Through the bioethical retrospectoscope

Abstract

Abstract A retrospectoscope is understood here as a fictional instrument through which the past history of certain ideas can help the understanding of their present sense, including the awareness of how our ideas may have drifted off the path. Concretely, this retrospectoscope will seek out the origins of the ethical principles that are so prominent in contemporary bioethics and show how interpretations of these principles have led contemporary bioethics astray, making paradoxes and dilemmas out of what should be resolutions and illuminations. This essay explores, in particular, how the principle of autonomy originated in the protection of subjects of biomedical research and then moved into the relationship between physicians and patients. This shift took place without sufficient recognition of the significant differences between these settings. Respect for autonomy clearly has priority as an ethical principle in the endeavor of medical research. It may not have such priority, at least not in the same sense, in medical practice. The Belmont Report (which concerned medical research) defined Respect for Persons as “the ethical conviction that individuals should be treated as autonomous agents…”, and stated that this autonomy was self-determination. Clinical medicine, however, differs from research radically. It begins with a person bringing an apparently compelling need to a practitioner. Healing is a helping activity, focused on response to a specific request from a specific person in need. The primary moral quality of this activity is the formation of a trusting alliance between physician and patient, in which the focus on the patient's needs is straight and clear, communication is honest and illuminating, and acceptance and collaboration are real. At the same time, the therapeutic relationship must often be formed at a time when the autonomy of the patient is often buried deeply under pain, debility, and physical and moral distress, or extinguished by radically altered mental status. If one wishes to express that alliance in moral terms, one might still invoke the same phrase, Respect for Persons. But that phrase should take on a quite different meaning in the therapeutic alliance than it has in the research enterprise. Unfortunately, in most of the current literature the issue of Respect is focused almost entirely on Informed Consent, the procedure in which autonomy is supposed to be realized.