Hostname: page-component-cd9895bd7-hc48f Total loading time: 0 Render date: 2024-12-26T09:44:13.946Z Has data issue: false hasContentIssue false
  • English
  • Français

Physician Value Neutrality: A Critique

Published online by Cambridge University Press:  01 January 2021

Francis J. Beckwith  and
John F. Peppin
Get access Rights & Permissions [Opens in a new window]

Extract

Although the notion of physician value neutrality (PVN) in medicine may be traced back to the writings of Sir William Osler, it is relatively new to medicine and medical ethics. We argue in this paper that how physician value neutrality (PVN) has been cashed out is often obscure and its defense not persuasive. In addition, we argue that the social/political implementation of neutrality, Political Liberalism (PL), fails, and thus, PVN's case is weakened, for PVN's justification relies largely on the reasoning undergirding PL. For these reasons, we conclude that PVN has no philosophical or ethical warrant and thus should be abandoned. We suggest that the physician present to her patients some type of statement or creed that would give them an idea of where she stands on important axiological issues and how these stands are cashed out clinically.

Type
Article
Information
Journal of Law, Medicine & Ethics , Volume 28 , Issue 1 , Spring 2000 , pp. 67 - 77
Copyright
Copyright © American Society of Law, Medicine and Ethics 2000

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Ackerman, B., Social Justice in the Liberal State. (New Haven: Yale University Press, 1980): At 11.Google Scholar
Sandel, M. J., Liberalism and the Limits of Justice (Cambridge: Cambridge University Press, 1982): At 1.Google Scholar
Ceccin, G., “Hypothesizing, Circularity, and Neutrality Revisited,” Family Process, 26, no.4 (1987): 405–413, at 405.Google Scholar
For those interested in a more detailed explication of the concept of value and valuation, see Frankena, W. K., “Value and Valuation.” in Edwards, P., eds., The Encyclopedia of Philosophy, vol 8 (New York, New York: Macmillian Publishing Co., Inc. 1969): 229–232.Google Scholar
Dougherty, C. J., “Ethical Values at Stake in Health Care Reform,” JAMA, 268, no. 17 (1992): 2409–2412.Google Scholar
See id. at 2409. Dougherty seems to miss the central focus of Judeo-Christian religious tradition, namely, God. From this tradition individuals have worth because they are created in the image of God and to have communion with God.Google Scholar
The term “worldview” will be taken to mean those values and beliefs that shape a physician's approach to moral and ethical concerns. Therefore, what a physician believes concerning God, human nature, and human community would establish how he or she might feel about abortion, euthanasia and many other moral issues.Google Scholar
Edell, D.S., “Acting for Patients,” JAMA, 269, no. 9 (1993): 1182, 1187.Google Scholar
Orentlicher, D., “The Illusion of Patient Choice in End-of-Life Decisions,” JAMA, 267, no. 15 (1992): 2101–2104, at 2101.Google Scholar
Miller, B.L., “Autonomy and the Refusal of Lifesaving Treatment,” in Gorovitz, S. Macklin, R. Jameton, A. L., eds., Moral Problems in Medicine, 2nd ed. (Englewood Cliffs, NJ: Prentice-Hall, 1983), 63–72, at 63.Google Scholar
Beauchamp, T.L. Childress, J.F., Principles of Biomedical Ethics. 3rd ed. (New York, New York: Oxford University Press, 1989): At 88.Google Scholar
See Rawls, J., Political Liberalism (New York: Columbia University Press, 1993); and Rawls, J., A Theory of Justice (Cambridge, MA: Harvard University Press, 1971).Google Scholar
Rawls, , Political Liberalism, supra note 12, at 22–28. Rawls' two principles of justice are: “a. Each person has an equal claim to a fully adequate scheme of basic rights and liberties, which scheme is compatible with the same scheme for all; and in this scheme the equal political liberties, and only those liberties, are to be guaranteed their fair value, b. Social and economic inequalities are to satisfy two conditions: First, they are to be attached to positions and offices open to all under conditions of fair equality of opportunity; and second, they are to be to the greatest benefit of the least advantaged members of society.” (Rawls, Political Liberalism, supra note 12 at 5–6).”Google Scholar
