n What is ethics? n What is autonomy? n Models of the health- professional-patient relationship

What ought to be done in a given situation, all things considered? --Benjamin and Curtis

What ought to be done... n Action oriented n Implies personal ownership and responsibility n Implies choice n Implies reasonable control

…in a given situation... n All ethics is “situation ethics” n Concrete facts matter n What makes one situation like another situation in ethically relevant ways?

…all things considered? n There is no “ethical point of view” distinct from other (“practical”) points of view n Good ethical reasoning is not a new viewpoint but an integration (and critical analysis) of all existing viewpoints n Can we ever in practice “consider all things” finally and irrevocably? (Provisional nature of ethical conclusion)

What ought to be done in a given situation, all things considered? Is this the only “ethical” question?

Snapshot ethics vs. Videotape ethics

Snapshot vs. videotape n What does it mean to do the right thing now? n What does it mean to live a morally good life?

Snapshot vs. videotape n What does it mean to do the right thing now? n Rules, principles, case study n What does it mean to live a morally good life? n Virtue

(Respect for) Autonomy n Not interfering in another’s wishes and choices n Treat others as ends-in-themselves and not as means only (Kant) n = Self-determination n Assumes “adult” capacities

Paternalism n Refusing to acquiesce in another person’s wishes or choices for that person’s own benefit. --Childress

Paternalism and Principles n Paternalism = principle of benefit/harm takes priority over principle of autonomy n Other, non-benefit-based reasons to reject autonomy not paternalism n Is it “really” paternalism if principle of autonomy does not apply due to lack of capacity?

Why paternalism and not parentalism? n Is concept gender-specific? n Does it derive from a gender-specific role? n “Father Knows Best” (TV show, 1950’s)

Paternalism and the history of U.S. medical ethics n Hippocratic ethic: no challenge to physician paternalism n 1960’s: traditional authority questioned n Veatch: Contractual vs. priestly model of physician-patient relationship, 1972 n Veatch, “generalization of expertise,” 1973

Paternalism and the history of U.S. medical ethics n Much of U.S. medical ethics since the 1960’s amounts to the refutation of physician paternalism

Autonomy: Problems to flag n Is autonomy culturally specific? n Is autonomy gender biased? n Does autonomy favor some life stages over others? n Does autonomy focus on individual in isolation rather than as member of family and community?

Models of P-patient relationship n Veatch, 1972: Priestly vs. Contractual models n Miller, 1981: 4 senses of autonomy n Emanuels, 1992: Paternalistic vs. Informative models-- and more

Miller, 4 senses of autonomy n Free action n Authenticity n Effective deliberation n Moral reflection --Miller, Hastings Cen Rep 1981

Autonomy and Relationship

Emanuels’ Models

If you went to your physician for medical care, what role would you want him or her to play, and why? Would it matter what the medical problem was?