 On behalf of the McLean Center and Dr. Meltzoo's Center for Health and the Social Sciences and the Bucksbaum Institute, it's a delight to welcome you to today's lecture in the 2019-2020 series on the present and future of the doctor-patient relationship. I am delighted to introduce you to Professor Daniel Brodney, who will be our speaker today. Dan Brodney is the Florin Harrison Pew Professor in the Department of Philosophy and in the college. After receiving his bachelor's degree in history and literature from Harvard, he later received his PhD in philosophy also from Harvard. And then Dan joined the faculty here at the University of Chicago in philosophy and in the college as well as in the Divinity School. During his years here at the University, Dan joined the McLean Center as a faculty member, if I have this right, Dan, in 2004. Yeah, a couple of years back. Here at the University, Professor Brodney writes and teaches political philosophy, bioethics, philosophy in literature and philosophy of religion. Dan's research interests include patient autonomy, ethics of liver transplantation, the conscientious refusal on the part of healthcare professionals, and conflicting interests in clinical decision-making. Dan has been the recipient of many awards, including the Quantrell Award for Excellence in Undergraduate Teaching, one of our university's oldest prizes. Dan's talk today is entitled Three Philosophical Questions at the Bedside. Please join me in welcoming Professor Dan Brodney, but also on congratulating him on his appointment as the Florin Harrison Pew Professor. Thank you. Thank you, Mark. It's good to see you all here. Happy New Year. Welcome back. I'm delighted to be speaking to you. What I want to do today is just to motivate some conversation about philosophical issues that I think are, you guys are all in the back, so I'm going to have to use the mic. If you just came down, it would be easier. Issues that I think are embedded in clinical practice and that, you know, you all are constantly making these decisions, and you may not be aware that they're philosophically contentful and robust. And I just want to bring out the philosophical issues at stake in them, and then in three places ask you what you think, where you think, why you think the right thing to do is what you think it is, what sorts of philosophical commitments you're willing to take on. So I'm going to start from my first question by looking at three cases of refusal of treatment. Let's see if I can figure out how to do this. Oh, look at that. I did it right. This is a case from the Siegler Johnson and Winslay Classic Book on Clinical Medical Ethics. It's from the sixth edition, I think. And I'm not going to read the whole slide because there's too much there, but the basic idea is that you have a graduate student brought to the emergency room complaining of a severe headache and stiff neck. Ultimately, his diagnosis is bacterial meningitis. When told his diagnosis and that he'd be admitted to the hospital for treatment with antibiotics, he refused further care without giving a reason. He would not engage in discussion with the staff about his refusal. The physician explained the extreme dangers of going untreated and the minimal risk of treatment. The young man persisted in his refusal and declined to discuss the matter further. Other than this strange adamancy, he exhibited no evidence of mental derangement or altered mental status that would suggest decisional incapacity. And let's just stipulate it's not an example, but let's just say he really, really dislikes injections. And that's what's motivating him. That's our first case. Come on now. Second case. This is a 56-year-old Devat Jehovah's Witness. She's read broadly and thought deeply about and believes profoundly in witness theology. She's lived her life in accordance with witness precepts, and she sees a substantial part of the meaning and value of her life as tied up with her witness identity and so with adherence to the requirements of that identity. She needs a major operation in order to survive, but the operation can't be done without the use of the kind of blood products that her witness theology proscribes, so she's refused the operation. So then, a third case. This is an 86-year-old man, terminally ill, likely to die within two months. He's breathing too dependent, so also in considerable pain that can be relieved only by sedation that deprives him of consciousness. After a great deal of reflection, as well as discussion with family, friends, and a spiritual counselor, he's decided to have the breathing tube removed. I want to use these cases to point to the need, as I say, for philosophical thought at the bedside. I don't mean that doctors are going to do what philosophers do, extract concepts, make fine-grained distinctions, see if arguments are valid and sound and so forth. I mean merely that bedside decisions are often made on the basis of fundamental philosophical views. Aristotle recounts the following tale from the pre-Socratic philosopher Heraclitus. This is from Aristotle on Heraclitus when the strangers who came to visit him found him warming himself at the furnace in the kitchen and hesitated to go in. Heraclitus is reported to have bitten them not to be afraid to enter as even in that kitchen divinities were present. Heraclitus' point and Socrates' point in doing his philosophical work in the marketplace is that philosophy is often part of ordinary life. Now, I'm not going to be arguing for or against any specific way of doing clinical practice. As I say, I just want to try to identify the philosophical commitments that one takes on when one believes that at the bedside one ought to do things this way rather than that. So these first three cases, and there will be a fourth one eventually, are all cases of refusals of treatment. In modern American medical practice, a central moral and not merely legal feature is that a patient with what's called decisional capacity as you all know may refuse medical treatment including life-saving treatment. And treatment may be refused for what might seem to be foolish reasons and even when treatment would prolong a good life. So why do we do this? Why do we let patients decide? There's more than one reason why we do so and it may be that in the end the reason we do so, the reason we have this rule is based on a combination of multiple factors. But a thing that's often talked about is this thing called patient autonomy. As with many philosophical concepts, autonomy is susceptible of multiple interpretations. Philosophers would say about it that there is the concept of autonomy and then there are various conceptions of that concept or interpretations of the concept. Philosopher Joel Feinberg has identified, I think it's 13 distinct conceptions of autonomy. I may have miscounted, maybe it's 12, maybe it's 14. Other philosophers have counted more. I'm just going to look at four conceptions of autonomy. My initial claim is that at least in some hard cases at the bedside, the doctor is making a philosophical decision about which conception or conceptions of autonomy singly or jointly are supposed to be applied. I want to lead up to the first three