Principles and Metaphors in Biomedical Ethics Philosophy 179-757-01, Georgetown University, Fall 1985 Friday, 1: 15- 2:55, Kennedy Institute Conference Room James F. Childress This seminar offers a systematic examination of the way principles and metaphors shape practical and theoretical discourse in biomedical ethics. We will use several principles and metaphors to explore some major problems (such as the authority of professionals, the allocation of health care resources, the procurement and distribution of organs for trans- plantation, and withholding or withdrawing artificial nutrition and hydration) and to analyze critically some important recent literature in biomedical ethics. Format, procedures, requirements, and readings will be discussed at th first meeting. Tentative list of topics for each session: 1. Principles 2. Metaphors 3. Metaphors and Models of Relationships between Health Care Professionals and Patients 4. Professional Paternalism and Patient Autonomy 5. The Significance of Theological Perspectives: The Problem of Suicide 6. Virtues and Vices: Self, Character, and Conduct 7. Moral Distance 8. Withholding or Withdrawing Medical Nutrition and Hydration: The Significance of Symbolic Actions 9. Valuing Lives 10. Justice, Triage, and Rationing 11. The Gift of Life: Justice and Charity in the Procurement and Distribution of Organs for Transplantation 12. Conclusions Readings Session #1, “Moral Principles” Required Readings: Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 2nd ed. (1983), chaps, 1-2, the first part of chaps. 3-6 Steven Toulmin, “The Tyranny of Principles,” Hastings Center Report 11 (December 1981 ) Additional Readings R.M. Hare, “Principles,” Freedom and Reason (1963) Marcus Singer, “Moral Rules and Principles,” Essays in Moral Philosophy, ed., A. I. Melden (1958) I.. M. Crombie, “Moral Principles,” Christian Ethics and Contemporary Philosophy, ed. I. T. Ramsey (1966) J. B. Schneewind, “Moral Knowledge and Moral Principles,” Knowledge and Necessity, Royal Institute of Philosophy Lectures, Vol. 3 (1979) Albert Jonsen, Mark Siegler, William Winslade, Clinical Ethics (1982) Stanley Hauerwas and Alasdair MacIntyre, eds., Revisions: Changing Perspectives in Moral Philosophy (1983) James M. Gustafson, “Moral Discernment in the Christian Life,” Theology and Christian Ethics (1974) Session #2, “Metaphors” Required Readings: George Lakoff and Mark Johnson, “Conceptual Metaphor in Everyday Language,” Journal of Philosophy 77 (August 1980): 453-86 Virginia Warren, “A Powerful Metaphor: Medicine is War” John Noonan, “How to Argue About Abortion,” in Contemporary Issues in Bioethics, eds. Tom L. Beauchamp and LeRoy Walters (1978) Additional Readings: George Lakoff and Mark Johnson, Metaphors We Live By (1980) Susan Sontag, Illness as Metaphor (1979) Samuel Vaisrub, Medicine's Metaphors: Messages and Menaces (1977) Mark Johnson, ed., Philosophical Perspectives on Metaphor (1981) Paul Ricoeur, The Rule of Metaphor (1977) Seldon Sacks, ed., On Metaphor (1979) Max Black, “Metaphors,” Models and Metaphors (1962) Ian Barbour, Myths, Models and Paradigms (1974) Andrew Ortony, ed., Metaphor and Thought (1979) Donald A. Schön, “Generative Metaphor: A Perspective on Problem-Setting in Social Policy,” in Ortony, ed., Metaphor and Thought (1979) H. Richard Niebuhr, The Responsible Self (1963), esp. I and app. A Stanley Hauerwas, “The Significance of Vision: Toward an Aesthetic Ethics,” Vision and Virtue (1974) Margaret Macdonald “The Language of Political Theory,” in Logic and Language, 1st and 2nd Series, ed. Antony Flew (1965), pp. 174-94 Philip Wheelwright, Metaphor and Reality (1962) Debra C. Rosenthal, “Metaphors, Models, and Analogies in Social Science and Public Policy,” Political Behavior 4 (1982): 283-301 Lawrence Pray, Journey of a Diabetic (1983) Session #3, “Metaphors and Models of Relationships between Health Care Pro- fessionals and Patients” Required Readings: Robert Veatch, A Theory of Medical Ethics (1981), chaps. 4 & 5 “Models for Ethical Medicine in a Revolutionary Age,” HCR 2 (1972): 5-7 Mark Siegler, “Searching for Moral Certainty in Medicine: A Proposal for a New Model of the Doctor-Patient Encounter,” Bulletin of New York Academy of Medicine 57 (1981): 56-69 , Gerald R. Winslow, “From Loyalty to Advisory: A New Metaphor for Nursing,” HCR 14 (1984): 32-40 “Code, Covenant, Contract or Philanthropy,” HCR 5 (1975): 29-38 Additional Readings: Jay Katz, The Silent World of Doctor and Patient (1984) James F. Childress, Who Should Decide? Paternalism in Health Care (1982), chap. 1 Tom L. Beauchamp and Laurence B. .McCullough, Medical Ethics: The Moral Responsibilities of Physicians (1984) Paul Ramsey, The Patient as Person (1970), preface, chap. 1 