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What is ethics? What is autonomy? Models of the healthprofessional-patient relationship What ought to be done in a given situation, all things considered? --Benjamin and Curtis What ought to be done... Action oriented Implies personal ownership and responsibility Implies choice Implies reasonable control …in a given situation... All ethics is “situation ethics” Concrete facts matter What makes one situation like another situation in ethically relevant ways? …all things considered? There is no “ethical point of view” distinct from other (“practical”) points of view Good ethical reasoning is not a new viewpoint but an integration (and critical analysis) of all existing viewpoints Can we ever in practice “consider all things” finally and irrevocably? (Provisional nature of ethical conclusion) What ought to be done in a given situation, all things considered? Is this the only “ethical” question? Snapshot ethics vs. Videotape ethics Snapshot vs. videotape What does it mean to do the right thing now? What does it mean to live a morally good life? Snapshot vs. videotape What does it mean to do the right thing now? Rules, What principles, case study does it mean to live a morally good life? Virtue (Respect for) Autonomy Not interfering in another’s wishes and choices Treat others as ends-in-themselves and not as means only (Kant) = Self-determination Assumes “adult” capacities Paternalism Refusing to acquiesce in another person’s wishes or choices for that person’s own benefit. --Childress Paternalism and Principles Paternalism = principle of benefit/harm takes priority over principle of autonomy Other, non-benefit-based reasons to reject autonomy not paternalism Is it “really” paternalism if principle of autonomy does not apply due to lack of capacity? Why paternalism and not parentalism? Is concept gender-specific? Does it derive from a gender-specific role? “Father Knows Best” (TV show, 1950’s) Paternalism and the history of U.S. medical ethics Hippocratic ethic: no challenge to physician paternalism 1960’s: traditional authority questioned Veatch: Contractual vs. priestly model of physician-patient relationship, 1972 Veatch, “generalization of expertise,” 1973 Paternalism and the history of U.S. medical ethics Much of U.S. medical ethics since the 1960’s amounts to the refutation of physician paternalism Autonomy: Problems to flag Is autonomy culturally specific? Is autonomy gender biased? Does autonomy favor some life stages over others? Does autonomy focus on individual in isolation rather than as member of family and community? Models of P-patient relationship Veatch, 1972: Priestly vs. Contractual models Miller, 1981: 4 senses of autonomy Emanuels, 1992: Paternalistic vs. Informative models-- and more Miller, 4 senses of autonomy Free action Authenticity Effective deliberation Moral reflection --Miller, Hastings Cen Rep 1981 Autonomy and Relationship Miller: Sense of Emanuels: Model of Autonomy Relationship Effective Deliberation Informative Authenticity Interpretive Moral reflection Deliberative Emanuels’ Models Informative Competent technical expert Interpretive Counselor or adviser Deliberative Teacher or friend If you went to your physician for medical care, what role would you want him or her to play, and why? Would it matter what the medical problem was?