Neither autonomy nor utility:
Traditions and the Critique of Consequentialist Bioethics
17th ASEACCU Conference 2009 Sydney, Australia
Bernadette Tobin
Director, Plunkett Centre for Ethics, St Vincent’s Hospital, Sydney
Reader in Philosophy, Australian Catholic University
1
Introduction
Recently, the Plunkett Centre for Ethics here in Sydney was asked to give some advice on
Guidelines for the Provision of Critical Care in Response to Influenza Pandemic issued by a
local health authority. In setting out arrangements to be made by hospitals to prepare for a
surge in the demand for beds in intensive care, a surge which might exceed a hospital‟s
capacity to care for very sick people, these guidelines said that these arrangements should be
informed by a ‘shift from [a] bioethical focus on patient autonomy to [a] utilitarian model to
do [the] greatest good for greatest number with available resources’.
1
This claim, that
hospitals would have to move from a „focus on autonomy‟ to an „ethic of utilitarianism‟,
caught the attention of an alert CEO in a local hospital. The CEO was worried by the thought
that critical care in an pandemic should be allocated according to utilitarianism‟s greatest
good for the greatest number. Though people sometimes use the word „utilitarianism‟ and
the idea of „greatest happiness for the greatest number‟ in relatively innocuous ways, as
labels for approaches which somehow addresses the overall good of a community, the CEO
knew that, strictly speaking, both refer to moral theories in which the needs of the individual
may ignored or overridden.
In fact the guidelines did not embrace a utilitarian ethic. They recognize that the principle
health care need (rather than, say the greater value for money of treating a younger person
ahead of an older (as some might say) or the superior value of a one person‟s life to that of
another (as others might say)) is the ethically-central notion in circumstances in the allocation
1
NSW Health. Guidelines for the Provision of Critical Care in Response to Influenza Pandemic, July 2009,
H09/24892, p 11.
For conferences participants only. Not to be quoted without permission of the author
of health care resources. They recognize that, in circumstances in which it is not possible to
provide all the health that everyone needs, it is necessary to make judgments about the
importance of one person‟s need relative to another‟s.
And they advise that, in the
circumstances of a pandemic, it is reasonable to give priority of access to intensive care beds
to patients who are sick enough to require intensive care and whose outcome will be poor if
they do not receive it but who are not so sick that they will not recover even if they do receive
intensive care. 2
The guidelines then categorize potential patients into each of these levels of priority. No
doubt, there would be plenty of room for discussion about the categorization. I for one think,
contrary to what the guidelines say, that a case can be made for giving preferential treatment
to people who provide care for others, those on whom other people depend.3 But the priority
principles employed in the guidelines are sound: they embody the idea that, when individual
patients and categories of patients are unwitting competitors for the same scarce resources,
priority may legitimately be given (a) to those who are more likely to benefit from the
treatment ahead of those who are less likely to benefit, (b) to the patient whose need is more
urgent, (c) to the patient who is more likely to benefit therapeutically from the available
treatment, (d) to the patient who is likely to gain the greater or longer therapeutic benefit
from the treatment, (e) to the patient who is likely to suffer the lesser burden from the
treatment,(f) to the patient who is likely to suffer the greater harm without the treatment, (f)
to the patient who is less at risk of various ill effects of treatment, (h) to the patient who is
more likely to gain the same therapeutic benefit from less of the treatment, (i) to the patient
who is likely to need the treatment for a shorter time or less frequently, (j) to the patient who
has fewer or no alternative sources of satisfying the need, or who is more likely to infect
others if untreated, etc.4 That is to say, they embody what might be called a „golden rule‟ or
2
These patients are to be given priority over those who are so sick that it is genuinely uncertain whether they
will benefit from critical care, and over both those who are either so sick that they will not benefit from critical
care and those who are well enough to be cared for without mechanical ventilation and other ICU-specific
interventions.
