Philosophy Compass 4 (2009): 10.1111/j.1747-9991.2008.00190.

Back to Basics in Bioethics: Reconciling Patient Autonomy with Physician Responsibility

Antonio Casado da Rocha*
University of the Basque Country

Abstract

Although bioethics is a lively and expanding interdisciplinary field, there is not enough research about the patient-doctor relationship, a central issue in philosophy of medicine. This article surveys the state of the field, paying attention to recent work by Alfred Tauber, and supplementing it with insights from Hans Jonass philosophy of technology in order to propose a principle of responsible autonomy for health care. Based on a comparative look across different sub-fields in bioethics, the resulting model claims that physician responsibility is essential to professional integrity, providing an alternative to other active trends emphasizing patient autonomy, such as Robert Veatchs contractual model.

1. Introduction According to prominent bioethicists such as Peter Singer, Edmund Pellegrino, and Mark Siegler, the major contribution to the philosophical foundations of clinical ethics has been the continued refinement of Principles of Biomedical Ethics, by Tom Beauchamp and James Childress (originally published in 1979; sixth edition, 2008). However, after more than 20 years of clinical ethics those authors acknowledge that its main focus of interest the doctor-patient relationship is in worse shape than it was when the field began (Singer, Pellegrino, and Siegler). The doctor-patient relationship describes the interactions between these two players and shows huge divergences across different cultures and societies, but a main theme in the literature about it during the 1990s in the USA was that of bureaucratization by managed care, a problematic attempt of health service modernization that has been reflected in other countries, such as the UK (Degeling et al.). A relationship which used to be a personal one is now dominated by medical technologies and bureaucratic procedures. As a result, patients and health care professionals have become strangers at the bedside, to use the title of David Rothmans classic book about this subject. If Singer, Pellegrino, and Siegler are correct in their diagnosis, it is ironic (and worrisome) that the doctor-patient relationship is deteriorating
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at a time when the field of bioethics has experienced an impressive progress, both socially and academically. Of course, bioethicists are aware of this situation, and have often framed it as a debate over whose values ought to guide the doctor-patient relationship. Some authors argue that we have entered a postmodern era, in which the patients own values play a robust role in framing accounts of medicine (Veatch, How Philosophy of Medicine Has Changed Medical Ethics; Engelhardt, Garrett, and Jotterand 566), but there is still a lively discussion about what should be the central paradigm upon which medical bioethics is based. Philosophy textbooks typically treat bioethics as a form of applied ethics an attempt to apply a given ethical theory to controversial moral issues in biology and medicine. However, this view has been criticized on several fronts (Baker and McCullogh), generally by arguing that in bioethics there is a bidirectional, dynamic process of appropriation or exchange between theory and practice. After all, many important authors in this field have combined careers in medicine and philosophy. This is the case with Alfred Tauber, born in 1947, who has published widely in the intersection of these fields. In his award-winning book Confessions of a Medicine Man (1999), he rejects the idea of medical ethics usually understood as applied ethics, as a tool to clarify the responsibilities of health care professionals, now complicated by amazing technological developments in the science of curing. He is more deeply interested in medicine becoming more self-consciously moral (93), and in providing a sketch of a philosophy of medicine true to its intrinsically ethical nature what he calls a moral epistemology and has developed in his book Patient Autonomy and the Ethics of Responsibility (2005). While the history of the doctor-patient relationship has often been read as a successful battle for patient autonomy and against medical paternalism couched as beneficence, attempts to curb autonomys expansion as the hegemonic value in bioethics are being mounted today, not only in America but also in Europe. We have, for instance, Onora ONeills emphasis upon trust and beneficence as opposed to autonomy, and the more recent effort by Margaret Brazier to dethrone the great god Autonomy by arguing that patients should bear responsibilities as well as rights. Those are attempts to maintain professional integrity in the face of moves towards a medical consumerism which threatens to reduce clinicians to technicians, and to render medical ethics otiose (Brazier 398, 420). So there seems to be a divorce, an increasing gap, between patient autonomy and an ethics of responsibility. Should there be reconciliation? To date, there is little literature on the concept of responsibility in bioethics (see Turoldo and Barilan for a comprehensive account of its development). By drawing mainly on Taubers two books on this issue, the following sections will summarize his argument that the principle of respect for autonomy one of the four principles popularized by Beauchamp and Childress cannot be divorced from the responsibility health care professionals
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assume in the care of the patient, and that patient autonomy often does (and ought to) give way to other principles present in biomedical ethics, such as beneficence. But first let us have a look at how the separation took place. 2. Autonomy and Responsibility: Anatomy of a Divorce Traditional ethics stressed responsibilities toward others in small societies governed by a given communal morality, but this changed in 18th-century Europe. Kants philosophy can be seen as a response to the moral philosophy of the preceding two centuries by unfolding the central notion of morality as self-governance. According to Schneewind, the history of modern moral philosophy culminates in the invention of this idea of autonomy, in which rational beings are subject to a moral law because it derives from them. For autonomy to become the flagship of modern ethics, traditional sources of authority had to recede. And indeed this happened in 19thcentury America and Europe, as exemplified by the philosophy of Emerson and Nietzsche, respectively. The former became a conduit of Protestant theology into a nonsectarian world, offering a rich template for defining personal identity with a particular emphasis on self-responsibility, understood as self-reliance, self-direction, and authenticity (Tauber, Patient Autonomy 93). The latter denounced