Beneficence and Health Care

278 Pages·1982·14.001 MB·English

by  Darrel W. Amundsen, Gary B. Ferngren (auth.), Earl E. Shelp (eds.)

BENEFICENCE AND HEALTH CARE
PHILOSOPHY AND MEDICINE
Editors:
H. TRISTRAM ENGELHARDT, JR.
Kennedy Institute of Ethics, Georgetown University, Washington, D.C., U.S.A.
STUART F. SPIeKER
University of Connecticut Health Center, Farmington, Connecticut, U.S.A.
VOLUME 11
BENEFICENCE
AND HEALTH
CA]~E
Edited by
EARL E. SHELP
Institute of Religion and Bay/or Col/ege ofM edicine, Houston, Texas
D. REIDEL PUBLISHING COMPANY
DORDRECHT: HOLLAND / BOSTON: U.S.A.
LONDON: ENGLAND
library of Congress Cataloging in Publication Data
Main entry under title:
Beneficence and health care.
(Philosophy and medicine; v. 11)
Bibliography: p.
Includes index.
1. Benevolence-Addresses, essays, lectures. 2. Altruism
Addresses, essays, lectures. 3. Medical care-Moral and ethical
aspects-Addresses, essays, lectures. I. Shelp, Earl E., 1947-
II. Series. [DNLM: 1. Ethics, Medical. 2. Religion and
medicine. 3. Delivery of health care. W3 PH609 v, 11 1982 /
W 50 B463]
B11474.B46 174'.2 82-540
ISBN-13: 978-94-009-7771-6 e-ISBN-13: 978-94-009-7769-3
001: 10.1007/978-94-009-7769-3
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T ABLE OF CONTENTS
EARL E. SHELP / Introduction vii
SECTION II HISTORICAL AND CONCEPTUAL BACKGROUND
DARREL W. AMUNDSEN and GARY B. FERNGREN / Philan-
thropy in Medicine: Some Historical Perspectives 1
ALLEN E. BUCHANAN / Philosophical Foundations of Beneficence 33
WILLIAM K. FRANKENA / Beneficence in an Ethics of Virtue 63
JOHN P. REEDER, JR. / Beneficence, Supererogation, and Role
Duty 83
SECTION II I BENEFICENCE IN RELIGIOUS ETHICS
RONALD M. GREEN / Jewish Ethics and Beneficence 109
WILLIAM E. MA Y / Roman Catholic Ethics and Beneficence 127
HARMON L. SMITH / Protestant Ethics and Beneficence 153
SECTION III I BENEFICENCE IN HEALTH CARE
NAT A LIE A BRA M S / Scope of Beneficence in Health Care 183
EARL E. SHELP / To Benefit and Respect Persons: A Challenge for
Beneficence in Health Care 199
JAMES F. CHILDRESS / Beneficence and Health Policy: Reduction
of Risk-Taking 223
RONALD M. GREEN / Altruism in Health Care 239
EARL E. SHELP / Epilogue 255
NOTES ON CONTRIBUTORS 257
INDEX 259
EARL E. SHELP
INTRODUCTION
The meaning and application of the principle of beneficence to issues in health
care is rarely clear or certain. Although the principle is frequently employed
to justify a variety of actions and inactions, very little has been done from a
conceptual point of view to test its relevance to these behaviors or to explore
its relationship to other moral principles that also might be called upon to
guide or justify conduct. Perhaps more than any other, the principle of benef
icence seems particularly appropriate to contexts of health care in which two
or more parties interact from positions of relative strength and weakness,
advantage and need, to pursue some perceived goal. It is among those moral
principles that Tom L. Beauchamp and James F. Childress selected in their
textbook on bioethics as applicable to biomedicine in general and relevant
to a range of specific issues ([1], pp. 135-167). More narrowly, The National
Commission for the Protection of Human Subjects of Biomedical and Behav
ioral Research identified beneficence as among those moral principles that
have particular relevance to the conduct of research involving humans (2).
Thus, the principle of beneficence is seen as pertinent to the routine delivery
of health care, the discovery of new therapies, and the rationale of public
policies related to health care.
Given the sort of central place the principle of beneficence commonly has
in guiding and justifying activity in health care, it is important to the moral
conduct of that enterprise to understand what the principle means, what it
rightly warrants and what it does not. The essays in this volume respond to
these concerns. A previous volume in the series, Philosophy and Medicine
(No.8), addressed the relevance and implications of the principle of justice
for health care [3]. The essays in that collection discussed what might be
owed to persons in health care as a matter of their due or right. As a compan
ion and complement to that earlier work, these essays interpret the principle
of beneficence from several philosophical and theological perspectives in
order to suggest its meaning, relevance, and application to a variety of moral
concerns in contemporary health care.
