 His speaker promises to be just as engaging. Daniel Bredney is a professor of philosophy in the college, he's an associate faculty in the Divinity School and a faculty member at the McLean Center. Dan Bredney writes and teaches about philosophy and bioethics. Professor Bredney is the author of the book, Marx's Attempt to Leave Philosophy and has published many articles and bioethics. Professor Bredney has served on the program committee for the Human Rights Program at the University of Chicago and on the board of the Frank Institute in the Fourth Humanities. Professor Bredney is also an associate editor for the journal Theoretical Medicine and Bioethics and is a member of the editorial board for the journal Ethics. Professor Bredney today will speak on the topic joint deliberation as a patient provider ideal. Yeah, no slides and no disclosures. Thank you, Mark, for inviting me on the wonderful to be here again. I'm going to talk today about a particular model of the patient-doctor relationship. I'll ask what the goal is when patient and doctor or patient and medical team communicate about which treatment option to choose. Now, I'm gonna be doing what philosophers do, namely I'm gonna be trying to separate concepts from one another in order to see which one is most important. Of course, actual medical encounters will be much more complicated, will be much muddier, but what philosophers can do is to try to see what conceptually is at stake. The model that I'm gonna present might seem to be a variation on the idea of shared decision-making, but I think the way that many writers talk about shared decision-making involves precisely the conflation of moral concepts that I'm trying to disentangle. So I begin with two bits of state-setting. One is historical, the other analytic. First, the historical. There are many reasons why American medicine moved from the physician paternalist paradigm to the patient-autonomy paradigm. In terms of philosophical positions, I'd like to describe it as a move from Aristotle to Kant. Now, we sometimes talk of physician paternalism as tied to benevolence, and this leads to an association of paternalism with the philosophical tradition based on benevolence, namely the utilitarian tradition that starts in the 18th century with Francis Hutchison and David Hume, and that leads to Kant's highly sophisticated forms of utilitarianism. In fact, however, I think it's better to see paternalism as rooted in Aristotle. For an Aristotelian, the justification for paternalism is fairly simple. I can characterize it as follows in a kind of a syllogism. Premise one, one's goal is the best outcome for the patient. Premise two, determining what is likely to be the best outcome for the patient requires the exercise of practical wisdom. Premise three, the exercise of practicalism requires a person who possesses practical wisdom, that is, a practically wise person, what Aristotle would call the fronimals. Four, key premise, among those at the bedside, the person who is most likely to be a person of practical wisdom is the physician. And so then we get the conclusion, therefore the physician should make the decision. Now, looking at things this way, we could say that the demise of paternalism was due in part to increasing skepticism about premise four. People became skeptical about the claim that a physician merely because of his or her technical training and experience is likely to be the wisest person at the bedside. However, the shift from physician paternalism to patient autonomy goes further, I think. I think it's not only a rejection of premise four. I think it's also in many ways a rejection of premise one. That premise, remember, was the premise that one's goal is the best outcome for the patient. I think we should see the shift to autonomy as part of a transformation of the very point of the patient-doctor conversation. And this brings us to the analytic movement of stage setting. Analytically, in the patient-doctor conversation, there are two elements to distinguish. There's the question of who makes the final decision about treatment, and there's the question of the goal of the conversation itself. These stages understood that the patient is the ultimate decision maker. Still, even granted that the patient is the decision maker, there could be more than one goal for the patient-doctor conversation. So consider two possible goals. I'll call them A and B. With A, the goal is to enable the decisionally competent patient to make an informed decision about her medical treatment. With goal B, the goal is to reach the best overall decision for the patient. The goal is to make the decision that would be made by a person of practical wisdom. Note that A is about process while B is about outcome. The focus in A is on the patient as decision maker. The focus is on the exercise of the patient's will. It's on having a certain kind of connection between the patient as an agent and what is finally done. The thought is that the patient is supposed to determine her own life. It would be nice if she determines it well and sensibly, but those are bonuses. The moral value at stake is the exercise of agents. Now, this value has many philosophical sources. One place where the point is put very clearly is in a manual Kant's book, The Metaphysics of Morals, published in 1797. This is a book written over a decade later than the book of the similar title that many of you might be familiar with, namely the groundwork of The Metaphysics of Morals from 1785. The later book, The Metaphysics of Morals Proper, Kant says that what separates human beings from animals is our capacity, as he puts it, to set ends, to be agents. And significantly, Kant says that what is distinctively human, separating, as he calls it, menchite or humanity from titheite or animality, what's significant and distinctive about us is the capacity to set any ends whatsoever, so not merely morally laudable ends. Agency per se, the power of choice is what is valued here. That seems to be what's at stake in goal A. Goal B, by contrast, is result oriented. It presumes that there is something that it is rational to do, any way that there's something that is more rational to do than the available alternatives. So goal B is about determining the content of that something. So the point of the patient-doctor conversation could be to facilitate the exercise of the patient's will, or it could be to find the best thing to do under the circumstances. Now, of course, A and B could, in some cases, yield the same result. As philosophers would put it, they might be extensionally equivalent. Still, even if the outcome might be the same, I think it's important