traditional Christian ethics as masks of illusion, exposing the treachery of belief in a stable and universal morality out there, and sought to replace it with a comprehensive self-responsibility, the nihilistic assertion that the self resides in, and of, and by itself (Tauber, Confessions of a Medicine Man 37). Because autonomy was then associated with individualism, moral responsibility became a one-person business. Thus in the 19th century a split was formed in the way we understand our selves: on one side, independence and autonomy; on the other, relation and responsibility. Because autonomy was central to modern ethics, responsibility was marginalized, and so the ethical nature of our responsibilities toward others. Of course, this change had consequences in the way health care ethics was conceived of. In the old days, fathers of Anglo-American medical ethics such as Gregory, Percival, and Rush, embraced the Scottish enlightenment notions of self-improvement as central to their profession and self-image, so when they identified as part of a profession, they did so with a strong leaning toward individual responsibility for others, toward the community at large, and, of course, toward God (Tauber, Patient Autonomy 69). As a result, no unique code of professional ethics was required for medicine until the end of the 18th century. This situation dramatically changed in the 20th century. As the influence of clergymen waned, reliance on medical technology increased and patients trust in doctors steadily declined. Modern medicine became defined by specialization, rapid technological advance, and a profit-driven industry
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(Imber), not by a particular type of relationship or professional responsibility. By the late 1960s and early 1970s bioethics was born and legitimated in and by North American institutions; the Tuskegee scandal, the Karen Quinlan case, and the Roe v. Wade decision are some of the main events that pushed autonomy to the fore in this period, which witnessed a radicalization of health-related rights and political issues, and extended the legal domain of personal moral choice. In the following decades, corporate interests benefited the most from the increased sophistication of medical consumers who insist on exercising their autonomy, as Jonathan Moreno put it (Triumph of Autonomy 41618). In the early 1990s, a doctor observed that the health care relationship is usually understood as a relation between citizens in the liberal state, and therefore it is not adequate to expect from its morality anything more than a simple contract between two autonomous people (qtd. in Imber 14). At the beginning of the 21st century, the hegemony of individual autonomy is asserted in all domains of American society. The concept of autonomy occupies today a central role in the legal and ethical frameworks governing clinical practice, particularly but not exclusively in the context of western health care (Slowther). Although Beauchamp and Childress did not postulate a hierarchy of principles, some authors have described autonomy as first among equals (Gillon). 3. The Present Paradigm: Factual Commercialized Health Care What is the problem with individual autonomy? After all, leading bioethicists such as Robert Veach (Patient-Physician Relation) see nothing wrong with it, arguing that bioethics should adapt to our individualist ethos by embracing a contractual model in which all parties have an equal standing. On the contrary side, Tauber suggests that the cultural hegemony of individualistic autonomy is especially problematic when introduced in the health care relationship. The reason why is that self-sufficient independence promotes self-reliance over relationship, and thus the idealized autonomous person forfeits trust, friendship, loyalty, caring, and responsibility as secondary attributes to those primary values of self-direction, self-determination, and self-realization (Patient Autonomy 118). In other words, the typically Nietzschean disregard for others is not acceptable as a foundation for health care ethics, because its positive ethic of self-responsibility and self-realization can easily tip over into selfishness, autocracy, and self-consuming narcissism (Tauber, Confessions of a Medicine Man 41). Of course, there is a positive side to the ethics of autonomy: it provides a sense of empowerment in terms of political rights. But Tauber reminds us of the negative one as well: because autonomy-based moral systems emphasize individual responsibility for ones health, and because disease destabilizes our sense of self, being ill can be regarded as a negative judgment, as a stigma. On the other hand, in a prevailing communal ethos the focus is on reciprocity of care.
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Individual autonomy is a bad model for health care ethics because its contractual underpinnings induce us not to acknowledge the deeply inequality of the power relationship between physician and patient (Tauber, Confessions of a Medicine Man 47; Patient Autonomy 126). This general problem expresses itself in many ways. As it will be immediately explained, it models a way of looking at medicine that sees it as a business dealing mainly with facts, or with facts as something radically separated from values, and generates mistrust both in the patient and in the professional. And, as it will be explained in the next section, it promotes an understanding of informed consent as a merely legal safeguard, emptying medical practice of its intrinsically moral character. The autonomist model has dominated bioethics through legal and commercial interpretations one focused on rights, the other on market forces requiring free choice of purchase. As for the first one, the Quinlan case of 1975 represented a critique of traditional medical ethics, by establishing that physicians were authoritative about medical facts, but not necessarily expert or autonomous regarding moral values. This case held that decisions concerning medical care were situated firmly within the patients autonomous domain, and scientific expertise could not be extended beyond its proper quarter (Tauber, Confessions of a Medicine Man 223), i.e., that of facts. But this merely factual, detached attitude of the physician qua natural scientist prevents a comprehensive understanding of the whole person, and without that engagement, according to Tauber (Patient Autonomy 192), physicians neglect their full moral responsibility. As for the second one, patients have become consumers and doctors providers of health care:
The purchase of care, the contractual agreement framing that commercial arrangement, and the resulting defensive autonomy adopted by the client are all products of a basic shift in the doctor-patient relationship from one dominated by a sense of personal commitment to a more distant and circumspect delivery of service. (159)