conceptions of autonomy by proposing the following hypothesis about what I take to be fairly common reactions to our first three cases. I suspect that clinicians find patients like our graduate student to be deeply frustrating. I sometimes ask the clinicians that I teach whether it would be morally acceptable to inject the student against his will. Most say no, but some say yes. You know, there is, he's dozing, you've got the syringe, he'll never even feel it. Should you give him an injection to save his life? As I say, most clinicians I teach say no, that would be wrong and the question is why. But if you actually think the right thing to do would be to do so, but even they are bothered by it. So that suggests that there's still something morally going on here. I want here just to digress not to let you fight the example. When philosophers give examples, non-philosophers often want to fight them. And in this case, the way you'd fight the example would be by denying that the graduate student has decisional capacity. I don't want to go there for two reasons. One, to get into that would get us into a very vexed question, namely about whether the decisional capacity standard on its best reading has morally contentful content and specifying what accounts to be sufficiently rational to make a decision. But I also don't want to get there because you don't need to. I'm sure all of you in your clinical practice have had patients whom you do believe had decisional capacity and whom you also believed were refusing treatment for what you were very confident was a foolish reason. So, Joe. Oh, really? All right. Is this better? All right. So I just have to be close to the mic. So most clinicians find the first case troubling. Even if they think the right thing to do is to let this graduate student alone and let him die. I think clinicians are more at ease with the case of the Jehovah's Witness. I lost track of my slides. And they might not think that this is what they would do, but they feel that somehow the witness's decision, fitting as it does with her fundamental convictions, in some way makes it proper to let her go. And clinicians tend to find the third case of the elderly man who's terminally ill, particularly an easy case. Even if they would not themselves, were they in that situation, make this decision, they think it fits within the bounds of what's reasonable. So I want to tie these three cases to three conceptions of autonomy. So here's conception one. Autonomy involves not having one's actions interfered with in the pursuit of one's desires. If nobody interferes with one's opting say for coffee over tea, autonomy obtains. And now it's conception two. It's going to be conception one, plus having one's uninterfered with actions be the expression of a relatively coherent, and at least to some extent, reflectively endorsed set of beliefs and values. The philosopher Gerald Dworkin has given a useful characterization of conception two. Dworkin writes, autonomy is conceived of as a second-order capacity of persons to reflect critically upon their first-order preferences, desires, wishes, and so forth, and the capacity to accept or attempt to change these in light of higher-order preferences and values. By exercising such a capacity, persons define their nature, give meaning and coherence to their lives, and take responsibility for the kind of person they are. Finally, a third conception, that's conception two, with the addition that one's beliefs are for the most part true and one's values for the most part defensible. So it's conception two, plus getting things sufficiently right. Now, each of these conceptions has had its adherence and detractors. Conception one is sometimes the sort of thing one finds among social scientists who tend to think that to be autonomous really is just to pursue your desires. Philosophers generally don't go there, and that's because philosophers don't generally think that desires are all just on their own or all that big a deal. Dan Brock has pointed out that a desire can be transient, can be arbitrary, can be trivial. There's little reason for anyone to do or refrain from doing anything simply because I desire it. As it happens, especially at this time of day, I have a great desire for a big slab of chocolate cake. But I don't think that this provides anyone with a reason to give me one. Of course, if I've exercised my will to buy a slab of cake, it might be wrong to interfere with my doing so. I'll get to why in just a minute. Well, my desire simply as a desire and not as actually enacted by my will is tied for the most part to its content. My desire for world peace is a desire for something intrinsically good. The goodness of the content is what gives everyone a reason to try to satisfy this desire, not the fact that I have it. If autonomy is to have substantial moral weight, it must be tracking something more significant than a mere desire. In contrast to conception one, conception two has a very distinguished philosophical lineage. This conception highlights the value of individuality. It's favored by John Stuart Mill and many others. It's sometimes talked of in terms of pursuing one's real self or one's authentic self. Don't let the talk from Gerald Dworkin of higher order decisions confuse you. All Dworkin's pointing to is that when we figure out our plan of life, and few of us figure out a whole plan, but we don't do things without some sense of continuity, it's because whether consciously or unconsciously to great extent or only a little bit, we've actually thought about whether the things we wish to do are worth the doing. They're not random desires and random choices. They're rather, as philosophers would say, things that we endorse. So this thought that it's important to lead a life in accordance with your own beliefs and desires is a thing that many people have thought. In fact, it's a widespread modern view. You find it in all sorts of places in Ralph Waldo Emerson's and Comium on Self-Reliance and in every cloying Hollywood film that says that you have to be yourself. As for the detractors of conception two, they point out that as an ideal of life, it's a formal ideal. In principle, one could be true to one's authentic self foolishly or wickedly. One's authentic self could be based on false beliefs or wicked values. Imagine Hans. Hans is an utterly unreflective Nazi. He's a Nazi because that's what everyone in his environment is doing. He hasn't thought about being a Nazi much. He just parrots the phrases. By contrast, Günter is a Nazi who's really thought about it all. He's taken a lot of time to think about what the Nazis believe and on due reflection, he's endorsed it all. It's not unintelligible, at least, to think that actually Günter's life is worse for the fact that he has reflectively endorsed his false and wicked beliefs compared to Hans who's just parroting them. The point here is that although in general one might think that part of a good life is to lead it and according to their own beliefs and values, it's at least open to question whether it's necessarily better to do so or whether there's at least some degree in which it's important that the content of your beliefs actually track the