Much in this volume is ground-breaking. And, the contributors report
that the ground was not easily broken! Several found that much of the
existing theoretical and applied literature on beneficence was inadequate
vii
Earl E. Shelp (ed.), Beneficence and Health Care, vii-xvi.
Copyright © 1982 by D. Reidel Publishing Company, Dordrecht, Holland..
viii EARL E. SHELP
or inappropriate for the specific selected concerns addressed here. Yet, in
spite of the difficulty of the assignment, all have been faithful to their charge.
The creative bounty of their labors is here presented to stimulate, enrich, and
advance contemporary moral reflection about the principle of beneficence
and its strategic importance to health care. The essays are presented within
three categories of investigation. The first section contains one historical and
three philosophical studies that provide an introduction to the history of
beneficence in medicine and an orientation to the foundation, nature, and
function of the principle of beneficence in theories of ethics. The second
section contains three essays. These examine the place of beneficence in West
ern religious ethics and comment on the relationship of these understandings
to moral questions in health care. The third section contains four essays that
investigate the meaning of beneficence for health care and the relevance of
beneficence to the distribution of health care resources.
The section of background studies begins with an historical study by Darrel
Amundsen and Gary Ferngren. They provide a description of a commen
tary on that elusive quality of the medical event that alternately has been
called 'caring', 'compassion', 'humanitarianism', 'altruism', 'beneficence', and
'philanthropy'. They focus on the use of 'philanthropy' and the concept of
beneficence in medical history in order to assess the meaning and implication
of the concept for present health care concerns, especially the patient-physi
cian relationship. Their review begins in the Greek period of medicine where
philanthropy carried within it a notion of reciprocity or obligation on the
part of the recipient to honor the giver. During the Roman period the scope of
philanthropy (humanitas) was extended in philosophical and popular ethics
to be more inclusive, giving voice to the notion of human brotherhood. But,
according to the authors, it was not until Scribonius !.argus (first century
C. E.) that philanthropy or love of mankind was considered an essential trait
of a physician. The relationship of the Christian idea of agape to philanthropy
also is discussed. The church's interest in the cure of bodies is traced to an
ethic of agape which was expressed at times in secular terms like philanthro
pia. As a result, hospitals were founded by the Christian church and medical
charity became a prominent part of the Christian movement. This was partic
ularly true for monasticism during the Middle Ages. With the advent of the
licensing of physicians (12th century), medical philanthropy was given a dif
ferent emphasis in both Christian and secular literature. The literary discussion
moves to a consideration of the treatment of the poor and the setting of fees.
Amundsen and Ferngren conclude that, during the periods reviewed, philan
thropy was considered by some an essential feature of the true physician. For
INTRODUCTION ix
others, competence enjoyed prominence with philanthropy or compassion
seen as merely desirable. The proper mix of these qualities among physicians
is still subject to debate. However, the debate gains perspective with a con
sideration of the historical precedents provided by this essay.
The background studies continue with a discussion by Allen Buchanan
of the role, function, and ground of beneficence in several moral theories.
He traces the basic lineaments of each theory and gives special attention to
the role of beneficence in Kant's moral theory, John Rawls's ideal contract
theory of justice, utilitarianism, Robert Nozick's rights-based libertarianism,
and rational egoism. His analysis draws upon three fundamental distinctions:
beneficence and benevolence, beneficence in special relationships and gener
alized beneficence, and the respective rational foundation of special and
generalized forms of beneficence. Buchanan observes that answers to questions
of who are the proper recipients of beneficence in health care and the place
of the principle of beneficence in a moral consideration of health care issues
depend on a general philosophical theory of beneficence. Thus, he critically
assesses the potential of each of the surveyed theories to provide an adequate
statement and ground for beneficence, finding areas of difficulty and profit in
all. He concludes his evaluation of beneficence in the selected, general moral
theories with suggestions of the implications of each for moral questions in
health care in terms of social policy and individual relationships.
William Frankena considers the implications of beneficence for health care
from the perspective of an ethics of virtue. He contrasts an ethics of virtue
with an ethics of duty. The former is concerned primarily with dispositions,
motives, traits, or ways of being as morally good, independent of the actions
which issue from them. The latter is concerned primarily with the rightness
of actions or duty independent of certain dispOsitions, motives, or traits.
Frankena notes that beneficence mayor may not have a place within an ethics
of virtue, noting that beneficence as now understood was not an important
virtue in the West before Christianity, with the possible exception of the
Stoics. He thinks that an adequate ethics of virtue must include justice as
a cardinal virtue as well as beneficence/benevolence. He does not consider
beneficence as a virtue. Rather, he combines benevolence and responsibility
as the disposition that can be properly characterized as virtuous. The central
component of this virtue is a motivation to do good and not evil to others.