to know the goal of the patient-doctor conversation. It's important to know what one is seeking. Suppose that one takes the proper goal of the patient-doctor conversation to be A. In that case, the focus will be on adequately informing the patient about the medical risks and benefits of the various treatments, and also on helping the patient to clarify her own goals of treatment. No, and this is important. Such clarification is not, anyway, need not be transformation. The metaphor of clarification is of something that's already there, but merely needs to be held up to the light. If the goal of the patient-doctor conversation is to clarify the patient's own thinking to help the patient to figure out her own preferences, then the doctor or the other members of the medical team are not there to help the patient to reflect upon that thinking or those preferences. They are there to facilitate the exercise of the patient's will. After all, in this picture, that is the value that's being endorsed. We could wonder why this is a value worth endorsing. What's so great about the exercise of the will? That's a historical matter. The exercise of the will has not always been thought to be great. 17th-century Calvinists would see the exercise of the will as the root of all evil. So one might think instead that what is of value is the exercise of preferences that have been reflected upon and that have been affirmed upon due reflection. That's the picture that one finds in John Stuart Mills in Comium on individuality in his book, Unliberty. There, Mills insists that our preferences have little moral weight merely as preferences. But if one would, they have a moral weight for military, once they've been questioned, criticized, reflected upon, and then endorsed. But if one were to take Mills seriously about this, one would have to think not in terms of mere clarification, but of facilitating a process of reflection. So let's now take the proper goal of the patient-doctor conversation to be different. I'm gonna call it goal B. This is likely to lead to a rather different conversation. Such a conversation would be a specific form of what I will call joint deliberation. All those involved would pool their knowledge and their cognitive powers in search of the best decision. Such a conversation would involve discussing and exchanging reasons with no party starting with an ex-anti-assumption that he or she is right. This picture of patient-doctor deliberation comes from the history of thinking about the best forms of political decision-making. The idea goes back to Aristotle. In his politics, Aristotle remarks that a group decision might show greater wisdom than an individual decision in so far as each member of the group that's deciding brings a bit of wisdom to the process, in effect. Many heads are better than one. The idea is also related to Juergen Habermas' concept of an ideal speech situation, a condition in which we all seek the best answer to the question at hand, and in which the only currency is that of good reasons rather than institutional authority, rhetorical flair, personal charisma, and so forth. Of course, this concept of joint deliberation of an extended process of reason-giving among patient-doctor and medical team is an immense idealization. Any actual patient-doctor conversation will fall very far short of it. The question for us to ask, however, is whether this is what we take, in fact, to be the proper ideal. If it is, we can then ask whether steps can be taken to approximate it. Yes, might be no, but then we would at least learn that the proper ideal is out of our reach. Now joint deliberation might look similar to the shared decision-making model of the patient-doctor conversation, and it's fine with me if the two converge. However, in the articles that I've read about shared decision-making, the goals seem to be rather different. On one hand, shared decision-making often seems to have as its goal the facilitation of informed patient preference, that is, preference clarification. On the other hand, the goal is sometimes described as consensus-building, where the patient and the doctor start from different places and work their way through to an agreement, and sometimes this is termed negotiation. These pictures are quite different and they rest on different values. The first rests on the belief mentioned above that what is of value are the patient's own preferences, and so prior to the patient exercising her will through making a decision, she should understand what her preferences are. Preferences must become informed in the dual sense that she must learn what they are and that they must be adjusted in the light of medical information. This is the view that what is of great value is agency and that this value is what is being facilitated in the patient-doctor conversation. The second picture that seems to be presented in the discussions of shared decision-making actually goes back to the older idea that the physician has more practical wisdom than the patient. On the second picture, the doctor's goal is to get the patient to make a sensible choice. The patient will ultimately decide what the doctor has to bring her around to the decision that is best for her, hence the talk of negotiation, and it's a question of getting the patient to yes. I wanna stress that neither of these is what I'm calling joint deliberation. For while joint deliberation descends from the Aristotelian tradition, in the model of joint deliberation, both terms of the phrase are to be stressed. What happens is deliberation. The parties are thinking about what to do. They don't start with their minds made up and merely seek to convince the other. They start with uncertainty with puzzlement, or at least with the potential for an openness to puzzlement. And both parties, or all parties if there's more than two, must deliberate and discuss and must exchange reasons. By contrast, negotiation is a form of bargaining. It is not the exchange of reasons. Suppose now that joint deliberation is in fact our ideal of the patient-doctor conversation. Clearly it requires the doctor to have a new skill set. These days there's much talk of fostering virtue in physicians. In philosophy speak, this means that a doctor must have a certain set of beliefs of attitudes, responses, and feelings to name just a few things among men. It's quite a challenge to become and to continue to be such a person. My analysis seems to burden the poor doctor with even more requirements. Now she must become first, able to elicit the patient's beliefs and preferences. Second, able to help the patient to reflect upon her beliefs and preferences, perhaps