Rawls probably would not agree with our depiction of his view, for he considers his theory of justice to be deontological and not utilitarian or egoistic. He writes in one place that his principles of justice, like Immanuel Kant's, are categorical imperatives. (Rawls, , Theory of Justice, supra note 12, at 253). However, some scholars, such as: Sandel (supra note 2); Galston, W.A., Liberal Purposes (New York: Cambridge, 1991), Emanuel, E. (The Ends of Life (Cambridge, MA: Harvard University Press, 1991; Moreland, J.P., “Rawls and the Kantian Interpretation,” Simon Greenleaf Review of Law and Religion 8 (1988-89): 27–55); and Pavlischek, K., John Courtney Murray and the Dilemma of Religious Toleration (Kirksville, MO: Thomas Jefferson University Press, 1994): At 208–212, have made assessments of Rawls' theory which are similar to ours.Google Scholar
Rawls, , Political Liberalism, supra note 12, at 115.Google Scholar
Id., at 13.Google Scholar
See id., at 195–211. There are those to Rawls' political right, such as secular libertarians, who espouse state “neutrality” when it comes to questions of “the good.” For example, libertarian social philosopher Murrary Rothbard writes: “[W]hile the behavior of plants and at least the lower animals is determined by their biological nature or perhaps by their ‘instincts,’ the nature of man is such that each individual person must, in order to act, choose his own ends and employ his own means in order to attain them. Possessing no automatic instincts, each man must learn about himself and the world, use his mind to select values, learn about cause and effect, and act purposively to maintain himself and advance his life. … Since each individual must think, learn, value, and choose his or her ends and means in order to survive and flourish, the right of self-ownership gives man the right to perform these vital activities without being hampered and restricted by coercive molestation.” (emphasis added) (Rothbard, M. N., For a New Liberty: The Libertarian Manifesto, rev. ed. (San Francisco: Fox & Wilkes, 1978): At 28,29).Google Scholar
Rawls, , Political Liberalism, supra note 12, at xxviii.Google Scholar
Rawls, J., Political Liberalism, 2nd ed. (New York: Columbia University Press, 1996): At xiii. All references to Political Liberalism are to the first edition, supra note 12, unless indicated otherwise.Google Scholar
George, R.P., “Public Reason and Political Conflict: Abortion and Homosexuality,” Yale Law Journal 106, no. 8 (June 1997): 2475–2504, at 2477–2478.Google Scholar
Rawls, , Political Liberalism., supra note 12, at 10.Google Scholar
Rawls admits as much in his article, “The Idea of Public Reason Revisited,” University of Chicago Law Review 64 (Summer 1997): 765–807.Google Scholar
See, for example, Beckwith, F.J., Politically Correct Death: Answering the Argumens for Abortion Rights (Grand Rapids, MI: Baker, 1993); Lee, P., Abortion and Unborn Human Life (Washington DC: The Catholic University of America Press, 1996); Mitchell, J.A. Rae, S.B., “The Moral Status of Fetuses and Embryos,” in Stetson, B., ed., The Silent Subject: Reflections on the Unborn in American Culture (Wesport, CT: Greenwood, 1996): 19–32; George, R.P. Bradley, G.V., “Marriage and the Liberal Imagination,” Georgetown law Journal 84 (1995): 301–320; Coolidge, D.O., Same Sex Marriage?, Crossroads Monograph Series in Faith and Public Policy, vol. no. 9 (Wynnewood, PA: Crossroads, 1996); and Moreland, J.P. Rae, S.B., Body and Soul (Downers Grove, IL: InterVarsity Press, 2000)Google Scholar
See Dworkin, R., Life's Dominion: An Argument About Abortion, Euthanasia, and Freedom (New York: Alfred A. Knopf, 1993).Google Scholar
Dworkin, R., “When Is It Right to Die?,” New York Times, May 17, 1994, at A19.Google Scholar
Dworkin, R., “Abortion in Court,” in Taking Sides: Clashing Views on Controversial Political Issues, 9th ed., McKenna, George Feingold, Stanley (New York: McGraw-Hill, 1995): 66–271, at 270. This selection is excerpted from Dworkin's monograph, Life's Dominion, supra note 24.Google Scholar
Rosenberg, J.E. Towers, B., “The Practice of Empathy as a Prerequisite for Informed Consent,” Theoretical Medicine, 7, no.2 (1986): 181–194, at 182.Google Scholar
See, for example, Kuhn, T.S., The Structure of Scientific Revolutions, 2nd ed., (Chicago: The University of Chicago Press, 1970); Lakatos, I. Musgrave, A., eds., Criticism and Growth of Knowledge (Cambridge: Cambridge University Press, 1970); Laudan, L., Progress and Its Problems: Towards a Theory of Scientific Growth (Berkeley, CA: University of California Press, 1977); Laudan, L., Science and Values: An Essay on the Aims of Science and Their Role in Scientific Debate (Berkeley, CA: University of California Press, 1984); and Moreland, J.P., Christianity and the Nature of Science: A Philosophical Investigation (Grand Rapids, MI: Baker Book House, 1989)Google Scholar