true and the good. And that's the considerations that lead philosophers like Susan Wolfe to say that the importance of autonomy is precisely in being able to form one's values on the basis of what is true and good, not merely on the basis of what one thinks is true and good. Another fine philosopher, Joseph Rods, favors a life that is indeed one's own and that meets standards of the good. He says that autonomy is valuable only if exercised in pursuit of the good, not merely what one thinks is good. Now, what I want you to see about these three conceptions is that they're all about what it is good for the person who acts. On these three conceptions, the value of autonomy is either in its tendency to facilitate the pursuit of one's desires or in its tendency to facilitate a life lived according to one's sincerely held beliefs and values, that's conception too, or in its tendency to facilitate a life lived according to one's beliefs and values, where those beliefs are sufficiently true and the value sufficiently good. For all of these conceptions, the point or value of autonomy is in its relation to what is good for the patient. None of them talks about the patient's moral right to make the treatment decision. So it's important that you see this, there are conceptions of autonomy that are not tied intrinsically to the thought of a moral right, but that are tied intrinsically to the thought that a certain picture of what it is to lead a life is better for a person. Now, there is however another conception of autonomy that focuses on the idea that one has, a right to make certain decisions. I'm going to link this to the work of Emmanuel Kant, but in fact not to his own discussion of autonomy in his book, The Groundwork of the Metaphysics of Morals, published in 1785. So far as I know Kant was the first writer to use the term autonomy to refer to individuals or to actions of individuals. To be autonomous is just in terms of the meaning of the words to give oneself laws. The term was originally applied to political entities. For instance, the Italian city-states of the Renaissance. Florence was autonomous because it gave itself its laws. It was not subject to the laws of Milan or Rome. When Kant introduces the term autonomy in The Groundwork, it is to describe an individual who acts on the basis of a law that she gives to herself purely as a rational being. For Kant, the only such law is the moral law, and it has nothing to do with the pursuit of one's desires or rather it's a constraint on such things. And so his use of the term autonomy, Kant's use, is actually rather at odds with its use in medical contexts. So that's just one of the interesting vagaries of intellectual history that although the term goes back to Kant's use in medical contexts, it does not track his use of it. But there's another place in Kant's writings where I think one can find something that is relevant to medical contexts. This is his stress on the end setting in a work published a dozen years after The Groundwork, so in 1797, the Metaphysics of Morals. In this later text, Kant writes that what separates humanity from animality, what he calls menschheit from tihite, is our capacity to make a choice. That is to exercise one's will whereas he puts it to set ends. For Kant, there is a moral standard for when one person may interfere with the exercise of another's will. Any interference must be in accordance with the law that all could affirm. Kantians are likely to claim that to exercise compulsion to promote another's good in our cases to extend a person's life does not fit with the law that all could affirm. Kantians are likely to consider it wrong forcibly to inject our graduate student or to compel treatment in the other cases. I want to be clear for those of you who know your Kant that in contrast to his Groundwork discussion Kant's concern here is not the proper motive for morally worthy action, but rather the conditions under which, regardless of motive, it is permissible for one human being to interfere with another's will. To the Kantian what is crucial in these cases is not the attainment of the good life, but the condition of not being dominated. Now, you don't have to be a Kantian to see something morally important about the condition of not being dominated. Joel Feinberg claims that one has the sovereign authority to govern oneself, that one has a sovereign personal domain over which one is entitled to absolute control. And this is a very, very ordinary thought. It's simply the thought, you're not the boss of me. On this fourth conception of autonomy patients should be the ones to make medical decisions because they are persons. They are agents, they have a will, and agents have a strong moral right not to have their will overridden. One might add to this as a kind of a corollary that is normally wrong to interfere with a person's body without that person's consent. So our fourth conception is patients should be on the ones to make medical decisions. I'm sorry, the fourth conception is that to be autonomous is to have a moral right to make decisions about one's own life. Now, if you believe in general that patients should make their own medical decisions, one major reason might be that you believe that it's normally wrong to interfere with a person's agency and bodily integrity. That sounds sensible. Where the rubber meets the road is when you have to decide how much value there is in agency and bodily integrity. Are these always more valuable than prolonging human right? Two philosophers, Richard Arneson and Joel Feinberg disagree. Here's Arneson. In a particular case, the good of the individual that's at stake can be enormous, and the degree to which paternalistic interference would frustrate the agent's interest in self-determination can be very slight. Voluntary choice is important, but does not plausibly have make or break significance. Even taking into account the crucial value of autonomy, I think Arneson has conception foreign mind, it remains the case that sometimes a hard coercive shove away from the bad can improve anyone's life. So it looks as if Arneson would think it right to inject the graduate student, the hard shove, and so to save his life. Feinberg says no. The life that a person threatens by his own rashness is after all his life. It belongs to him and to no one else. For that reason alone, he must be the one to decide for better or worse what's to be done with it and that private realm where the interests of others are not directly involved. This is the interpretation that follows from what he calls a pure conception of individual sovereign autonomy. A graduate student's refusal might be rash, but Feinberg thinks he has a right to refuse. So the first question I want to just have you discuss is which conception or conceptions of autonomy do we need to accept and how far must we weight the value of these conceptions to be able to conclude, if we do conclude, that it's always right to let patients with decisional capacity make the medical decision. So that's going to be question one. So now, discuss. I take it that most of you, maybe all of you, do think that the rule that we have that a patient with decisional capacity ought to be allowed