Yet, he remarks that dispositions can be good without being morally good
and that virtues need not be necessarily moral ones. His representation of
beneficence in an ethics of virtue as beneficence/responsibility suggests that
all moral agents are to cultivate the virtue and then do in each situation what
x EARL E. SHELP
the virtue moves one to do. Frankena doubts that health care could be pro
vided adequately in a society that relied solely on personal virtue. He discusses
the implications of such an approach to various forms of individual and social
relationships pertinent to health and health care. The essay concludes with a
consideration of the relevance of an ethics of virtue to professional ethics.
John Reeder's review of the nature of the duty of beneficence concludes
the first section. He suggests that there are three levels or forms of duties of
beneficence. The first form, mutual aid, is held to be a general duty for all
members of the moral community apart from institutional provisions to
render assistance. Reeder distinguishes welfare and well-being, suggesting that
a moral agent has a duty to promote the former at the expense of the agent's
own well-being in whole or in part. He argues, recognizing that a justification
of his view is problematic, that a moral agent is obligated even to sacrifice
one's welfare up to an indeterminate point. This point is indeterminate
because of variations in empirical predictions of the future, levels of risk
people will tolerate, and value judgments regarding the ranking of various
goods. Yet, he holds that such a principle of obligation would be adopted
as a form of self-interest. Beyond this level of duty, Reeder's theory terms
actions on behalf of others as desirable or supererogatory but not required.
He suggests that supererogation can take several forms beyond the require
ments of mutual aid but that, again, the difference between mutual aid and
supererogation is sometimes difficult to determine. Medical treatment is not
considered by Reeder as subject to mutual aid or supererogatory beneficence
in situations where a specialized class of personnel function within a social
institution to perform this service. In the absence of unusual circumstances,
the duty of mutual aid is replaced by the system of medical care. Although
his analysis of role duties for medical personnel accommodates supereroga
tory beneficence, ''the beneficence which is proper to the therapeutic role is a
duty of justice."
Transitioning from philosophical investigations, the three essays in the
second section examine the role of beneficence or its equivalent in Judaism,
Roman Catholicism, and selected forms of Protestantism. Ronald Green
initiates this area of inquiry with a review of "Jewish Ethics and Beneficence."
He finds the tradition to be rich with reflection on matters of beneficience.
Opinions vary within the Jewish community regarding acts of beneficence
or self-sacrificing love, depending on the weight given to the worth of each
individual in a situation of conflict. Green sorts out several strands of Jewish
teaching about this complex and diverse area of inquiry. He notes that the
Rabbis encouraged generosity but held one's duty to be limited by one's
INTRODUCTION xi
responsibilities to oneself or one's community. Thus, the Rabbis recognized
a duty to save another's life but not necessarily at the cost of one's own
life. In health care contexts, the Rabbis held physicians to have certain
role-related duties that required the assumption of certain risks, beyond the
usual requirements, in order to serve one's patients. Green draws upon the
historic views of Judaism toward self-sacrifice or beneficence to conclude
his essay with a discussion of their implications for such concerns as visiting
the sick, financial support of institutions of health care, donation of blood,
medical experimentation, and organ donation.
William E. May finds the tradition of Roman Catholicism to be rich, like
Judaism, in reflection on acts of the virtue of charity which is the equivalent
to philosophical beneficence. His survey of Roman Catholic moral thought
includes a report of the relevant moral teachings issued by thl! magisterium
and an account of the debate among Roman Catholic writers about these
teachings, particularly as they relate to issues in health care. The magisterium
teaches that some goods like human life, justice, truth, love, and peace are
good in and of themselves. Further, evil ought not be done to produce good.
From these basic claims, specific norms of conduct are derived. Thus, accord
ing to May, certain acts in health care are incapable of being described as
beneficent because they would violate certain principles held to be universally
binding. He identifies euthanasia, abortion, contraception, and mutilation as
examples of violating acts. In addition to these universal principles, May
shows how the principles of 'double effect' and 'totality' have been used to
interpret and apply the teachings of the magisterium to contexts of health
care. The discussion then shifts to a summary of the contemporary debate
within the church regarding the relationship of the principle of beneficence
to the principle of utility or its Roman Catholic counterpart, proportionalism.
Advocates of proportionalism hold, according to May, that there are no moral
proscriptions that are absolutely unexceptional. Thus, they admit, in opposi
tion to the view of the magisterium, that certain acts in health care can be
beneficent if done for a proportionate reason. He thinks that the adequacy
of this view turns on an interpretation of the principle of double effect and
the distinction between a directly intended and an indirectly intended effect
of some action. The major features of this debate are detailed. May concludes
that the more proper view of beneficence in health care reflects agreement
with the teaching of the magisterium rather than with the thOUght of those
who favor proportionalism.
Harmon Smith examines the theologies of Martin Luther, John Calvin, and
John Wesley as representative of major traditions in Protestant Christianity.