This commercial medical economy often has demands that go against an ethics of responsibility, thus creating mistrust. Patient autonomy has assumed a defensive character as patients increasingly wonder, Will my doctor do what is best for me? An ethics of responsibility is needed as a foundation for the trust/mistrust phenomenon, which itself is a psychological or social product of moral engagement and, as we will see now, plays a crucial role in the health care relationship between patient and professional (181, 1612, 171). 4. Mistrust and Informed Consent as Defensive Practices Informed consent is generally seen as an exercise of patient autonomy, embedding their responsibility for making the delegated choices. Indeed, informed consent is an important practice in contemporary medicine, one which has improved the ethical standards of good medical practice, but
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also one that has shifted responsibility to the patient, thus offering the physician a strong defense or protection against malpractice suits. Tauber is particularly dissatisfied with how it has become a stopgap measure to protect against abuses of trust (Patient Autonomy 134, 60, 126). After all, the oft-quoted notion of effective consent is mainly a legal one, and in practice it often amounts to the mere signing of an informed consent form. It does not necessarily protect patient autonomy, as it might simply be a way to address the institutions legal obligations and therefore protect it against malpractice suits. Consequently, the patients intentions and understanding remain the keystone of the consent process, and the responsibility for almost every choice remains theirs. Mistrust goes both ways: according to Tauber, when patients do not trust physicians, the later lose the ethical grounding in their profession. If health care professionals identify themselves as health scientists, administrators, providers, or technocrats, they become so estranged from their patients that they must self-consciously seek guidance, directives, orders, and shared responsibilities to practice ethically; hence the institutional growth of medical ethics programs could actually be a sign that something is going wrong in the way medicine is practiced: the basic intuition of care as part and parcel of the health care professions is lost. In this respect, Tauber finds it telling that
a patients legal recourse is almost always channeled through charges of negligence, not through fiduciary responsibility, as this reveals that the law recognizes the weakness of moral responsibility as a guiding ethos for the doctor-patient relationship. (Confessions of a Medicine Man 101)