to make the treatment decision, including refusing life-saving treatment, is the right rule. Or maybe some of you think it's not always the right rule. My question here is there are various ways of thinking of the different moral considerations at stake. You could put heavy weight simply on the value of letting people do what they want, because somehow you think that's part of a good life is to do what you want. You could put the weight on not just doing what you happen to want, but rather on doing those things that fit with your general picture of what a good life would be. That's this thought of authenticity. Or you could be like someone like Susan Wolfer, Joseph Ross, and say, well, wait a second. The real value is in doing what you think is the best life to live. When you've got it sufficiently right, when you're not like Gunter, are very reflective Nazi, who simply gets it all wrong. Or you could say none of that matters. What's really going on is this last conception, conception for the thought that agents have a will and that it is just plain wrong to violate somebody's agency. This is what is very important about a human being, unlike animals. Animals have desires, but they don't have, in cons terms, a will. Or you can think it's a combination. And maybe it is. Maybe that's the best answer. The justification for an institutional rule needn't rely on any one thought. It could rely on multiple thoughts. But the philosopher's job is to ask, what's going on? And in particular, we will move soon to noting a place where whether you think conception three is the way to go, or conception two is the way to go, or conception three pursuing an ideal, or pursuing an ideal that's right will have an impact on how you think the doctor-patient conversation should go. But I'm curious. Come on. Go ahead. Got to be truly good. Got to be truly good. Good. Conception three. I got this attention in the case conference, like in part, your conception of monarchy depends on how serious the consequences of the medical decision you made are. And that's where you see people moving through these different conceptions and invoking them. If it's, you don't want a blood draw because it hurts, but you're a stable patient, you've had stable labs, and that's the ethical question. Well, conception one is probably okay. But the life and death questions often I think lead to people to really want the patient to describe and reflect and have values consistent with the decision of making a more important decision of the physician thinks they should be popular. That's conception two. The physician thinks they should be making a problem. Conception three. Right. Others? Javad. It seems to me that autonomy is a relative and social thing in our relation with each other. An example of a patient or a person who has the autonomy to say to jump out of the window if he wants to do it and he is rational and John Stuart Mill says, well, if you found out that he is rational you don't give him anything that he has tried. However, if I am a doctor and he is sitting in my office he cannot do that in my office. He cannot jump out of the window through my office because now his autonomy affects me. A pilot has an autonomy to commit suicide but not why he is trying me. So it all depends what autonomy of one person affects another. So that's a wonderful question and since you've mentioned John Stuart Mill I will put this in the terms that Mill uses in his book on liberty in which he asserts what he calls the principle that a person's liberty should not be infringed upon for his own good but only to prevent harm to others. The question then is what counts as the relevant kind of harm? In the case you're imagining in your office Mill might agree with you that it would be wrong for the patient to jump out of the window of your office because that would traumatize you and he might have an obligation not to traumatize you. At the bedside we don't usually say that maybe we should but when someone proposes to refuse life-saving treatment we don't say oh you've got two children who depend upon your income we won't let you do that whether we should talk to the person about that is a question I will get to but in terms of whether we forbid someone from doing that and compel treatment in order to preserve interests that are causally connected to the patient maybe we should do that but we don't do that and that's why in thinking about these conceptions of autonomy I have not brought in ways of thinking about it such that it's intrinsically tied to someone else's good that would be a radical departure from our practices maybe a one we could talk about but that would be another talk David So I'm on service right now with applications about their care that surprise us and one of the biggest consequences when it happens is that it takes a great deal of time and when it takes a great deal of time that has consequences for everyone else to be careful and it has consequences sometimes the clinician feels like jumping out the window the other patients don't get hurt so it's just an interesting example that that is a reality of the constrained world that there are these connections between people's preferences and the welfare of a whole bunch of others both those who have willingly chosen to be clinicians and those who have unwillingly happened or unparalleled happen to be just affected by this person as an external act So what you're proposing whenever we bring this up the concept of rationing in case conference Mark immediately gets upset and says we don't do that here now I disagree as to whether in practice we do but in this case what you are proposing is time rationing and I'm not making it a budget constraint and that budget constraint is real and therefore we need to think about how all these things play out once you have an awareness Now the question is going to be is that awareness does that bring in something of sufficient moral weight that rather than chatting with our graduate student and trying to persuade him to accept a life-saving injection you say, hey, look at that squirrel and then you give him a jab and then we're done So, well, that would be another way to save time, that's true Other thoughts? Michael wants to jump back in Question 3 is the right one because when I go to see Dr. Siegler because I don't feel well and I ask him why I don't feel well and what I should do I'm engaging him and therefore like if I go against what I've asked him then I should have some higher order thinking about that to argue what is really true and separate from what he has recommended And if he is utterly convinced that you've gotten it wrong he should still let you get it wrong He should not let you get it wrong He should compel treatment I'm wondering if even Mark wants to go quite there Well, we go back to the first case Can you hear me in the back? We go back to the first case which is sort of reflected a little bit in this question 1 We did in that first case in the emergency room bring in both psychiatrists and legal people to assess the decisional capacity of this 25-26 year old graduate student And both of the people we consulted agree it is as you pointed out that the patient had as is indicated