3
See page 12, 2nd dot point. A case can be made for giving preferential treatment to those who provide care for
others. It can be seen as an extension of the criterion of need: by caring for the health of those with dependants,
we care for a wider group as well. In addition, favouring those with dependants helps preserve family bonds
(which benefits family members and the community), it saves the expense of social support for the dependants,
and it expresses a high social valuation of family life. Fisher, A, Gormally, L: Healthcare allocation: an ethical
framework for public policy, London. The Linacre Centre, 2001, p 115
4
Fisher & Gormally. op cit, p 129
For conferences participants only. Not to be quoted without permission of the author
„common good‟ way of thinking about justice in the allocation of resources: justice consists
in doing unto others what you would have them do unto you or to someone who is amongst
the weakest in the community (sick with a chronic, disabling and expensive ailment, poor,
illiterate, etc.5
So my questions are: Does a „focus on autonomy‟ adequately describe how we normally
should allocate health care resources, and does a „utilitarian model to do the greatest good for
the greatest number with available resources‟ adequately describe how we should allocate
them in circumstances in which we are not able to provide all that people need (let alone
want)? 6
2
Is a focus on ‘autonomy’ the default position in bioethics, from which there
needs to be a deviation in a pandemic?
Nearly forty years ago Beauchamp and Childress from Georgetown University published the
first edition of their Principles of Biomedical Ethics. In that work they argued that common
morality contains a set of moral standards that include principles that are basic for biomedical
ethics.
They are respect for autonomy (respecting the decision-making capacities of
autonomous persons), nonmaleficence (avoiding the causation of harm), beneficence
(providing benefits and balancing benefits against risks and costs), and justice (distributing
benefits, risks, and costs fairly). They claimed that most classical theories of ethics include
these principles in some form, but that traditional medical codes had neglected respect for
autonomy and justice. Beauchamp and Childress argued that these principles function as an
analytic framework – a professional code of ethics - that expresses the general values
5
Bernadette Tobin. The principle of justice: a bioethical perspective, Bioethics Outlook, 12,4, Dec 20011-12
This idea, and this way of putting the idea, comes from Anthony Fisher. The principles of distributive justice
considered with reference to the allocation of healthcare, Unpublished thesis, 1994
6
Note that the subject matter of this enquiry comes from the „reason-based‟ strand in the Judeo-Christian
tradition. In the Catholic tradition (and, I understand, a similar kind of thing can be said about both the Jewish
and the Islamic traditions, a distinction can be made between two kinds of propositions: one kind which is
entirely open to natural human, „secular‟, reason and another kind which is not entirely open to natural human
reason. The first includes a set of claims about the nature of a human being and the nature of society and in
particular about the kinds of conduct that conduce to human well-being. The second includes a set of claims
about the nature of God and in particular the life and teaching of Christ. The reason-based ideas belong to a
robust, well-regarded, if nonetheless debated and debatable, school of thought in secular philosophy: natural law
theory.
For conferences participants only. Not to be quoted without permission of the author
underlying the rules in the common morality.
Beauchamp and Childress said that you can
find all four principles in our „considered moral judgments‟, that is, in how we think when we
are thinking carefully, and the way that our moral beliefs cohere with each other, the way we
modify our judgments when we find that they conflict with each other).7
Four principles, but quickly one came to dominate. By 1976, so strongly had respect for
personal autonomy prevailed that most people simply could not understand why Karen Ann
Quinlan‟s doctors did not accept the court‟s judgment that they must act in accordance with
her previously expressed wishes not to remain on a life-support machine even though they
feared that they would be doing the wrong thing by her if they were to let her die.
The almost immediate dominance of respect for autonomy has been the subject matter of
much historical attention: the explanation must include that increasing distrust of authority
which was associated with the unpopularity in the US of the Vietnam War and an increasing
acceptance of cultural and moral pluralism in the West. But one thing is clear: the „four
principles‟ framework for bioethical reflection both reflected and fed a revolution in favour
of the primacy of autonomy.