Autonomy is also a double-way street: true patient autonomy requires self-responsibility, but not only that it requires physician responsibility as well. If there is a conflict between patient and physician, generally patient wishes must override other opinion. But physician responsibility remains whatever degrees of patient autonomy are exercised (Tauber, Confessions of a Medicine Man 68; Patient Autonomy 13840). What, then, does physician responsibility entail? In the following section, we will see how responsibility should move professionals to recognize asymmetry in the health care relationship, thus abandoning the contractual model; to integrate fact and value in a moral epistemology; to include compassion and empathy in the interaction with the patient; to understand care as an opportunity for professional fulfillment, and autonomy as a quest for self-knowledge and for reflective equilibrium between moral principles not as an exclusive, hegemonic principle, as it is sometimes pictured today. 5. Towards Relational Autonomy: Asymmetry, Care, and Self-Fulfillment Still recommended by some bioethicists as a partnership grounded in a complex contractual relation of mutual promising and commitment,
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covenant medical ethics (also known as the contract model) relies on notions such as moral equality between the partners, fidelity to promises made, and a sense that the parties are autonomous agents capable of pledging and fulfilling pledges (Veatch, Patient-Physician Relation 3, 38). This way of looking at the health care relationship stresses the features that both patients and physicians might equally have, and is therefore symmetrical. Tauber agrees that the physicians expertise grants no moral superiority, but argues that there is no equality or parity between the roles of the healer and the ill. Doctors have superior knowledge in their field of practice after all, this is what made them doctors in the first place and their moral responsibility is to exercise it in the effort to restore patient autonomy. As a matter of fact, most health care relationships are initiated by this very inequality or asymmetry. We all generally value our autonomy, but to be ill is already to admit that our selfhood has been compromised. Patients enter into a relation with health care professionals not as equals, because they do so precisely in the hope of regaining or improving their lost autonomy and equality. This explains why the guidance model is most typical and more adequate than the contract model. The disparity in expertise and the consequent compromise of patient autonomy for the sake of regaining health drive patients to delegate much decision making in the hands of the professional. In the guidance-cooperative model, professional dominance takes precedence in a process in which the patient is also offered input, but still most patients, realistically and appropriately, want the doctor to take responsibility for their health (Tauber, Patient Autonomy 623). Tauber does not want to substitute science with morals rather, he claims that in the case of medicine they cannot be separated, and that health care demands full attention to both domains. What is needed is a different way of conceptualizing autonomy, one in which relational aspects of health care (such as empathy) are included. In turn this makes it possible to reintroduce responsibility into medicine, humanizing it, and providing self-fulfillment to those involved in it. By assuming responsibility for care, doctor and nurse complete their individual identity. However, this activity is more difficult for the former than for the latter. In contrast with that of doctors, the care provided by nurses is more intimate. In addition, traditionally nurses have had fewer responsibilities competing with those private acts of personalized attention which constitute the primary interpersonal encounter with their patients. (That is why we are particularly shocked when nurses distance themselves from the patient; see Tauber, Confessions of a Medicine Man 128 9). In other words, the awesome responsibility of being a doctor is not something external or imposed to their professional identity. Care and responsibility define what to be a doctor is, and their exercise must be regarded as the fulfillment of any health care professionals aspirations.
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In general, all health care professionals are defined by this responsibility (74, 117). Tauber claims that in the medical scenario the other is given as the object of care (105). Physician responsibility, as the answer elicited by the object of care, is thus construed as primary, even pre-reflective. On the other hand, patient responsibility does not need to be this automatic; on the contrary, it is by means of deliberation, by the weighing of alternatives, that persons assume responsibility for their choices and actions and thereby enact their autonomy: The act of reflection, the quest for self-knowledge that will balance rational and emotional forces, often represents the exercise of autonomy (Tauber, Patient Autonomy 201). Relational autonomy is a result, not a starting point in health care ethics, and it is intrinsically deliberative: it does not expect or deserve automatic respect for its demands. Rather, it must take into account other moral principles, and sometimes give way to them. It is the only means for individuals to be authentically autonomous: in Taubers way of understanding the self as a confluence of relationships and social obligations that are constitutive of identity, respect for autonomy may legitimately be subordinated to other moral principles that determine how the self is governed within a social context (85). Thus his notion of selfhood and autonomy allows for a balance of rights and responsibilities consistent with the deeper moral agenda of an ethics of care. To summarize, let us now remember the three basic precepts of Taubers ethics of responsibility (Confessions of a Medicine Man 11217). First, the health care relationship is already given, a priori, as one of responsibility, and this sense must emanate from compassion. Second, health care ethics must acknowledge the primacy of trust, wherein the patient abdicates a portion of her autonomy. Third, in a health care context, the relationship between self and other is radically nonsymmetrical. In the following section, I will supplement and illustrate this position with that of Hans Jonas (190393) in order to provide a more comprehensive sketch of the ethics of responsibility. 6. The Principle of Responsible Autonomy Jonas is considered as a philosopher of biology and of technology, not a bioethicist at least not in the restricted sense that identifies it as a subfield of ethics applied to medicine. However, his position is quite in tune with the historical origins of bioethics, with its more general concerns about the consequences of new technologies on human life. After all, V. R. Potters original coinage of the term bioethics in 1970 referred to a bridge between science and the humanities, as a global integration of biology and values, designed to guide human survival (Whitehouse). In one of his main works, Das Prinzip Verantwortung the principle or imperative of responsibility Jonas attempts to consider the global
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condition of human life after modern technology has introduced possibilities to act of such novel scale that traditional ethics can no longer provide a basic framework of principles (Imperative of Responsibility 68). He then argues that the enlargements of human power through technology carry with them expansions of human moral responsibility. This basic thesis is grounded on three general conditions of responsibility: causal power (that is, that acting makes an impact on the world), that such acting is under the agents control, and that the agent can foresee its consequences to some extent. Under these necessary conditions, responsibility appears in two senses: first, responsibility as being accountable for ones deeds, whatever they are; and second, responsibility for particular objects that commits an agent to particular deeds concerning them. We speak then of two different things when we say that a physician is responsible for what happened to a given patient and that a given person is a responsible physician, that is, someone who honors his or her professional responsibilities (90). Jonas calls the first formal responsibility, and the second substantive responsibility. Formal responsibility concerns actions of the past, the caused damage or other consequences of the action, even if they were not intentioned or foreseeable; it is linked with basic notions in civil and criminal law such as compensation or penalty. On the other hand, substantive responsibility tends toward the future, toward the things to be done and the object of responsibility:
Here, the for of being responsible is obviously distinct from that in the purely self-related [formal] sense. The what for lies outside me, but in the effective range of my power, in need of it or threatened by it. (92)