modifying or even rejecting. Third, able to help the patient to understand the medical options. Fourth, able to help the patient understand the doctor's reasons for recommending option alpha over beta and perhaps over options, gamma and delta, et cetera. While the doctor herself must not be too weighted to any of these options. And fourth on the patient must be, the doctor must be able to listen to the patient's reason for preferring beta, rather than alpha sec, and to digest those reasons, possibly changing her own mind. And finally the doctor must be able to respond to the patient in a way that helps the patient to hear and to digest further reasons for preferring this option over that. Now what I'm describing is the best sort of dialectical discussion. People spend years in doctoral programs and still can't do it well. Now it looks as if I'm requiring every budding physician to learn this skill on top of everything else that she needs to learn. Isn't this asking too much? So before responding to that, the first question is to ask what kind of an ideal is at stake? Roughly we can divide ideals into two, threshold and scalar. A threshold ideal is an on-off switch. There's no point in seeking it and trying to attain it unless you can get a long way. Chico Marx gives an example of a threshold ideal in a talk he gives in the movie The Night of the Opera. He talks about how he attempted to fly solo across the Atlantic Ocean. He got halfway across, ran out of gas and had to go back. That's a threshold ideal. It does you no good to get nearly halfway there. By contrast, a scalar ideal would be losing weight. You might say it's your target that you're gonna lose 10 pounds. But you know what? Even if you lose two pounds, you've done something. So now the question for any ideal is whether it's a threshold or a scalar. And so the question for the joint deliberation model is whether it's a threshold or a scalar ideal. Offhand, it looks to be scalar. It looks as if this is the sort of thing which can be done better or worse. I'm gonna have to, running out of time so I'm gonna cut something, but I just wanna mention what may be the practicing physicians worry about this. Namely that what I've described is a wonderful ideal of interaction amongst patient and medical team in which all are equal parties to deliberation, all engage in reason given. The practical worry might be that in reality, the physician will run the show. That the patient has less knowledge. The patient always comes in, usually taking a kind of a one down status. The patient is often ill and even if competent to make a decision is not necessarily thinking at his or her best. And the worry would be that this model will give the physician license in effect to bully the patient into deciding what the physician wants. I can't really speak to that. That is, as a patient, I have more faith in clinicians than to think that that's how things are likely to be. And I certainly think that if we train physicians with a certain kind of model, they're less likely to bully patients and to try to facilitate deliberation. But I'm going to have to leave it to the clinicians to decide whether or not how dangerous, so to speak, this model is to embark upon. So let me close this way. When I submit papers to medical conferences, the online form always asks me to list the things that I want my listeners to learn and affect what the take home's supposed to be. And this amuses philosophers because philosophers always remember the adage that any philosophy that can be put in a nutshell belongs there. Still, I'll try for a take home. It's this. Patients should make decisions. That's the moral right that's good that it's their legal right. To this extent, we should endorse the value of the exercise of the will. But the decisions that patients make are often momentous. And so we should be clear about the values that we're trying to advance prior to that decision, the values being advanced in the patient-doctor conversation. In general, I think it's sensible for people to deliberate about momentous decisions. It's male stresses that's part of making the decision their own. It's part of making their preferences their own rather than merely impulses that happen to them. One might then think that part of the medical team's obligation is to facilitate deliberation about the patient's momentous decision. And if one is to do that, then shouldn't one strive to do it in a way that instantiates the very point of deliberation, namely to find the best option, the one that a wise person would choose. Thank you. I know if I have a question. Hi, there. Thank you. I like the idea of the scalar option and the other option, because I think that practicing physicians and people who teach residents and medical students live in that world. I'm having trouble hearing you because there's a fan going on. No, there's... I think the mic is on. It's the screen. I should speak louder? Okay. So I think that people who are training young physicians, whether medical students or residents, deal with that issue of, is it a scalable task or is it a threshold task all the time? And you're talking at a time that's right in the middle of recruitment season and I'm in the process of recruiting residents. And I would say that the process of recruitment really deals with exactly that issue. Is this somebody who is gonna get halfway there and run out of gas? In which case we don't want them. Is this somebody who's gonna get most of the way there but spend the rest of their life moving toward an ideal? That's a trainable person. So that that's a very useful concept. I'd like to thank you for that. You're very welcome. Thank you. Dr. Rudney, I was curious if you would say there's some isomorphism or parallel process between shared decision-making in the medical context and ethical decision-making in ethics consultation. Would you apply the same joint deliberation in that context? Sure, that's a nice point. I mean, ideally I think our case consults are aspire to be an example of joint deliberation of Habermas's ideal speech situation, which there's an issue that's raised and people discuss it and in principle, parties are equal in the discussion and the only currency is what Habermas calls the force of the better argument. So in any kind of group deliberative situation, that is sort of the ideal, it's one ideal. And if we're not deliberating in order to facilitate what I've called the clarification of somebody's preferences or desires for trying to find the best outcome, then the right way to do that seems to be to take into account as many reasons as we can and try to think them through. Thank you. So, thank you.