The Way of Medicine

Ethics and the Healing Profession

Farr Curlin, Christopher Tollefsen

• Publisher: University of Notre Dame Press
• Year: 2021
• ISBN:
  9780268200879
• Topic: Medicine
• Subtopic: Ethics in Medicine

Today's medicine is spiritually deflated and morally adrift; this book explains why and offers an ethical framework to renew and guide practitioners in fulfilling their profession to heal.

What is medicine and what is it for? What does it mean to be a good doctor? Answers to these questions are essential both to the practice of medicine and to understanding the moral norms that shape that practice. The Way of Medicine articulates and defends an account of medicine and medical ethics meant to challenge the reigning provider of services model, in which clinicians eschew any claim to know what is good for a patient and instead offer an array of "health care services" for the sake of the patient's subjective well-being. Against this trend, Farr Curlin and Christopher Tollefsen call for practitioners to recover what they call the Way of Medicine, which offers physicians both a path out of the provider of services model and also the moral resources necessary to resist the various political, institutional, and cultural forces that constantly push practitioners and patients into thinking of their relationship in terms of economic exchange.

Curlin and Tollefsen offer an accessible account of the ancient ethical tradition from which contemporary medicine and bioethics has departed. Their investigation, drawing on the scholarship of Leon Kass, Alasdair MacIntyre, and John Finnis, leads them to explore the nature of medicine as a practice, health as the end of medicine, the doctor-patient relationship, the rule of double effect in medical practice, and a number of clinical ethical issues from the beginning of life to its end. In the final chapter, the authors take up debates about conscience in medicine, arguing that rather than pretending to not know what is good for patients, physicians should contend conscientiously for the patient's health and, in so doing, contend conscientiously for good medicine. The Way of Medicine is an intellectually serious yet accessible exploration of medical practice written for medical students, health care professionals, and students and scholars of bioethics and medical ethics.

NOTES

PREFACE

1. David L. Sackett, William M. C. Rosenberg, J. A. Muir Gray, R. Brian Haynes, and W. Scott Richardson, “Evidence-Based Medicine: What It Is and What It Isn’t,” British Medical Journal 312, no. 7023 (1996): 71–72.

INTRODUCTION

1. It is important for us to clarify our use of “well-being” here. Our own moral theory has a substantive account of human flourishing at its foundations, and such flourishing could equally be designated as a form of well-being. However, throughout this book, when we use the expression in italics—well-being—we mean to designate the thin, preference- and desire-satisfaction model that many medical ethicists presently use. We typically italicize the first use of the expression in a chapter, and then rely on context to make it clear which sense of “well-being” we mean.

2. As we discuss further in chapter 1, Beauchamp and Childress’s enormously influential framework focuses on four principles: beneficence, nonmaleficence, justice, and autonomy. See Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 7th ed. (New York: Oxford University Press, 2013), 13–14.

3. See Ronit Y. Stahl and Ezekiel J. Emanuel, “Physicians, Not Conscripts—Conscientious Objection in Health Care,” New England Journal of Medicine 376, no. 14 (2017): 1380–85.

4. H. Tristram Engelhardt, The Foundations of Bioethics, 2nd ed. (New York: Oxford University Press, 1996), 7.

5. A 2016 U.S. News & World Report article showed that “nearly half of U.S. physicians—49 percent—meet the definition for overall burnout.” In addition, physicians’ “satisfaction with work-life balance is far lower than that of others: 36 percent versus 61 percent.” See Steve Sternberg, “Diagnosis: Burnout,” U.S. News & World Report, September 8, 2016. See also Tait D. Shanafelt, Omar Hasan, Lotte N. Dyrbye, Christine Sinsky, Daniel Satele, Jeff Sloan, and Colin P. West, “Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population between 2011 and 2014,” Mayo Clinic Proceedings 90, no. 12 (2015): 1600–1613.

6. Michael J. Balboni and Tracy A. Balboni, Hostility to Hospitality: Spirituality and Professional Socialization within Medicine (New York: Oxford University Press, 2019).

7. As will become clear, we see two interrelated disagreements about medicine: one over whether health should be the primary and largely exclusive purpose of medicine and one over what health is.

8. Edelstein’s translation renders the Greek well: “I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy” (οὐ δώσω δὲ όυδὲ ϕάπρμακον οὐδενὶ αἰτηθεὶς θανάσιμον οὐδὲ ὑϕηγήσομαι ξυμβουλίην τοιήδε· ὁμοίως δὲ ούδὲ γυναικὶ πεσσὸν ϕθόριον δώσω). Ludwig Edelstein, The Hippocratic Oath: Text, Translation, and Interpretation (Baltimore, MD: Johns Hopkins University Press, 1943), 2–3.

9. For discussion of this claim in relation to the oath itself, see T. A. Cavanaugh, Hippocrates’ Oath and Asclepius’ Snake (New York: Oxford University Press, 2018).

10. C. S. Lewis, The Abolition of Man, or, Reflections on Education with Special Reference to the Teaching of English in the Upper Forms of Schools (San Francisco: HarperSanFrancisco, 2001), 43.

11. Gerald P. McKenney, To Relieve the Human Condition: Bioethics, Technology, and the Body (Albany, NY: State University of New York [SUNY] Press, 1997), 16. McKenney himself engages dialectically with a number of previous critics, such as Hans Jonas Leon Kass and Stanley Hauerwas, from whom we have also learned much.