Secondly, there is the way the law speaks about medical treatment. Lawyers and legally
trained academics often make valuable contributions to bioethics. They can bring a muchneeded clarity to our thinking, and the law itself can remind us of truths that misguided or
self-serving professionals may well prefer to forget: think for instance of the judgment of
Australia‟s High Court‟s in Rogers v Whitaker: it has greatly improved our appreciation of
one of the moral standards intrinsic to the encounter between doctor and patient: telling it as
it is. But the language of the law, with its emphasis on individual rights, has also helped to
promote the idea that, since a proper respect for autonomy of the patient means that the
doctor will be guilty of battery if he treats the patient without that person‟s consent, or
without the consent of that person‟s representative, it follows that the patient‟s (or proxy‟s)
wishes, or even demands, are sovereign over every aspect of the medical encounter: which
7
T. Beauchamp and J. Childress, Principles of Biomedical Ethics: 5th Edition, Oxford University Press, 2001, p
398
For conferences participants only. Not to be quoted without permission of the author
treatments should be offered, whether a failed treatment should be maintained, with whom
the doctor may share information about the patient, etc.
And thirdly, there is the effect of the penetration of the market into health care, with its
reductive language: „doctors‟ as mere „providers‟ and sick people as mere „consumers‟, and
its accompanying ethic of keeping the customer satisfied. An advisory committee on organ
donation and transplantation of which I am a member was recently asked to ensure that it had
adequate consumer representation. While the committee debated who is the consumer, the
donor, the donor‟s family, the recipient, it struck me as ludicrous for any of them to be called
„consumers‟. Who could be less like a savvy shopper in a big department store than the
members of the family who grieve the death of a generous person who decided to donate her
organs? Who could be less like a consumer than a sick and desperate person on hospital
based dialysis? Or indeed the grateful recipient of an organ?
Of course, several things can be said in favour of giving prominence to idea of respecting
patient autonomy.
For a long time now, that great doctor and exponent of both the
Hippocratic and the Judeo-Christian traditions, Edmund Pellegrino, has said that the recovery
of respect for patient autonomy has made the relationship between doctor and patient more
open, more adult, more transparent, and thus more attentive to the patient‟s values and
wishes. 8 Some of the edge has been taken off physician arrogance and self-assurance. The
patient‟s dignity as a person is now better respected. If Edmund Pellegrino says so, that‟s
good enough for me. But his use of the word „recovery‟ alerts us to the fact that respect for
autonomy was not invented in the late sixties and early seventies: it re-emerged then as a
corrective to the prevailing benign, authoritarian, „doctor knows best‟, conception of the
doctor-patient relationship. And when it did, it had the flavour of Mill‟s thinking about
individual liberty, as a right of the individual against the rest of the society, in this case,
against the doctor.
8
Edmund Pellegrino. „Physician Integrity: why it is inviolable‟, Connecting American Values with Health
Reform, The Hasting Center 2009. p 19
For conferences participants only. Not to be quoted without permission of the author
But it was an old idea even if in new and unbecoming clothes. Respect for patient autonomy
was always prominent in the Judeo-Christian tradition‟s thinking about the individual‟s
responsibility for his or her own life, even if it was only latent in a Hippocratic understanding
of that relationship. In the Judeo-Christian tradition, all members of the human family are
radically equal in their responsibilities as stewards of their own lives and in their capacities to
shape their own lives by the decisions and choices they make. In this tradition, we all have
an inalienable responsibility to take good care not only of the lives of those others from
whom we have a responsibility but also of our lives: „humanity in ourselves‟ as Kant put it as
he tried to explain in secular, rational, terms the Judeo-Christian idea of the sanctity of all
human lives. And let‟s not forget that, in the Christian tradition, that responsibility has
traditionally been conceived as a not-unreasonably-demanding one: Christians are not asked
to do what is beyond us: we are invited to accept only ordinary means of preserving our lives.
