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A Critique of Traditional Relationship Models

Published online by Cambridge University Press:  29 July 2009

Roberta Springer Loewy
Roberta Springer Loewy
Affiliation:
A Ph.D. candidate in the Philosophy Department and a Teaching Associate in the Medical Humanities Program, Loyola University of Chicago
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Extract

Today's ever-widening expert/novice gap–in technology generally but in healthcare technology especially–has been implicated as both cause and consequence of a sharp rise in fundamental misunderstandings between medical professionals and lay populace. Recently created social roles (e.g., clinical medical ethicists) and institutions (e.g., hospital ethics committees) have further prompted critics to suggest that a multiplication of “disinterested” experts not only fails to resolve such misunderstandings, it compounds them. As a result, it should come as no surprise that the problem of paternalistic expertise has emerged as an ethical issue of immense interest from both a theoretical and practical standpoint. For this reason, a critical inquiry in healthcare today centers on finding a practical model that most adequately and accurately characterizes patient–physician relationships.

Type
Special Section: Healthcare Relationships: Ties that Bind
Information
Cambridge Quarterly of Healthcare Ethics , Volume 3 , Issue 1 , Winter 1994 , pp. 27 - 37
Copyright
Copyright © Cambridge University Press 1994

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References

Notes

1. The earliest I found was Szasz, TS, Hollender, MH. A contribution to the philosophy of medicine: the basic models of the doctor-patient relationship. Archives of Internal Medicine 1956;97:585–92CrossRefGoogle Scholar, though the “classic” work most familiar to healthcare ethicists begins with Veatch, RM. Models for ethical medicine in a revolutionary age. Hastings Center Report 1972;2(06):5–7.CrossRefGoogle Scholar Alternative accounts are either presented or summarized in the following works: Pellegrino, ED, Thomasma, DC. A Philosophical Basis of Medical Practice. New York: Oxford University Press, 1981;Google ScholarEngelhardt, HT Jr. The Foundations of Bioethics. New York: Oxford University Press, 1986;Google ScholarBrody, B. Life and Death Decision Making. New York: Oxford University Press, 1988;Google ScholarGraber, GC, Thomasma, DC. Theory and Practice in Medical Ethics. New York: Continuum, 1989. My description of beneficence-based and autonomy-based models is loosely based on numerous such distinctions in the literature for the last 20 years or more.Google Scholar

2. For example, Dewey, J. Logical conditions for a scientific treatment of morality. In: Boydston, JA, ed. John Dewey: The Middle Works, 1899–1924. Vol. 3. Carbondale: Southern Illinois University Press, 1903:3–39;Google Scholar and Dewey, J. Reconstruction in philosophy. In: Boydston, JA, ed. John Dewey: The Middle Works, 1899–1924. Vol. 12. Carbondale: Southern Illinois University Press, 1920:77–201.Google Scholar

3. The most stalwart defender of the philosophical basis of the commercial model in general is, of course, Nozick, Robert: Anarchy, State, and Utopia. New York: Basic Books, 1974.Google Scholar For the model's defense specifically in the context of medicine, see note 1. Engelhardt, . 1986.Google Scholar For the original statement of its thesis, see Engelhardt, HT JrBioethics in pluralist societies. Perspectives in Biology and Medicine 1982;26:64–78.CrossRefGoogle ScholarPubMed

4. The philosophical position that denies the possibility of such a radical conception of the individual as an isolated, self-contained entity capable of the objective determination of its situation is not new, but is especially prominent in the works of Hegel, Marx, Freud, Heidegger, virtually all of the pragmatists (though chiefly Mead and Dewey), and most recently critical theorists of various stripes.

5. I have developed a sustained argument for this distinction in an earlier unpublished paper entitled “Ignoring unmet needs: unraveling the knitted sleave of care.” Also see a more recent article from a similar perspective, but specifically related to healthcare: Loewy, EH. Commodities, needs and health care: a communal perspective. In: Jensen, U, Mooney, G, eds. Changing Values in Medicine and Health Care Decision-making. London: John Wiley and Sons, 1990.Google Scholar

6. Kant, I. Foundations of the Metaphysics of Morals. Indianapolis, Indiana: Bobbs-Merrill Educational Publishing, 1978:47.Google Scholar

7. My discussion of responsibility for the weak was prompted by a similar characterization of it in Jensen, UJ. Are selves real? In: Shaskar, R, ed. Harre and His Critics. Oxford, England: Basic Blackwell, 1990.Google Scholar

8. Because John Dewey believed all ethics is essentially social, see any of the vast number of his writings in ethics –but, perhaps, especially Dewey, J. Human nature and conduct: an introduction to social psychology. In: Boydston, JA, ed. John Dewey: The Middle Works, 1899–1924. Vol. 14. Carbondale: Southern Illinois University Press, 1988Google Scholar. Dewey, J. The public and its problems. In: Boydston, JA, ed. John Dewey: The Later Works, 1925–53. Vol. 2. Carbondale: Southern Illinois University Press, 1988Google Scholar. Dewey, J. Individualism, old and new. In: Boydston, JA, ed. John Dewey: The Later Works, 1925–1953. Vol. 5. Carbondale: Southern Illinois University Press, 1988.Google Scholar

9. Habermas, J. Moral Consciousness and Communicative Action [translated by Lenhardt, Christian and Nicholsen, Sherry Weber, introduction by Thomas McCarthy]. Cambridge, Massachusetts: MIT Press, 1990. See especially the chapter bearing the same title, which begins on page 116.Google Scholar

10. Dewey, J. Logic: the theory of inquiry. In: Boydston, JA, ed. John Dewey: The Later Works, 1925–1953. Vol. 12. Carbondale: Southern Illinois University Press, 1991:32–4.Google Scholar

11. See note 8. Dewey, . 1988;14:175.Google Scholar

12. Miller, DL. George Herbert Mead: Self, Language, and the World. Austin: University of Texas Press, 1973;chapter 3.Google Scholar

13. For a fuller explication of what Dewey was up to just before his death, see Rucker, D. Selves into persons: another legacy from John Dewey. Rice University Studies 1980;66(4). He discusses an ideain one of Dewey's unpublished manuscripts, “Things and Persons”: “To possess and exercise an office is to be representative, and the history of development of offices, or representative functions, is the history of transfer of biological traits into traits constituting persons.”Google Scholar

14. See note 10. Dewey, . 1988;12:108.Google Scholar

15. Habermas, J. Moral Consciousness and Communicative Action. Cambridge, Massachusetts: MIT Press, 1990:88–9.Google Scholar

16. Dewey, J. The quest for certainty. In: Boydston, JA, ed. John Dewey: The Later Works 1925–1953. Vol. 4. Carbondale: Southern Illinois University Press, 1988:224–5.Google Scholar

17. See note 6. Kant, . 1978:47.Google Scholar