11 Patients and Physicians — Core Values

You’ve been thinking about what good medical care looks like, both from the perspective of being a patient and from the perspective of physicians.

Let’s now step back and think more broadly about what the core values are that underlie both patient and provider perspectives on healthcare.

First, remember that core values are those things which are taken to be of highest value within a given area of human activity. It is these which that activity tries to protect and promote, and from which follow principles, rules, guidelines, and sometimes laws governing relevant actions and behavior. It is these values which therefore determine what rights and responsibilities people (individuals but also groups) have in that sphere.

Here’s a suggestion for what two core values lie at the heart of medical practice as we’ve been discussing it. There may be others, but I think most will readily agree that these must be among them.

1. Health:  health is the sound functioning of mind and body.
2. Autonomy:  autonomy is the ability to act and decide for oneself how to live one’s life. Autonomy comes in degrees, but we tend to assume that fully functioning adults are at least mostly autonomous.

Note that health is a foundational good, i.e. it is a good or value on which a lot of other goods we seek to acquire or achieve depend on it. If you are mentally or physically unhealthy, it gets in the way of your ability to do the things you want to do, which is to say, being unhealthy inhibits your ability to exercise your autonomy.

So, why think health and autonomy are core values of medicine?

It’s pretty obvious with health. When we as patients seek medical advice or treatment, it’s because we are trying to protect or improve our health or remedy damage to it. Likewise, what a medical professional tries to do for a patient who has sought care from them is, in most cases, to help that patient stay healthy or get healthier. (I say “in most cases” because there are exceptions. For instance, in situations of terminal illness, maintenance or improvement of health isn’t really an option. The goal becomes to help patients live as well as possible even as they are dying. You can think of that as an attempt to provide whatever level of health is possible relative to the situation.)

Autonomy’s status as a core value may be slightly less obvious, but there are (at least) two reasons to see it as having that status. First, as noted, health is a precondition for autonomy — less health typically means less autonomy. When we seek medical care, it’s often because we want to be free from physical or mental impediments that limit our ability to act and our ability to make decisions for ourselves. Thus, patients seek medical care for their health because they ultimately want autonomy, and caregivers give care to improve health in order to promote autonomy.

Second, patient autonomy is the basis for a number of core principles of physicians and other medical providers. For instance, the need for informed consent before treatment is a need to make sure that decisions for treatment are freely (autonomously) made by the patient. It is only when a patient’s autonomy is significantly or totally impaired (as in some traumatic emergencies, situations of mental impairment such as dementia, etc.) that a doctor may act on behalf of the patient without their consent.

And it’s not just patient autonomy that we’ve seen recognized as important, however. Physician autonomy is important, too. You’ll remember that among the AMA’s principles in its Code of Ethics is one that states that, unless it’s an emergency, a doctor should be allowed to decide when, where, and to whom to provide treatment. That’s to say that doctors should, for the most part, be able to decide for themselves, i.e., autonomously, when to offer medical care.

So, both patient autonomy and physician autonomy are important in medicine.

There’s another important concept that goes hand-in-hand with autonomy, which helps us think about how core values are realized in practice:

Respect: respect is the acknowledgement and recognition of the importance of another’s autonomy, and, more generally, of the value of their life, particularly the value it has for them.

If you are a physician, you show your patients respect by (among other things) making sure they are informed and consent to any treatment you give. In earlier versions of this class (and possibly in your posts about your own values as patients), many students, maybe the majority of them, stressed how important they felt it is for your medical providers to be kind and to listen to them. Those are also elements of respectful treatment. (It’s worth noting, though, that a few students said they don’t really care about this element of treatment, or at least the kindness part. All they cared about was whether the doctor could solve their medical problem, not how nice they were while doing it.)

I mentioned above rights and responsibilities. These are two concepts that we use to articulate what it is to be autonomous.

• Rights are moral/ethical or legal entitlements to act in a certain way or to obtain something for oneself.
• Responsibilities are moral/ethical or legal requirements to act in a certain way.

In general (there may be exceptions), if you are autonomous, you have the right to make decisions for yourself, and others have the responsibility to respect your decisions. But, as autonomous, you also have the responsibility  to respect others’ rights to exercise their own autonomy. Some of these rights and responsibilities are encoded in our laws, others are not.

This set of concepts — autonomy, respect, rights, responsibilities — has been explored and elaborated by a huge amount of Western moral/ethical and political thought over the last several centuries, and it is embedded both in our everyday life and in our constitutions and laws.

For instance, these concepts underlie the idea, so central to our society, that we should each have the freedom to live our lives as we see fit without undue interference from others, or, put slightly differently, that we should be free to do as we like so long as we do not impinge on others’ doing the same.

A last observation: most of the emphasis in the AMA Code is on the physician-patient relationship, and what it ethically requires of physicians. This is mirrored by the fact that, when we go to see a doctor or other medical provider, usually we are interested in helping ourselves, or perhaps someone close to us whom we are assisting. The main values in all of this are thus ones that are centered on the individual. This fits with the idea that the value of individual freedom or autonomy so central to our society shapes the values governing medical treatment.

But: individuals only live as parts of communities and societies. Ultimately, to think about ethics we need to think about how individuals are part of larger social wholes. This is reflected to some extent in the attention the AMA Code of Ethics gives  to physicians’ responsibilities that go beyond those they have to their individual patients and to the public more generally.

If we really take seriously the fact that individuals, even autonomous individuals, only exist in societies and in concrete relationships with other individuals, all sorts of very hard ethical (and ultimately political) questions arise.

One such question of contemporary relevance in the U.S. is this: If health is a foundational good, and we can’t be autonomous and live our lives well without it, does everyone have a right to adequate healthcare?

To help think about that, consider these two situations:

Suppose that, as a result of someone’s risky, careless, or poor choices, they find themselves in need of medical care (e.g., a motorcyclist riding without a helmet who sustains a head injury in an accident that a helmet would have prevented, or a drug addict who started out as a recreational user). What obligation is there for others to provide it? Does it matter whether the person in need of care has the resources to pay for it?

Suppose that someone has a debilitating condition that they cannot be held responsible for, such as a  genetically caused illness or a condition resulting from environmental pollution (asthma, lead poisoning, cancer, etc.). Does that change whether that person has a right to receive medical treatment? What if they lack the resources to be able to pay for it?

Related to both of these is another more general question: suppose there are limited resources for medical care — how should they be allocated? Who should get them and who shouldn’t?

There are many more questions along these lines that can be asked, but these give you a sense of how we need to broaden our focus from the individual to the individual within society when we think about ethical or moral matters.

And these are obviously difficult questions, ones which people disagree very strongly about in our society. Here the goal is not to try to resolve them, but to understand first of all that they are evaluative questions (answers to them reflect the values of those giving the answers), and to understand the various core ethical concepts that shape them.