here in the next to last line decisional capacity very smart very bright and yet there were those of us who were looking after the young man who had seen a dramatic change from the way he presented to the emergency room and allowed evaluations and blood tests and even a spinal tap to be done and a sudden sudden change in his attitude and behavior from the point of treatment which was as we said admission and fairly simple antibiotics So there were those of us who were unsettled about the next to last line on decisional capacity And of course as you know there is no gold standard to assess decisional capacity There is no definitive test that says that the doctor is lacking and working from that perspective we treated the young man against his wishes that first case So conception 3 So conception 3 So conception 3 And 2 or 3 days later when he had begun to recover from his bacterial meningitis he began to explain to us that our decision had been right that he had a fundamental fear within the family about antibiotics because several of the family members had had allergic reactions and one of them was life threatening and he couldn't express any of that he didn't quite have his mental capacities or his decisional capacity at the time So that first case was a tough one but now you're doing what I asked you guys not to do what doctors always do you're fighting the example because you managed to handle this by assuming a way eliminating a basic premise of the example namely that there is decisional capacity So the philosophical question of course arises only if you accept the premise that there's decisional capacity I mean in most cases there is decisional capacity but your thought was that although it looked like it it really wasn't there and that's what warranted compelled treatment I want to know what would you have done if you've been forced to conclude oh full capacity no problem with capacity just a loony preference ranking right no antibiotics is my first order preference my highest ranking preference prolonged life is my second I think you can see to the autonomous right of individuals to make decisions even if in your view the decisions are tragic and that suggests that it's conception 4 that is the one that's doing the moral work here I'm going to now move us on but can I ask my question which is the most troubling of your slides I'm sure other people were not troubled by it but it troubled me that was a slide of the chocolate cake do you remember the chocolate cake slide and here's my question for you the chocolate cake slide was something that you wanted at noon because you were ready for chocolate cake and my question about autonomy and where it exists in the practical world is whether autonomy is most powerful in declining proposals or in or in initiating requests and demands for what you prefer but like the chocolate cake I'll stop so autonomy and everything else is most important when it's a matter of chocolate cake that's clear but what's at stake here is a distinction between thinking of why we let people choose in terms of believing that letting them choose is good for them and that could mean because we think it's good simply to have your desire satisfied and of course many of our desires are good for us maybe not chocolate cake but many of the things that we desire do track what's good for us but many of the things we desire do not track what's good for us and it's well known we're not often all that good at making our own choices about what's good for us so you might think that what you're really after is not just the business of desire satisfaction but the business of having a life in certain kind of structure and the witness case is the one of someone whose life is organized around a set of beliefs and a major reason one might think for allowing the witness to refuse life sustaining treatment is that it would undermine the integrity of her life it would not be unintelligible to say that her life as a whole would actually be worse if it is prolonged while violating the integrity of her life then if it's a shorter life but one that fits with her beliefs and her desires that's the sort of thing that someone like John Stuart Mill in chapter 3 of his book on liberty might be tempted to say that's what I'm calling conception 2 this is independent from either from the claim quite apart from questions of her desires quite apart from whether she has a picture of her life that she's adhering to she has a moral right not to have her will overborn that's conception 4 it's also not independent from but not the same as the thought that a good life is one lived in accordance not only with beliefs and desires that you think about and make your own and make in the jargon authentic but that as Micah wants in some sense track what's true and good in the world and all I'm trying to explore is which of these ways of thinking about what's good and the one way of thinking about what's right a different moral notion are really at stake when we think the correct thing to do the correct rule to have is to let people refuse treatment David I'm gonna maybe your question will come up again when I move on to the next set of topics or to the next topic with the next topic the focus is not on whether to allow someone to refuse treatment we're gonna assume that that's in place it shifts to share decision making and here I want another case um patient 4 um this comes from an old article by Julian Sevelescu a patient with breast cancer um refuses the surgery that at the time this was the early 1990s clearly held then the best chance for survival her reason for refusal is that she thinks the surgery will make her unattractive to her husband her oncologist is upset by this decision and urges her to reconsider um now to see what's going on here I want to give an account of what I'm going to call the elements of practical reasoning um one of my philosophical colleagues is in the audience I hope he's not offended by how quick and dirty this description is um I'm going to isolate just three elements of practical reasoning instrumental reasoning what might be thought of as means ends reasoning reasoning about the various parts of a given end or goal and how they fit together this could be called values clarification and finally reasoning about the proper goal or goals to have reasoning about what's good um do not think that the last is something highfalutin you do it all the time um some of you are clearly old enough to have raised or be raising children so you're making choices about schools you're deciding soccer versus basketball versus violin versus ballet and so on and so forth all of those are decisions about what you think is good for your child we're constantly making decisions about the good all the time it's an ordinary part of ordinary life now when we ask about the patient-doctor conversation it's clear that element one the means ends reasoning is in play um the physician presumably knows um what means are likely to lead to what end um it's probable that values clarification is also in play so you want to get a sense of what the patient really wants and sometimes the patient will want both A and not A or want A and B but B entails not A um and