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Respect for Persons: the Foundational Moral Disposition in Medicine (A Renewed Physician Ethos: Respect for Patients As Persons)

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Respect for Persons: the Foundational Moral Disposition in Medicine (A Renewed Physician Ethos: Respect for Patients As Persons) RESPECT FOR PERSONS: THE FOUNDATIONAL MORAL DISPOSITION IN MEDICINE (A RENEWED PHYSICIAN ETHOS: RESPECT FOR PATIENTS AS PERSONS) By Pascal Michael Caruso Dissertation Submitted to the Faculty of the Graduate School of Vanderbilt University In partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Philosophy May 2016 Nashville, Tennessee Approved: John Lachs, Ph.D Jeffrey S. Tlumak, Ph.D Michael P. Hodges, Ph.D Keith G. Meador, M.D., Th.M., MPH DEDICATION For my mother, Johanna Caruso, who exuded love toward all, encouraged us to think for ourselves and, by example, showed us that it is never too late to follow your bliss. A woman of extraordinary gifts and talents, who endured these being taken from her, one by one, with grace and without complaint, teaching us, in the end, how to suffer. She left us too soon. ii ACKNOWLEDGEMENTS The list of those who have contributed meaningfully to my developing and completing this project is long and you know who you are. To each of you I extend my heartfelt gratitude. I wish to thank John Lachs for his enthusiasm, reassurance and positive prodding. As my dissertation committee chair, graduate advisor, mentor and friend, he never lost faith in me, even when I doubted myself. His gentleness with students and unassuming nature exemplifies the disposition of respect for persons. Virginia, my loving wife, deserves my highest acknowledgement, for without her editorial assistance, guidance, criticism and continual encouragement, this dissertation would have never been submitted. iii TABLE OF CONTENTS PAGE DEDICATION………………………………………………………………………………………….. ii ACKNOWLEDGEMENTS ……………………………………………………………………………. iii TABLE OF CONTENTS ………………………………………………………………………………. iv DISSERTATION INTRODUCTION ………………………………………………………………….. 1 CHAPTER I. THE ELEMENTS AND ENTAILMENTS OF RESPECT FOR PERSONS IN MEDICINE: IDENTIFYING CONSTRAINTS AND DEMANDS……………………………………............... 30 II. KANT’S ETHICS OF RESPECT FOR PERSONS IN THE PRACTICE OF MEDICINE……… 81 III. BELMONT AND RESPECT FOR PERSONS………………………………………………....... 122 IV. FROM RESPECT FOR PERSONS TO RESPECT FOR AUTONOMY…………………………162 (Beauchamp And Childress: The Problems With Principlism) V. THE COVENANTAL PHYSICIAN-PATIENT RELATIONSHIP AND ITS CHALLENGERS. 207 VI. CARING, RESPECT AND CARING-RESPECT: THE SYNTHESIS OF THE UNIVERSAL... 273 AND PARTICULAR ASPECTS OF MEDICINE REFERENCES .................................................................................................................................... 319 iv DISSERTATION INTRODUCTION This dissertation seeks to establish Respect for Persons as the foundational moral concept of medicine and in particular for the doctor-patient relationship. It also seeks to establish that the fundamental moral commitments of medicine are entailed by the conceptual recognition of patients as persons. I argue that these combined conceptions ground the therapeutic relationship as a fundamentally moral one. I propose and provide evidence that these key concepts can serve as guideposts in actual medical practice, when understood as both moral dispositions (or moral feelings) and as moral principles at the core of moral medical practice. Respect is the primary ground of physician-patient ethics and serves as the basis for our attitudinal, cognitive and behavioral orientation toward patients. Respect for persons grounds a host of mid-level, contingent principles including, but by no means limited to, autonomy, beneficence, non- maleficence and justice. Respect grounds not only obligations but also virtues that physicians must develop and exemplify if they are to appropriately show the respect for their patients to which they are committed. Examples of virtues that are particularly applicable to medical practice include fidelity, trustworthiness, honesty, humility, respect and caring. This dissertation seeks to describe the moral commitments that underlie patient-centered care by analyzing the key ideas that are commonly described in the literature on respect for persons and relate them to caring. As the moral basis for patient-centered care, respect begins to take effect through the entailed physician obligation to establish an atmosphere of trust with the patient that ensures mutual participation and shared decision-making. In the literature of moral and political philosophy, the notion of respect for persons commonly means a kind of respect that all people are morally owed, just because they are persons, regardless of social position, individual characteristics, achievements, or moral merit. An explanation for our belief that humans (and perhaps other