Here lies a first point of contact with our previous discussion. The shrinking of responsibility found by Tauber in the social and cultural movements associated with the birth and development of bioethics could be understood as a replacement of substantive with formal responsibility. Relational autonomy brings about substantive responsibility, while individualistic autonomy favors the formal sense of the word. If this is correct, Jonass characterization of substantive responsibility could provide elements for a better understanding of relational autonomy. For him, the archetype of substantive responsibility is that of parents for their children: it is in this relationship to dependent progeny that Jonas finds the origin of the idea of responsibility in general. This kind of responsibility is basically one-sided (39), that is, asymmetrical, which again is another point of contact with physician responsibility. This archetype provides another interesting analogy between the parental and the health care relationship. Child-rearing, writes Jonas, has a definite substantive goal: the autonomy of the individual, which essentially includes a capacity for responsibility, and with reaching it also a definite termination in time: Parental responsibility has maturity for its goal and
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terminates with it (108). It could be said, in the same way, that physician responsibility has the patients health for its goal and terminates with it. According to Jonas, the power of the acting agent (or subject) over the object gives an objective meaning to responsibility, which in ideal cases is complemented by a subjective emotional commitment, the sentiment of responsibility. This sentiment does not originate from the idea of responsibility, but from the rights and needs of the object of responsibility as we perceive them. The ought-to-be of the object calls the subject to responsible and caring action. Thus the object of responsibility is submitted to the subject, but the actions of the subject are controlled by the needs of the object. This is also echoed in Taubers ethics of responsibility (Patient Autonomy 123), in which response to need guides the physicians actions. Finally, Jonas interprets substantive responsibility as a nonreciprocal relation in which the agents power is there to begin with, it is natural. On the other hand, formal responsibility is mostly a contractual relationship of equal partners, and somewhat secondary to the substantive one:
Evidently, in moral (as distinct from legal) status, the natural is the stronger, if less defined, sort of responsibility, and what is more, it is the original from which any other responsibility ultimately derives its more or less contingent validity. This is to say, if there were no responsibility by nature there could be none by contract. (95)