then so you're puzzled and you try to get the patient to think through what she wants my question is is it part of the doctor-patient conversation to think the patient believes is good not about simply what she says are her goals of care but about what's good what the right goals of care should be for her in the Savalescu case um Savalescu thinks that it would have been appropriate for the oncologist to push back against the values that the patient was articulating the patient was buying into um a very conventional and probably quite pernicious notion of female attractiveness and she was deciding that was more important than the likelihood of a longer life and one might think that it's part of the oncologist's job to say really? don't we want to question those values and if she says well my husband might not like me as much if I have the surgery I know this counselor who can help you think about whether you should get another husband well no I'm serious here because and it's interesting I've now it turns out been listening to the case conference for 15 years and what I hear often is a description of a patient-doctor interaction in which the doctor thinks that the patient's values are in some way profoundly problematic the doctor has a vision of what's good for the patient that's at odds with what the patient thinks given the patient's values and what I hear often is a description of how the doctor has talked to the patient in terms that the doctor says are really about values clarification but aren't when you're listening what the doctor is trying to do is to change the patient's values and my thought here is if you think that's the right thing to do sin boldly and so my question is now that we have after all values clarification fits with conception 2 of autonomy with the thought that it's a good life is one in which you've figured out what you want you've reflected on it you've thought it through and we're not going to make any assessment of whether you've gotten it right or not but it just has a certain kind of coherence and meaning to you and by the way you've got it sufficiently right and now what I want to know from you clinicians is do you think it's wrong or do you think it's right obligatory perhaps in your conversations with patients not only to find out what they want not only to help them clarify what they want but at least at times to push back against their values and in fact say what you want is a bad idea meaning it's not literally it's not part of your good it's not good for you but where that means you have a view of what's good for the patient that they at that moment might not have so now that's question 2 what are your goals some of us needs to bring daughter's to another 35 counts and I said we need to do what are your short-term goals what are your short-term goals it gets to get to the beach next week and I think it's beach next month I think it's to get to a buggy in two months those are your short-term goals you know but you need to wait and I don't think we ask those questions enough when the patient says I want to keep on we give up so in the case that comes from Saturday last week as a woman who goes with the long surgery would you as the doctor try to wrestle with her about that obviously the choice is at the end I would totally try to wrestle it's your physical appearance that important is the physical appearance to be honest I think we all feel like we have expectations of our loved ones our loved ones have expectations of us but I don't really deal with those now I tend to agree with you but it's important to see the door that has just been open one of the reasons for rejecting the old paternalist model was that the paternalist model takes as among its various premises the thought that the doctor is a person of practical wisdom and as the others have argued there's no particular reason to think that mere medical training makes anyone wiser than anybody else and yet to push back against the patient's values implicitly means you think you are wiser than this patient about this particular issue at hand when he pushed back and said we want chemo it would only be a chemo so fundamentally in her case if she said yes my husband is going to run away with another woman then ok she can make more decisions what's the matter here is that you have hopefully some personal relationship with the patient and the patient values that so going to a computer that will do everything they could have in principle in defending patient's identity I don't think we'll be the same experience maybe a physician who cares who can maybe feel what she's feeling and is able to address her on a human level not even just the accident level I think that makes the difference in how she thought about thinking this so you would think it proper to say to this woman maybe you should get another husband or an internet let me give you some literature about this conventional view of female effectiveness in the way it's quite predictable and so forth you would put back yeah I would and I would say well I don't fully can appreciate how you feel but honestly if I felt that my husband is married to my dress and the rest of me is going to be better you know I would ask is something wrong with me or with my husband like I would reveal that it doesn't make sense to me and understand that it's not making sense to me sorry if this sounds kind of silly I don't feel that this explanation about my husband would want me or like me or his very good explanation for it and our thing in my area of medicine is if you look close enough and all these values because we hear you know my husband is going to leave me but if you talk to him you might learn that it's very important for her to feel loved by a man who she has a long history and maybe her fears are unfounded etc etc but people have to ration out we don't know deep enough to understand how we actually deserve you know again sometimes maybe someone is right alone but in terms of fear etc etc the value of things is high enough that would be a reasonable thing that what they want actually makes sense and on that obviously every case is complex and every case is a dumb case what a philosopher can do is to try and purify the case to see what the conceptual issues are so I'm going to have to push back and you would say there might be cases of the kind that you describe but what I am curious about is whether in a case where you fully help the patient to clarify what's going on in the room and at the end of that full clarification you deeply believe that her values are profoundly misguided and will have a customer say that she will which she was a life saving intervention wouldn't be part of your job as a doctor not merely to say ok, here's what happens if you do this and what happens if you do that thank you for helping me to understand your thinking but to no further than say by the way, let's talk about your thinking because it seems to be based on values that are high on the counter to challenge is that part of your knowledge? when you say misguided do you mean that they deviate from what most people do? do you think they are wrong? yes and you think you have good reasons for thinking that that's what it is to think