See Kuhn, supra note 28.Google Scholar
Id., at 64.Google Scholar
Ratzsch, D., Philosophy of Science. (Downers Grove, IL: InterVarsity Press, 1986): At 66.Google Scholar
At least the effect of social values has a powerful impact on clinical practice. For example, “a surprising 85 percent of everyday medical treatments have never been scientifically validated.” Millenson, M. L., Demanding Medical Excellence (Chicago, Ill: The University of Chicago Press, 1997): At 4.Google Scholar
van Fraassen, B.C., The Scientific Image (Oxford: Clarendon Press, 1980): At 87–88.Google Scholar
Dorpat, T.L., “On Neutrality.” International Journal of Psychoanalytic Psychotherapy, 6 (1977): 39–64, at 50.Google Scholar
Cassell, E.J., The Nature of Suffering and The Goals of Medicine (New York: Oxford University Press, 1991): At 227.Google Scholar
Id., at 226.Google Scholar
Rosenberg, J.E. Towers, B., “The Practice of Empathy as a Prerequisite for Informed Consent,” Theoretical Medicine 7, no. 2 (1986): 181–194.Google Scholar
Osler, W., Equanimitas, 3rd ed. (Philadelphia: P. Blakiston's Son & Co., Inc., 1932): At 3–11; Osler, W., Aphorisms (New York: Henry Schuman, 1950): At 105.Google Scholar
Osler, supra note 38, at 93. It may not have been Osler's intention to help establish PVN as a dominante belief for patient-physician interactions. However, his work has helped foster PVN.Google Scholar
Dorpat, supra note 34, at 46.Google Scholar
Freud, S., Recommendations to Physicians Practicing Psycho-Analysis, Standard Edition, Vol. 12 (1912): At 109–120.Google Scholar
Mach, E., Popular Scientific Lectures, 5th ed., trans. McCormack, T. (La Salle, IL: Open Court, 1943).Google Scholar
Passmore, J., “Logical Positivism,” in Edwards, P., ed., The Encyclopedia of Philosophy, vol 5 (New York: Macmilliam, 1967): 52–57.Google Scholar
For a defense and presentation of the principle of respect for autonomy, see Beauchamp, Childress, supra note 11, at 67–119.Google Scholar
Coined by K. McDonnell at the 10th Medical Ethics Conference held at the University of Notre Dame, March 1994.Google Scholar
Roe v. Wade 410 U.S. 113, 159 (1973)Google Scholar
For a detailed critique of this argument, see Beckwith, F. J., “Ignorance of Fetal Personhood as a Justification of Abortion: A Critical Analysis,” in The Silent Subject, supra note 23, at 33–42.Google Scholar
Concerning the legal status of abortion in the United States, see the editors' introductory comments as well as the essays in part II of Pojman, L.P. Beckwith, F.J., eds., The Abortion Controversy 25 Years After Roe v. Wade: A Reader, 2nd ed. (Belmont, CA: Wadsworth, 1998)Google Scholar
Roe v. Wade 410 U.S. 113, 157–158 (1973)Google Scholar
Planned Parenthood v. Casey 505 U.S. 833, 851 (1992)Google Scholar
We believe this description was coined by Notre Dame law professor G.V. Bradley in his article, “Shall We Ratify the New Constitution?: The Judicial Manifesto in Casey and Lee,” in Eastland, T., ed., Benchmarks: Great Constitutional Controversies in the Supreme Court, (Washington, DC: Ethics & Public Policy Center / Grand Rapids, MI: Eerdmans, 1995): 117–140, at 123.Google Scholar
See, for example, id., at 117–140.Google Scholar
Not only religious and political values, in a general sense, are considered inappropriate, according to PVN proponents, but also specific positions on certain issues. For example, the American Medical Association favors a prochoice position on abortion, a position proposed as appropriate for the profession. (See Council on Ethical and Judicial Affairs, American Medical Association, Code of Medical Ethics: Current Opinions and Annotations [Chicago, IL: American Medical Association, 1997]: At 3). Yet, abortion is a controversial issue over which there is reasonable disagreement among well-meaning people. See, for example, the anthology edited by Pojman and Beckwith, supra note 48.Google Scholar
Council on Ethical and Judicial Affairs, supra note 53, at 67. Law, S.A., “Silent No More: Physicians' Legal and Ethical Obligations to Patients Seeking Abortions,” New York University Review of Law and Social Change 21 (1994–95): 279–321.Google Scholar