So there is much to be said for a proper recognition of respect for patient autonomy, and more
so now than ever, when medicine is able to keep people alive in circumstances in which they
would not want that. For many reasons, advance care plans are needed to ensure that the
focus on the patient is not lost in the circumstances in which medicine is now delivered: when
many more people die having lost decision-making capacity, when all citizens at least in
affluent countries like Australia have access to advanced medical technology, when the
power of medical technology is so great that end of life decisions affect everyone, when the
burden of decision-making falls largely on third parties, and when increasing numbers of
people have no families to make decisions for them as they are dying.
On the other hand, as Pellegrino points out, the contemporary focus on patient autonomy has
had some bad effects on bioethics. 9 It has made doctors think that are required to satisfy
patient or family demands or be guilty of paternalism, the „the original moral sin of modern
bioethics‟. It has made some doctors think that, in order to avoid paternalism, they should be
morally neutral. Without sanctioning obvious harm, they should yield to patients who choose
a less effective treatment over a more effective treatment, or a treatment of no proven use
over a treatment whose usefulness is well-known, or even a treatment that violates the
9
Pellegrino, op cit
For conferences participants only. Not to be quoted without permission of the author
doctor‟s beliefs about what it right and good for a particular patient. Indeed, more subtle, but
perhaps more important, is doctor‟s growing reluctance to urge the course that he or she
believes is preferable for this patient. It has made some doctors think that, in the name of
patient autonomy, they must protect all confidences even when others may be harmed – for
example, not reporting the incapacitated driver who is a public danger. It has encouraged
intolerance about both individual and institutional judgments about medical practice. It has
made some doctors think that it is an act of beneficience to exaggerate the severity of disease
or disability to increase the likelihood here in Australia that the patient will qualify for a
subsidized drug or, in the States, that the patient‟s insurance company will cover a needed
treatment.
And, if or when assisted suicide and voluntary euthanasia are legalized, „respect for
autonomy‟ will likely be used to widen the scope of legal euthanasia to the non-voluntary. Dr
Rodney Syme, who thinks that physician-assisted suicide for the competent patient should be
legally available, was recently asked what he thought about providing euthanasia for the
„demented‟. He said: ‘At the moment, we are struggling to get legislation for what is a very
much simpler problem, and that is the person who does have clearly demonstrable
competence, who is perfectly rational, and I don’t think that we want to muddy the water in
any way with discussions about dementia. Ultimately, if society deems that laws for people
who are rational and competent are appropriate, it may well be that society will eventually
see that that is perhaps an unfair situation, that people with dementia ought to be considered.
And we will work out some mechanism for dealing with that. But in my opinion that will
probably be 20 or 30 years in the distance.’
10
Why would that be unfair? Presumably
because the law would allow us to respect the person‟s choice in one case but not allow us to
respect what we think would be, or perhaps should be, their choice in another case.11
10
http://www.abc.net.au/rn/australiatalks/stories/2008/2285797.htm - 26 Jun 2008
11
J. Finnis & A. Fisher. „Theology and the four principles: A Roman Catholic View‟ in Principles of Health
Care Ethics edited by Raanan Gillon, John Wiley and Sons, New York, 1994, p 41.
For conferences participants only. Not to be quoted without permission of the author
Even when that is properly acknowledged and understood, even when every human being is
recognized as equal with respect to autonomy, even when respect for autnomy is not
distorted, nor recast as the political value of liberalism, respect for autonomy is not the
foundation of bioethics but only a cornerstone which has to be properly fitted in with other
stones. And we understand it better if we think of it in the light of what a really good doctor
or nurse already does, rather than as abstract moral principle to which medical practice ought
to conform.
3
In a pandemic, should the focus shift to a utilitarian method of allocation?
Broadly there are four ways of thinking about the allocation of scarce health care resources:
They are: (1) allocate on the basis of the greatest good for the greatest number
(„utilitarianism‟); (2) allocate on the basis of a lack of constraints on individual liberty
(„libertarianism‟): (3) allocate so as to bring about equal opportunity for healthcare
(„egalitarianism‟); and (4) allocate on the basis of the relative importance of healthcare need
(„Good Samaritanism‟ or „the Golden Rule).
