tight corner from which to get out. Correspondence: Dr d’Aloja, Department of Forensic Medicine, Cagliari University, SS 554 bivio Sestu, Cagliari 09042, Italy (ernestodaloja@pacs.unica.it). References 1. Varma SWendler D Medical decision making for patients without surrogates Arch Intern Med 2007;167 (16) 1711- 1715PubMedGoogle ScholarCrossref 2. Kass L Neither for love nor for money: why doctors must not kill. Public Interest Winter1989; (94) 2921- 2922PubMedGoogle Scholar 3. Pellegrino EDThomasma DC For the Patient's Good: The Restoration of Beneficence in Health Care. New York, NY Oxford University Press1988;51- 58 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Neither Freedom nor Autonomy Without Beneficence

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Publisher
American Medical Association
Copyright
Copyright © 2008 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.168.5.548-b
Publisher site
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Abstract

Varma and Wendler1 recently focused on the medical ethical challenge represented by the treatment for people lacking advanced directives or designated surrogates. They argue that it is fundamental to give them the same level of respect afforded those with surrogates. The clear identification of instruments to help physicians make treatment decisions consistent with the patient's preferences is mandatory. They propose a “population-based treatment indicator,” a computer-based tool that should be able to unravel a patient's choice by relying on the treatment preference of comparable individuals. The data to be implemented into the decisional algorithm are mainly based on “age and sex, and features of the patient's clinical situation, such as diagnosis.”1(p1712) We all know that the patient-physician relationship underwent an in-depth transformation over the last 50 years. The main achievement was the awareness that physicians cannot heal a person just by curing the disease, while ignoring or disregarding the patient's view. Subsequently, the patient's autonomy gained a leading position in the hierarchy of values entangled in the relationship. We believe, however, that the deepest ethical principle mastering the physician behavior has to be the good of the patient rather than his or her autonomy or freedom.2 Therefore, beneficence is paramount. This statement could seem out of fashion if not backed with the firm belief that it is impossible to truly achieve what is for a patient's good without respecting the patient's wishes. In this way “the principle of beneficence joined concern for the best interest of patients with concern for their autonomy.”3 Pellegrino and Thomasma named this approach “beneficence in trust.”3 Respecting patients’ wishes is an essential feature of acting for their good, but patients' preferences could not be consistent with the best medical knowledge (eg, if they want to undergo chemotherapy, although the treatment is an ineffective procedure because of the disease stage). In this scenario, the physician has the right not to carry out what the patient wills. In other situations, the patient is unable to give directives anymore. In such cases, a physician has a duty to do everything possible to give the best care to the patient. If uniqueness is a cornerstone of a patient's autonomy, to let a computerized flowchart decide what is good on the basis of the most frequent choice has to be considered a denial of the patient's freedom. To delegate to a computer the physician's responsibility, besides being an illusion, is a perilously tight corner from which to get out. Correspondence: Dr d’Aloja, Department of Forensic Medicine, Cagliari University, SS 554 bivio Sestu, Cagliari 09042, Italy (ernestodaloja@pacs.unica.it). References 1. Varma SWendler D Medical decision making for patients without surrogates Arch Intern Med 2007;167 (16) 1711- 1715PubMedGoogle ScholarCrossref 2. Kass L Neither for love nor for money: why doctors must not kill. Public Interest Winter1989; (94) 2921- 2922PubMedGoogle Scholar 3. Pellegrino EDThomasma DC For the Patient's Good: The Restoration of Beneficence in Health Care. New York, NY Oxford University Press1988;51- 58

Journal

Archives of Internal Medicine – American Medical Association

Published: Mar 10, 2008

Keywords: beneficence

References

  • Medical decision making for patients without surrogates
    Wendler D; Arch Intern Med
  • Neither for love nor for money: why doctors must not kill.
    Kass L; Public Interest
  • For the Patient's Good: The Restoration of Beneficence in Health Care.
    Thomasma DC