something is wrong you've got it right and again, what I'm asking is what's your job description there's all this talk of shared decision making for the last couple of decades and I'm asking what goes into it Mark, how much time do I have? oh, Jovon, I'm going to push it off because I want to get to my third question let me tell you philosophers don't sit with cigars if only let me tell you philosophers don't sit with cigars if only when we become ill we are not only physically ill we are emotionally ill we are a different system when we become ill how value would be a different issue when we and as a doctor we have a different duty it's not only respect what the person just believes he says, really I have to find out what does it really mean now if the person says the only reason I don't want to have my breast removed because I'm the only one in my life a husband doesn't like me from my point of view that it's love is basically on your breast I'll find another husband it's just so much somebody lies because husband doesn't like it and the only reason the husband has is because for the whole selfish reason so I think emotionally people aren't it and they become ill and as a doctor you can just say what's your value you need to convince them you need to talk to them you need to help them and that's what they do so it sounds like at least some of you think that the right thing to do as a clinician is in fact to challenge the patient's values so the third question I'm going to have is only for those of you who think that all that should be in the patient doctor conversation is values clarification the next question is not a question for you it's only for those of you who think actually sometimes it's right to challenge the patient's values I was going to lead up to this third question with a discussion of an article by Ezekiel and Linda Emanuel I don't need to do that I'm going to go right to it once you open the door to saying you may challenge your patient's beliefs and values now let's go back to our Jehovah's Witness there you are you're convinced that her beliefs are false you might be convinced for any number of reasons you might be an atheist to think that he's no god or you might be a religious believer and think there's a god that the witness has in hand or it might be that prior to going to medical school or nursing school or whatever you did a Ph.D. in the Torah and you were a scholar of those parts of I think it's Deuteronomy and Leviticus that are the verses that are the basis the text of the Middle East and you know you wrote your dissertation on this that that's the wrong reading of those books right I mean you forget about these verses whichever is you know both and if you know and now my question is if you think it's only a to argue with the woman breast cancer about your decision do you also think it's only to argue with the Jehovah's Witness and if you think there's a distinction that is one we borrow away so that we should argue in the first case but not the second I want to know what it is and don't tell me religion is a matter of faith that's a philosophical view there are no religions that have been followed to show the rationality sufficiently rational and so to rest things on that is itself to take a philosophical position in my experience you've got at the bedside these are philosophical decisions that are making for all the time so now I'm telling you for those some of you might think all beds are off you can go and wrestle with the Jehovah's Witness about anything to try to save your life just like you're trying to save the family to do this life and the woman with cancer's life but if some of you think I keep your mouth shut about the Jehovah's Witness I don't know why the difference I was going to respond to this question I think the critical is that the way you phrase questions is strong in the sense that you're trying to push the path and I think the answer is strong maybe over the edge and I think the same answer works in some sense you could say something like you might be interested to know I actually studied medicine there are other ways to think about this it's a much gentler way to give what others would say this is wrong at the end of the day so Matt is this a tactical point which I would absolutely accept for a substantive moral okay to sort of gently say do you want to so the question is can you have a philosophical conversation with each of them where your goal is to change your patient's mind about something I think the answer is absolutely yes I'm not a physiologist I can have a physiological conversation I can explain what I know and don't know about it and refer to other people as experts if I have some substantive knowledge why I shouldn't state that while stating the extent and limitations of my qualifications and if your dissertation you did two dissertations one is scholarly the other is on patriotism you have all your arguments should we talk about it to the presentation I think you should go on that's a whole system others that's my job okay everybody it's strongly challenging but it turns into a value when it comes to certification and discussion because it's their style that's why I'm stating that it's more often than not able to speak because I think that when I'm coming out it's more likely than a certain head of federal policies so that's where the charm would you push the same way for the adult? absolutely and I think that it's different I know the child parent isn't quite the same but I think it's a similar sort of process and I think what it is is a sort of challenge to provide their value but I want to know the question if you go beyond helping them to come on do you think their values are false and distorted or something like that do you have time given that their life is at stake would you spend the time literally trying to shift their religious beliefs so that they will accept an intervention I see when you think of part of your job part of my role I'm not so surprised because in case of in case of I have not witnessed any of these cases a great deal of effort to try to find a way to persist in religious beliefs but not in cases in which the mechanism for getting the witness to agree to an intervention is a change in the substance but I think the reason is that the first thing that you do is try to come up with practical ways to avoid the fundamental capital dilemma but sometimes it's not as fundamental and then it's because of the budget history that we work through all that and we rarely get there but when you do your lap with this core nugget of this dilemma and it's actually pretty weird now I don't get it but I'm not going to give a talk in which I said here are the 80 techniques to avoid wrapping the patrols off so I understand my question is once it's there which way do you go and I don't really know a lot about actual political accountants but I don't think I think I agree with what I'm trying to call the medical education and I think it's not giving practical wisdom exactly at least in this part of my job at the stake of my training I don't think I'm wiser than anyone else to say that I have a better judgment the best you should take my opinion so it seems to me