Charles Fried, Medical Experimentation (1974) “The Lawyer as Friend: The Moral Foundations of the Lawyer-Client Relation,” Yale Law Journal 85 (July 1976): 1060-89 Roy Branson, “The Secularization of American Medicine,” Hastings Center Studies 1, no. 2 (1973): 11-28 Leon Kass, “Ethical Dilemmas in the Care of the Ill: I. What is the Physician's Service?” JAMA 244 (October 17, 1980) Robert A. Burt, Taking; Care of Strangers: The Rule of Law in Doctor-Patient Relations (1979) Bernard Barber, Informed Consent in Medical Therapy and Research (1979), chap. 4 Miriam Siegler and Humphry Osmond, Patienthood: The Art of Being a Responsible Patient (1979) Thomas Szasz and Marc H. Hollender, “A Contribution to the Philosophy of Medicine: The Basic Models of the Doctor-Patient Relationship,” Archives of Internal Medicine 97 (May 1956): 585-92 Thomas Szasz, William F. Knoff, and Marc H. Hollender, “The Doctor-Patient Relationship and its Historical Context,” The American Journal of Psychiatry, Vol. 115 (December 1958) P. Lain Entralgo, Doctor and Patient (1969) Roger D. Masters, “Is Contract an Adequate Basis for Medical Care?” HCR 5 (December 1975): 24-28 Eric Cassell, The Healer's Art (1976) Talcott Parsons, “The Sick Role and the Role of the Physician Reconsidered,” Milbank Memorial Fund Quarterly (Summer 1975): 257-77 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Making Health Care Decisions (1982), report and two appendices Edmund D. Pellegrino and David C. Thomasma, A Philosophical Basis of Medical Practice (1981) “Autonomy and the Doctor-Patient Relationship”" Theoretical Medicine 5, no. 1 (February 1984) Earl Shelp, ed., The Clinical Encounter: The Moral Fabric of the Patient-Physician Relationship, Philosophy and Medicine 14 (1983) Session #4, “Paternalism and Autonomy” Required Readings: Robert Veatch, A Theory of Medical Ethics, chaps. 6 & 8 James F. Childress, Who Should Decide?, chaps. 1,4 & 5 Additional Readings: David Jackson and Stuart Youngner, “Patient-Autonomy and 'Death with Dignity,'” The New England Journal of Medicine 301 (August 23, 1979): 404-408 S. Imbus and B. Zawacki, “Autonomy for Burned Patients....” NEJM 297 (August 11,1977): 308ff. Bruce Miller, “Autonomy and the Refusal of Lifesaving Treatment,” HCR 11 (August 1981): 22-28 Wade Robison and Michael Pritchard, eds., Medical Responsibility (1979) Richard Sennett, Authority (1980), esp. 2 & 3 John Kleinig, Paternalism (1983) Rolf Sartorius, ed., Paternalism (1983) Tom L. Beauchamp and Laurence B. McCullough, Medical Ethics: The Moral Responsibilities of Physicians (1984) Tristram Engelhardt, Foundations of Bioethics (1985) H.L.A. Hart, Law, Liberty and Morality (1963), chap. 1 Tom L. Beauchamp, “Paternalism,” Encyclopedia of Bioethics (1978) “Paternalism and Bio-behavioral Control,” Monist 60 (January 1977) Gerald Dworkin, “Paternalism,” Morality and the Law, ed. Richard Wasserstrom (1971) . Dan Wikler, “Paternalism and the Mildly Retarded,” Philosophy and Public Affairs 8 (1979) Bernard Gert and Charles Culver, Philosophy in Medicine (1982), as well as various articles A. Buchanan, “Medical Paternalism,” Philosophy and Public Affairs 7 (1978) Joel Feinberg, Social Philosophy (1973) Session #5, “The Significance of Theological Perspectives” In some areas of moral disagreement in medicine and health care, theological perspectives are significant, and theologians frequently appeal to perspectives, vision, metaphors, stories, and narratives, as well as to principles, in developing biomedical ethics. Two major areas will be used to explicate some differences between many theological and many (though by no means all) philosophical approaches: suicide and refusal of life-sustaining treatment. Of particular interest is the work of James Gustafson and Stanley Hauerwas-- the former offering a theocentric perspective and the latter a narrative-shaped-character – over against the principle of autonomy. General theological convictions undergird or are expressed in several images, metaphors, and analogies (e.g., the body as property, given, loaned or entrusted by God to human beings for thoughtful stewardship) and principles for guiding that stewardship. Required Readings: M. Pabst Battin, Ethical Issues in Suicide (1982), excerpts James M. Gustafson, Ethics from a Theocentric Perspective, Vol. II, (1984), excerpts Stanley Hauerwas, “Rational Suicide and Reasons for Living,” in Rights and Responsibilities in Medicine, ed. Marc Basson (1981) Additional Readings: Paul Ramsey, The Patient as Person (1970) Richard McCormick, S.J. How Brave a New World? (1981) M..Pabst Battin and David Mayo, eds., Suicide: The Philosophical Issues (1980) Karen Lebacqz and H. Tristram Engelhardt, “Suicide,” Death, Dying and Euthanasia, ed.,