12. Jeffrey P. Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying (Notre Dame, IN: University of Notre Dame Press, 2011).

13. Ibid., 9.

14. “Social imaginary” is a term that Charles Taylor explores in depth in his Modern Social Imaginaries (Durham, NC: Duke University Press, 2004), 23.

15. Edmund D. Pellegrino, “The Internal Morality of Clinical Medicine: A Paradigm for the Ethics of the Helping and Healing Professions,” Journal of Medicine and Philosophy 26, no. 6 (2001): 559–79.

16. McKenney, To Relieve the Human Condition: Bioethics, 16.

17. See Edmund D. Pellegrino, The Philosophy of Medicine Reborn: A Pellegrino Reader, ed. H. Tristram Engelhardt Jr. and Fabrice Jotterand (Notre Dame, IN: University of Notre Dame Press, 2008); Leon R. Kass, “Regarding the End of Medicine and the Pursuit of Health,” Public Interest 4 (1975): 11– 42; Alasdair MacIntyre, After Virtue: A Study in Moral Theology, 3rd ed. (Notre Dame, IN: University of Notre Dame Press, 2007), 194. See also John Keown’s assessment of John Finnis: “A New Father for the Law and Ethics of Medicine,” in Robert P. George and John Keown, Reason, Morality, and Law: The Philosophy of John Finnis (Oxford: Oxford University Press, 2014), 290–307.

18. See MacIntyre, After Virtue, 222.

CHAPTER ONEThe Way of Medicine

1. Alasdair MacIntyre, After Virtue: A Study in Moral Theory, 3rd ed. (Notre Dame, IN: University of Notre Dame Press, 2007), 187.

2. For more on the difference between experiencing one’s work as a job versus as a calling, see Robert N. Bellah, William M. Sullivan, Richard Madsen, Ann Swindler, and Steven M. Tipton, Habits of the Heart: Individualism and Commitment in American Life (Berkeley: University of California Press, 1985); Amy Wrzesniewski, Clark McCauler, Paul Rozin, and Barry Schwartz, “Jobs, Careers, and Callings: People’s Relations to Their Work,” Journal of Research in Personality 31, no. 1 (1997): 21–33; and Douglas T. Hall and Dawn E. Chandler, “Psychological Success: When the Career Is a Calling,” Journal of Organizational Behavior 26, no. 2 (2005): 155–76.

3. Aristotle, Nicomachean Ethics, trans. David Ross (New York: Oxford University Press, 2009), 1094a10.

4. For an introduction to debates about whether medicine has an intrinsic telos and an internal morality, see the collection of papers on the subject in the Journal of Medicine and Philosophy 26, no. 6 (2001).

5. See Jean Bethke Elshtain, “Why Science Cannot Stand Alone,” Theoretical Medicine and Bioethics 29, no. 3 (2008): 161–69.

6. See Paul A. Lombardo, Three Generations, No Imbeciles: Eugenics, the Supreme Court, and Buck v. Bell (Baltimore, MD: Johns Hopkins University Press, 2010).

7. Aristotle, Nicomachean Ethics, 1094b25.

8. See, particularly, Leon Kass, “Regarding the End of Medicine and the Pursuit of Health,” Public Interest 40 (1975): 11–42. See also Luke Gormally, “The Good of Health and the Ends of Medicine,” in Holder Zaborowski, Natural Moral Law in Contemporary Society (Washington, DC: Catholic University of America Press, 2010), 264–84. Gormally argues for views of both health and medicine very similar to ours.

9. See Christopher Boorse, “Health as a Theoretical Concept,” Philosophy of Science 44 (1977): 542–73. Some proponents of an objective account, such as Boorse, further understand health as merely the absence of disease. In contrast, we claim that health is a positive quality and is, in this important sense, prior to disease. Disease is knowable because it causes a diminishment of health, but health is knowable apart from any disease. What’s more, health can be diminished even in the absence of disease, as when a person becomes unhealthy as a consequence of inactivity. Therefore, the opposite of health is not disease but ill health—the privation or absence of health.

10. For a discussion of evaluative concepts of health and disease see Jacob Stegenga, Care and Cure: An Introduction to Philosophy of Medicine (Chicago: University of Chicago Press, 2018), chaps. 1 and 2.

11. These syndromes include conditions such as chronic fatigue and fibromyalgia. See Jiwon Helen Shin, John D. Yoon, Kenneth A. Rasinski, Harold G. Koenig, Keith G. Meador, and Farr A. Curlin, “A Spiritual Problem? Primary Care Physicians’ and Psychiatrists’ Interpretations of Medically Unexplained Symptoms,” Journal of General Internal Medicine 28, no. 3 (2013): 392–98.

12. Because humans are ever incomplete, to be human is to be disabled and dependent in significant measure, even if that dependence and disability are not socially conspicuous.

13. Gerald P. McKenny, To Relieve the Human Condition: Bioethics, Technology, and the Body (Albany, NY: State University of New York [SUNY] Press, 1997).

14. Some have interpreted Kass as disregarding mental health. He was at pains to distinguish pursuit of happiness from pursuit of health, but in our view, his account of the well-working of the organ...