In what follows I will identify and evaluate the main ideas in a utilitarian rationing scheme.
As I said, though the pandemic guidelines were not genuinely utilitarian, aspects of genuinely
utilitarian schemes regularly characterize bioethical thinking about resource allocation.
So, on a utilitarian view, we must maximize utility. We must work out all the predictable
benefits and losses of some proposed change or state of affairs, calculate the net sum of those
changes (the utility), and then choose that state of affairs which will bring about the greatest
good for the greatest number.
The best known application of utilitarian thought uses the idea of a „Quality-Adjusted Life
Year‟ or QALY. It goes like this. Health care saves lives, so our allocations should serve that
end. But when you ask people, they clearly value saving the life of a 90 year old differently
from saving the life of a 5 year old.
Thus we want health care to do more than save lives:
For conferences participants only. Not to be quoted without permission of the author
we want it to reduce pain and suffering. So we need a common standard for comparing
saving lives with enabling a bed-bound person to return to active life. Quality-Adjusted Life
Years are meant to do just that: to enable us to measure the two kinds of benefit achieved by
healthcare.
First, the years of life and the quality of life yielded by various health care interventions are
established from clinical data. These are then assessed according to a psychometric index
along which one year of life in perfect health is valued at 1 QALY, death at 0 QALY, and
one year of life in less than perfect health is valued at something less than 1 QALY and
greater than O (death): this is usually done by asking people what they would be prepared to
pay for various treatments.12
The cost of achieving one QALY is then calculated and
treatments are then ranked according to the relative value they provide. 13
Peter Singer recommended the QALY approach in a recent article in the New York Times.
He said: ‘The QALY tells us to do what brings about the greatest health benefit, irrespective
of where that benefit falls. Usually, for a given quantity of resources, we will do more good if
we help those who are worst off, because they have the greatest unmet needs.
But
occasionally some conditions will be both very severe and very expensive to treat. A QALY
approach may then lead us to give priority to helping others who are not so badly off and
whose conditions are less expensive to treat.’
14
12
A common method of for assigning values to „life in less than perfect health‟ is to describe medical conditions
- eg quadriplegia - to people and tell them then can choose between more years in that condition or less years
without it. Such a „willingness to pay‟ method may well suggest that extending the lives of people without
disability has twice the value-for-money as has extending the lives of people with disability for a similar period
of time.
13
According to one commentator, cholesterol testing and diet therapy for middle aged people, neurosurgery for
head injury and GP advice to stop smoking are twice to six times as good value for money as antihypertensive
therapy to prevent stroke, pacemaker implantation, hip replacement or heart valve replacement, and up to 80
times better value for money than coronary bypass, kidney or heart transplant, breast screening, up to 120 times
better as value for money than dialysis, and several hundred times better value for money than is neurosurgery
for brain tumour. A. Maynard. „The economics of rationing health care‟. In M. Tunbridge (ed). Rationing of
Health Care in Medicine. London. Royal College of Physicians, 1993. 1-12, at 6. (as quoted in Fisher and
Gormally, op cit, p. 57).
14
Peter Singer, Why We Must Ration Health Care. The New York Times Magazine, 19th July 2009
For conferences participants only. Not to be quoted without permission of the author
Utilitarian approaches tend to favour prevention over cure, cheaper therapies over more
expensive ones, short term services over long term ones, treatment for young over treatment
for the old.
When utilitarianism says that we should do the greatest good for the greatest number, who is
in that number? Who must we take account of? The theory of utilitarianism itself gives no
answer to this question: it just tells us that we should do the greatest good for the greatest
number of ... whoever is to be counted in!
Most utilitarians give one or other of the
following two answers to the question: who must we count in? Or they wobble inconsistently
between them.
