Challenges to the Moral Expertise Behind the Four Principles Approach: The “collective is not the patient”

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In The “New” Medical Morality: Hippocrates or Bioethics? Jeffrey Hall Dobken writes, “…the neo-discipline of bioethics must be examined for moral effectiveness as well as clinical outcome.” By examining whose “needs and interests” are served by bioethics, Dobken criticizes the marginalization of both the doctor and patient voice. Dobken also questions the four principles and the social compact behind them, comically asserting an assumption that bioethicists are “incorruptible”. By limiting the realm of acceptable choices, bioethics may be limiting the autonomy it claims to protect. His thesis is that bioethics is population-centric rather than person-centric. Interestingly, Dobken argues that bioethics sort of hijacked the virtues espoused by the Hippocratic Oath when the field condemned paternalism but failed to fairly address patient care and opted instead to favor the collective.

To me, bioethics under the four principles regimes fails individuals in the medical care process. Some people may want to apply rules across the platform with little regard to the voice of those most affected by the care. The individual voice is not conducive to universal norms and may be addressed by virtuous doctors fulfilling the non-paternalistic aspects of the oath. Under the four principles approach, the collective may be served by throwing a patient or two under the bus for the sake of standardization. “Moral expertise” works against individuality.

“The stated aim of preserving and protecting individual
autonomy in medical decision-making for patients and
their families has not only become limited in such a climate,
but has been effectively negated…” Dobken

I agree that the “collective is not the patient” but I would hate to see a reversion to the doctor holding all of the power in the doctor-patient relationship. The arms-length bioethics journal articles and hospital committees are a problem. Defining a code of acceptable conduct for professionals is vastly different from a code for individuals seeking or refusing care. The moral authority of the arms-length bioethicist must be challenged. There is not consensus on when, if ever, it is moral to make certain personal decisions for others, limiting their freedom and ignoring their autonomy. While one can develop expertise in ethics and philosophy, can one really be in a position to behave as judge and jury on issues as personal as someone else’s medical care? The concept of moral expertise draws criticism creating a space for bioethics to adapt, step back rather than imposing views universally in a complex, politically and culturally diverse system, and learn from those most affected by decisions.

Dobken Article Journal of Amer Phys and Surgeons Vol 23, No 2, Summer 2018 free and open access by the Faculty at Touro Scholar. Michael Cook, “A Dissenting View of Modern Bioethics,” June 16, 2018. Robert Truog, “Tackling Medical Futility in Texas” NEJM (ethics committees as “judge and jury.”)

Photo 193464165 © Lilas Ghannoum |

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