Council on Ethical and Judicial Affairs, supra note 53, at 67.Google Scholar
Law, supra note 54, at 315–21.Google Scholar
Id., 302. Planned Parenthood v. Casey, supra note 50, in contrast to earlier U.S. Supreme Court decisions (see City of Akron v. Akron Center for Reproductive Health, Inc., 462 U.S. 416 [1983] and Thornburgh v. American College of Obstetricians and Gynecologists, 476 U.S. 747 [1986]), allowed states greater freedom in passing informed consent laws that are intended to discourage pregnany termination. The Court, both in Akron and Thornburgh, struck down such laws as unconstitutional.Google Scholar
Law, supra note 54, at 302.Google Scholar
Id.Google Scholar
This is a distinction drawn by J.A. Shelly in her book with Miller, A.B., Values in Conflict, (Downers Grove, Ill: InterVarsity Press, 1991).Google Scholar
Of course not all members of a profession would have to agree on a given set of values. A majority, however, would embrace the set of professional values and “profess” them as appropriate behavior for members of that profession.Google Scholar
See Council on Ethical and Judicial Affairs, supra note 53, at 4–5.Google Scholar
Id., xxxix–xl.Google Scholar
Id., 126–29.Google Scholar
For a more in-depth defense of this reasoning, see Beckwith, F.J., “The Ethics of Referral Kickbacks and Self-Referral and the HMO Physician as Gatekeeper: An Ethical Analysis,” Journal of Social Philosophy 27, no. 3 (Winter 1996): 41–48.Google Scholar
Interestingly, some have argued that if patients were to smoke and drink more a tremendous amount of health care dollars could be saved. See, Wright, V.B., “Will Quitting Smoking help Medicare Solve its Financial Problems?” Inquiry 23, (1986): 76–82; and Leutwyler K., “The Price of Prevention,” Scientific American (April, 1995): 124–129.Google Scholar
Nicolosi, J., Reparative Therapy of Male Homosexuality: A New Clinical Approach. (Northvale, NJ: Jason Aronson, Inc., 1991); Socarides, C.W., Homosexuality: Psychoanalytic Therapy. 2nd ed., (Northvale, NJ: Jason Aronson, Inc., 1989); and Wolfe, C., ed., Homosexuality and American Public Life (Dallas: Spence Publishing, 1999).Google Scholar
For a defense of this claim, see George, supra note 20.Google Scholar
Hamel, M.B., “Patient Age and Decisions to Withhold Life-Sustaining Treatments From Seriously Ill, Hospitalized Adults; SUPPORT Investigators; Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment,” Annals of Internal Medicine 130.2 (1999): 116–25.Google Scholar
McCaffery, M. Ferrell, B.R., “Nurses' Knowledge of Pain Assessment and Management: How Much Progress Have We Made?” Journal of Pain Symptom Management 14.3 (1997): 175–188, at 177.Google Scholar
Sengstaken, E.A., “The Problem of Pain and Its Decisions Among Geriatric Nursing Home Residents,” Journal of the American Geriatric Society 41 (1993): 541–44.Google Scholar
Beyer, J.E. DeGood, D.E. Ashley, L.C., “Patterns of Postoperative Analgesic Use With Adults and Children Following Cardiac Surgery,” Pain 17 (1983): 71–81; and Levy, M. H., “Pharmacological Treatment of Cancer Pain,” N. Engl. J. Med. 335 (1996): 1124–1132.Google Scholar
See McCaffery, M. Pasero, C., Pain Control Manual, 2nd ed. (St. Louis: Mosby, 1999)Google Scholar
Evidence is legion that pain control has definite and critical medical advantages. See id.Google Scholar
Joranson, R., “State Medical Board Guidelines for Treatment of Intractable Pain,” American Pain Society Bulletin 5 (1995): 1–5.Google Scholar
Expressions of empathy, compassion, care, or sympathy are all extremely value laden. Removing values from the patient physician relationship seems of necessity to remove empathy and the like from the patient physician relationship. See, Peppin, J.F., “What is the Relationship between Physician Values and Physician Value Neutrality: A Christian Perspective,” in Kilner, J. Cameron, N. Schiedermayer, D., eds., Bioethics and the Future of Medicine: A Christian Appraisal (Grand Rapids MI: Eerdmans, 1995): 37–49. Although beyond the realm of this paper, it is interesting to speculate on studies correlating the lack of empathy with aggressive or antisocial behavior. See, Miller P.A. Eisenberg N., “The Relation of Empathy to Aggressive and Externalizing/Antisocial Behavior,” Psychological Bulletin 103, no. 3 (1988): 324–344.Google Scholar
American Law Institute, Restatement (Second) of the Law: Agency § 13 (1957): At 58Google Scholar
Dorpat, supra note 34, at 58.Google Scholar