This naturalness of substantive responsibility entails that, in parental relationships, the principle of responsibility requires no deduction from a previous or more general principle, because it is powerfully implanted in us by nature or at least in the childbearing part of humanity (39). Paraphrasing Jonas, it could be said the same about the health care relationship: the principle of responsibility is not reducible to a more general principle, since it is implanted in the very professional identity of the health care professionals. This use of the parental archetype might lead us to think that Jonass and Taubers ethics of responsibility are intrinsically paternalistic. The analogy with child-rearing certainly suggests so, but that is not the only comparison Jonas uses to describe this concept. He finds another example of responsibility in the real statesman, that who has acted for the good of those over whom he had power, that is, for whom he had it. The same could be said of the responsible physician: that the paternalistic power over patients becomes a responsibility to care for them sums up, according to Jonas, the essence of responsibility (96). 7. Conclusion This review of the most recent literature concerning the relationship of autonomy and responsibility in the clinical context found only one study
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(Degeling et al.) explicitly arguing that, to break their destructive antagonism over issues of health service modernization, doctors and managers should engage more directly with nurses and other health professionals when responding to reform initiatives. Enlarging its argument, and drawing upon the already described Tauber-Jonas model, this article proposes that only by re-establishing responsible autonomy as the primary organizing principle of clinical work can patients and professionals strike a balance between the conflicting ethical demands of health care. A crucial feature of the Tauber-Jonas model for an ethics of responsibility is that it does not rely on the fact/value dichotomy. Quite on the contrary, Tauber recognizes as a fact that physicians are constantly making value judgments
ranging from interpretations of data, to choosing a clinical strategy, to forming relationships with patients and hospital personnel. In a broad sense these choices are ordered by ethics the ethics of care, of professional integrity, of personal belief. And underlying each of these ethical structures is an ethics of responsibility. By this I mean that physician identity, irrespective of all the other contending personas, is formed in response to the physicians obligation to the patient. (Patient Autonomy 175)

In the health care relationship, facts are not previous to or independent from ethics, from values. This blurring of the fact/value distinction might be associated with a holistic, biopsychosocial approach to health and disease. This approach attempts to address elements of personhood that have no firm and delineated objective basis the social, the emotional, the moral because the organism is an integrated, functioning whole, and therefore medicine should be holistic in orientation. Even though a fact-driven clinical science has prevailed as medicines dominant ethos, the biopsychosocial approach has been widely adopted by primary care providers. The reason for the prevalence of the factual paradigm, George Khushf (20) argues, is that modern medicine involves a thought style that presupposes at multiple levels the fact/value dichotomy; in their everyday practice, most doctors think that they deal primarily with clinical facts, upon which decisions concerning values are to be subsequently made; those facts are biological function statements susceptible to descriptive analysis, and therefore not value-laden. But this allegedly value-free concept of health, in which clinical science has no underlying moral agenda, makes it impossible to properly understand central concepts in health care such as that of need. Health care needs are complex concepts, construed in a process of evaluations over time which inextricably combines facts and values. As a result, the aspiration to rigidly separate the factual and the evaluative collapses when physicians begin to view patients not as collections of diseases or organs but first and foremost as people in need, and medicine as an intrinsically moral activity.
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Acknowledgments The author would like to thank a Philosophy Compass reviewer for helpful comments and suggestions. This work was written during a stage at the Boston University Center for Philosophy and History of Science, and supported by the Spanish Government by means of research project FFI2008-06348-C02-02/FISO. Short Biography Antonio Casado da Rocha, Ph.D., is a Research Fellow at the Department of Philosophy of Values, University of the Basque Country at San Sebastian (Spain), and a member of the Ethics Committee in this citys hospital. His main interests are in healthcare, research, and environmental ethics. He has published reviews, commentaries and articles on these topics in journals such as Bioethics and The American Journal of Bioethics, and has authored a book length introduction to medical ethics in Spanish (Biotica para legos (Madrid/Mxico: Plaza & Valds, 2008)), with special emphasis on the role of the patients and lay participants in the healthcare relationship. Note
* Correspondence address: Tolosa etorbidea, 70, 20018 San Sebastian, Gipuzkoa, Spain. Email: antonio.casado@ehu.es.

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