They either adopt John Locke‟s view of personhood and say that strictly
speaking only persons in Locke‟s sense must be counted in: Locke defined a person as a
„thinking intelligent being that has reason and reflection and can consider itself as itself, the
same thinking being, in different times and places.‟ Or they go via a different route, defining
happiness as „preference satisfaction‟ and so tell us that we must take account of the
preferences of anyone (man, animal …) which has preferences in the matter at hand. Either
way, a lot of our fellow human beings are left out. They will be insufficiently cognitivelyable to count in their own right, or they will count only insofar as they and others have
preferences about their lives.
The QALY approach does have some positives: It aims at impartiality.15
It takes into
account both cost effectiveness and efficiency in any allocative arrangement, and we do have
a duty to use our resources in ways which are efficacious with regard to the purpose of the
project and not wasteful given the opportunity costs involved, and this duty is stronger when
we are the steward of other people‟s resources16.
But the QALY approach has some technical problems. (1) It says that health care has just
two kinds of benefit: lives saved and suffering reduced. However (a) are lives saved and
suffering reduced the only benefits of health care?
Think of what the Parable of the Good
15
Notice how the advertisements being run to try to sink President Obama‟s reform of the US healthcare system
are aimed at tapping into, and augmenting, people‟s fear that they may be worse off. Impartiality truly is a
virtue.
16
A first step is to eliminate harmful, ineffective or wasteful procedures. A second step is to cost the
effectiveness of healthcare procedures and of ways of distributing resources by peer-based utilization reviews,
evaluations of outcomes, randomize trials ,etc
For conferences participants only. Not to be quoted without permission of the author
Samaritan shows about health care. Not just that we should help people in distress. Not just
that providing healthcare is a way of helping people in distress. Not just that our obligation
to help people in distress extends to all others. Doesn‟t the parable say something about the
value of neighbourliness in and of itself? So isn‟t neighbourliness itself another „benefit‟ of
healthcare? And (b) are lived saved and suffering reduced always benefits of healthcare, and
are they equally so for all people? Of course, they are intrinsic goods but need they always
be chosen, by patient or by doctor? Not according to the Hippocratic tradition, not according
to the Judeo-Christian tradition, with the robust recognition in each of these traditions of
human finitude and the insistence that medicine‟s goal is to heal even as a patient dies. (2)
The QALY approach treats these two benefits (lives saved and suffering reduced) as
commensurate values. But are they sufficiently alike to allow them to be reduced to a single
factor for the purpose of measurement? Aren‟t they apples and oranges? Can we really say
that circumventing infertility though IVF is a greater (or lesser) benefit than curing pain and
immobility through a hip replacement operation? Of course, individuals may adopt personal
hierarchies for measuring and ranking diverse goods. And polls may tell us what people feel
about these tradeoffs.
But that does not make personal hierarchies and answers to polls
rationally compelling measures, which provide ethically reasonable principles for everyone.
And even if many people were to agree on their priorities in this areas, this may simply mean
that they share similar temperaments or social conditioning.
Most important, though, is the fact that the QALY approach is unjust in both of Aristotle‟s
two senses of justice: justice as the name for a part of ethics (fairness) and justice as the name
for the whole of ethics (the common good). (1) The QALY approach is unfair.
The
aggregation of community preferences and views about quality of life predictably duplicate
and even magnify common prejudices, deeming non-essential those treatments which are
most often required by vulnerable groups: eg psychiatric care, care for the elderly, treatments
for substance abuse and treatment for AIDS sufferers. Because of its focus on total or
average benefits, utilitarianism, while not aiming to bring about or confirm such
disadvantage, is „blind‟ to where it occurs. QALYS are especially „biased‟ against the
elderly, the handicapped, the chronically sick, the dying, and other already disadvantaged
For conferences participants only. Not to be quoted without permission of the author
people, for these groups are less likely to gain as many QALYs from a treatment as others.