that Conception 2 is the safest of these four for people who are here in our training but I guess my main issue is that I don't think it's wise to leave this ethical consideration to the physicians and the patient once the person is already sick what about we offer I think this is completely different that's probably never going to happen but what if everyone has access to a philosopher you grow up with your assets you're always questioning your values you're always given the resources to rethink about what you really value so at that point when you're really sick and you go see a physician these decisions are already made and it's not up to the physician to convince you because you already have this conversation with someone else for yourself a long time ago so we don't really run into a problem oh this person is in a they're not feeling wrong they're not thinking straight because they're sick therefore they can't make this rational decision all these decisions have been really thought out before this moment has come I guess I would say if you believe as a physician or if you watch the ordering of those hierarchical values the problem is how do you engage and so like proceed into that that third idea but I guess giving back to your optimization on case conference I think that's really interesting I would be intended probably that why in case conference we have a hard time getting into that area of partnering is that it requires a tremendous amount of intimacy just the way that medicine has gone over the past few decades a relationship with a patient is often very short particularly on the ethics constant service and so we don't practically speaking ever find ourselves into the find ourselves in a relationship and that's a very interesting thought I've said before by someone else something about a certain kind of document an ancient relationship and so I'm reminded here of a wonderful book by a great letter to Albert called Fortune Man in which he sort of shadows a country doctor in the 60s this country doctor who is his community what he used to see how he would engage in the challenges who he knows intimately over a long period of time I'm kind of looking to see how a doctor was just medication from a hospital to do so but now the need to ask the question is that just a psychological and that's a work tactic you're not going to convince a patient who you just met to live off of what he used to your steps time or is it a substantive moral thought that only if you reach the level you can see that the patient isn't proper like they succeed but actually moral proper to challenge if you simply think that there is a thing called a doctor-patient relationship it would be reduced to a tactical that is that relationship is more or less the same kind of thing in different contexts it has to be reflected in light of the realities of what that relationship would be like in different contexts but then as I said well it's not going to work but the underlying thought then would be that if somehow you quickly could get to the patient that would be fun to challenge but not really so as I'm thinking about adults all of you should read about the story so the two adults that I remember at this institution from the last one year it's actually in cases where the patient seemed disnicked so one was a young adult who had leukemia who desperately wanted treatment and desperately did not want life and he came to our ER weekly begging for chemo and repeating for life and no oncology to do and apparently went around to everybody and been like the second one that seemed more interesting was an older woman who had anemia from the coronary vertebrae cross and I visited the case and she adamantly told everybody she was a general miswitness and she adamantly told them they should give her blood and everybody was briefed out and said we need to call an expert because she's not making sense they gave her blood after we said no she does have a decision making capacity and she's decided which my experience is pediatrician doesn't make sense but we'll bring their child to clinic once they'll be to get a blood transfusion so that's a great case second one specifically because it suggests that maybe values clarification is important to talk about that if you've got the patient waiting along the patient don't explain that they're doing something as a policy it strikes me that the Jehovah's Witness case is different from the meningitis case and the breast cancer case me too, how? a bit rather than in that we're talking about a life long belief system rather than an immediate unique circumstance that has just come up for the patient with meningitis or for the elevation with breast cancer but this is a belief system and it's not so much that it's a religious belief system although this particular one was but it's a life long set of beliefs which are now applied to a particular circumstance it's not as if the circumstance creates a new set of beliefs that existed previously so I rarely question one's religious convictions and beliefs or the appropriateness of any religious tradition but it's not only religion there are other things that can lead to a life long system of ongoing belief and that's why I think this case is different from the two early beliefs but notice so I wasn't going to jump in and pose my own view but I wanted to press other assumptions that have to go into what I take to be the view marks sketching one could distinguish cases in which the clinician and the patient share the same values but rank them differently from cases in which the patient has fundamental life-diving beliefs physician doesn't share and you might think it's one thing to argue about the comparative ranking say of physical attractiveness there's no reason that the oncologist can't think that physical sexual attractiveness isn't a good thing the oncologist is just saying to that patient you're giving it too much weight compared to cold long life they're sharing values but they could be disagreeing about how to weight or rank that might be thought to be different from the Jehovah's Witness case in which I do have someone who has what I'm calling to have a broader term fundamental life-diving belief but then one of us knows what's wrong with and here I think if there is something wrong with it we look to the institutional role of a physician and to the fact that the physician has a kind of power and more that the physician is even in the American system in some ways a quasi-state agent in the sense that they're licensed huge amount of revenue comes from this or that form of federal program, the toolbox comes from the NIH and so on and so forth and I'm running a candy store and there is a principle of liberal political theory that says that state agents would not to try and impose a verse of pluralistic society on one or another on the fundamental life-diving belief and that this and that insofar as the relationship with your patients is one of a certain kind of asymmetry and power that's a relevant distinction that might provide a reason to tread very, very lightly in one kind of place and less so that's in the way Mike thought that out to some degree in those few instances institutional roles