beings) are owed respect may first lie in our actual felt experiences of 1 reverential respect and plays a significant role in our intuition and development of this disposition toward others. It has been argued by Susan Buss and others that what justifies accepting our experience of respect for humans (or other beings) as grounds for an obligation is its coherence with our other moral beliefs (Buss 1999, Margalit 1996, Gibbard 1990). Kant argues that rational beings are the only entities that are ends in themselves and that all rational beings are ends in themselves. The term “person” means a being whose rational nature “already marks them out as ends in themselves…and an object of respect” (Groundwork 4: 428). Kant calls this distinctive worth “dignity.” In Kant's theory of value, dignity is the supreme value; thus ends in themselves are to be valued morally above all other beings. Kant argues that although individuals, as members of some social community or other, may have or lack meritorious accomplishment or status or may deserve honor (or evaluative respect) to differing degrees (or not at all), all persons are members of “the moral community.” Kant refers to the community of persons, under the moral law, as the kingdom of ends (in themselves). As such, all persons are owed the same moral recognition respect, by virtue of the dignity that they possess unconditionally and independently of all other characteristics. While all normally functioning human beings possess the rational capacities that Kant argued (at least in some of his writing) grounded respect, there are humans in whom these capacities are altogether absent and who therefore, according to some theories of human rationality or autonomy, are thus not persons and are not owed respect. It is unlikely that this is even close to what Kant had in mind. Simultaneously, we now understand that these capacities may be possessed by beings who are not biologically human (such as higher primates). Such beings would also potentially be persons and whom we are morally obligated to respect. It is most unlikely that Kant would have agreed to such designations, for, fundamentally, Kant grounded respect for persons in humanity, not in autonomy (at least not in the actualized or functional sense of autonomy). 2 Kant also held that because dignity is an absolute worth grounded in the rational capacities for morality, it is in no way conditional on how well or badly those capacities are exercised, or on whether a person acts morally or has a morally good character. Thus, dignity cannot be diminished or lost through vice or morally bad action, nor can it be increased through virtue or morally correct action. Recognition respect is not something individuals have to earn or might fail to earn, but something they are owed simply because they are rational beings. Finally, Kant argued that because dignity is absolute and incomparable, the worth of all rational beings is equal. What grounds dignity is something that all persons have in common, not something that distinguishes one individual from another. The equality of all rational beings, however, does not entail that each person must be treated the same as every other person, nor does it entail that persons cannot also be differentially evaluated and valued in other ways for their particular qualities, accomplishments, merit, or usefulness. Such valuing and treatment must always be constrained by the moral requirement to accord recognition respect to persons as ends in themselves. In this there is agreement between Kant’s view and my own. The point of this dissertation is not to argue for Kant’s conception of persons as grounded in autonomy. This project focuses rather on Kant’s arguments that respect is grounded in humanity or human nature. This general perspective of respect for persons is the only defensible understanding of the value of human beings, as persons, and of human life as possessing the dignity that is commensurate with the goals of medicine. The claim I will argue for is that within the practice and domain of medicine, all patients are persons and are deserving of respect. Central to this idea is that patients as persons have a distinctive moral status and physicians have special categorical obligations to regard and treat them in ways that are constrained by certain inviolable limits. These limits require that both the ends chosen and the means by which they are to be achieved should not violate the duties of respect to oneself (qua physician) or to one’s patients (qua persons). From this rudimentary understanding it is my intention to focus these concepts and their entailments upon medicine and, in particular, upon the relationship of patients with their physicians. 3 Thus the concept of person plays an essential justificatory role in bioethics. Nevertheless, some writers in bioethics have argued that we ought not to use the term ‘person’ to resolve
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