17
And (2) the QALY approach is contrary to the common good. Maximizing utility („the
greatest good for the greatest number‟) leaves little place for mercy: but much of the health
care provided by my own hospital (St Vincent‟s) is done in the name of mercy: for people
addicted to drugs or alcohol or people whose lives are permanently blighted by mental illness
or homelessness. Maximizing utility leaves little space for rescue: but again much of the
health care provided by St Vincent‟s is done in the name of rescue, even when that is
inefficient. And who would argue with that? Think of the cost of rescuing Brant Webb and
Todd Russell after their 14 days and nights trapped the Beaconfield Gold Mine in Tasmania
in 2006. Mercy for those more vulnerable than ourselves, readiness to rescue, and the
character traits which go with both of them are worthy of cultivation: they preserve
individuals and communities and they express valuable social attitudes.18
Finally, (3) ,
when utilitarianism is combined either with John Locke‟s view of personhood or with
Hume‟s view of people as preference-satisfyers, then certain categories of people are likely
formally to drop out of consideration. Either way the decisions about how best to care for a
severely disabled newborn child, or about how best to care for someone who has lost, or
never had, the capacity to express preferences, is likely to depend on how other feel about
and towards them: the risk is that they themselves drop out of the category of beings who
count as our moral equals.
Well, as I said, the Pandemic guidelines do not express utilitarianism.
They use the
importance of healthcare need (“sick enough to require intensive care … but who are not so
sick that they will not recover even if they do receive intensive care”) and not value for
money of a treating one condition as against treating another. And they embody a proper
sense of the common good: it‟s not to be understood as the total value of the preferences of
17
One commentator has dubbed this „double jeopardy‟. „The first disaster leaves the patient with a poor quality
of life and when he or she comes forward for help, along come QALYs and finish him or her off!‟ J. Harris,
„Equality‟. In P. Byrne (ed) Health, Rights and Resources: King‟s College Studies 1987-1988. London: King
Edward‟s Hospital Fund for Children 1988:100-127, at 108. (as quoted in A. Fisher & L. Gormally, op cit:p.67
): „Instead of operating to the absolute benefit of the worst-off members of society, they operate to their
absolute detriment. For the worst-off members are those with the poorest quality of life coupled with the
poorest life expectancy.‟
18
The Good Samaritan does no utilitarian calculus before helping the man mugged and left for dead. He
displays spontaneous generosity, a merciful willingness to help in an emergency.
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all citizens but rather as the factor or set of factors which give reason for an individual to
collaborate with others and for them to collaborate with him.19
4
Conclusion:
In 1988, 21 years ago, Pellegrino and Thomasma began their book For the patient’s good:
the restoration of beneficence in health care with the following sentence: ‘Two major ethical
theories are today vying for dominance in medical ethics. The first, inherited from the
Enlightenment, stresses the liberty and autonomy of the individual. It gathers strength in the
nineteenth century in response to the depreciation of personal worth that accompanied the
Industrial Revolution. This theory grounds ethics in rights, duties and obligations. The
second theory stresses social utility rather than individual autonomy. Ironically it too gained
ascendancy during the Industrial Revolution to counter the social atomism of a purely
individualistic ethics.
This theory stresses social good, rules of conduct, and social
accountability.’20
Pellegrino and Thomasma were concerned about their distorting effect of these two values on
the doctor patient relationship.
Fisher and Gormally, whose work on this subject, is
mentioned in the footnote to those guidelines, were concerned with their distorting effect on
how we prioritize access to needed health care. In this talk I‟ve tried to show that these
concerns are more than ever justified, that we need to recover a proper understanding of the
meaning of (and proper limits to) respect for patient autonomy, and that we need to
appreciate what is wrong with a genuinely utilitarian approach to the allocation of health care
resources.
19
John Finnis, Natural Law and Natural Rights, Clarendon Press, Oxford, 1980, p 154
20
Edmund Pellegrino and David C Thomasma. For the patient’s good: the restoration of beneficence in health
care. Oxford University Press, New York, 1988, p3
For conferences participants only. Not to be quoted without permission of the author