In this companion volume to their 1981 work, A Philosophical Basis of Medical Practice, Pellegrino and Thomasma examine the principle of beneficence and its role in the practice of medicine. Their analysis, which is grounded in a thorough-going philosophy of medicine, addresses a wide array of practical and ethical concerns that are a part of health care decision-making today. Among these issues are the withdrawing and withholding of nutrition and hydration, competency assessment, the requirements for valid surrogate decision-making, quality-of-life determinations, the allocation of scarce health care resources, medical gatekeeping, and for-profit medicine. The authors argue for the restoration of beneficence (re-interpreted as beneficence-in-trust) to its place as the fundamental principle of medical ethics. They maintain that to be guided by beneficence a physician must perform a right and good healing action which is consonant with the individual patient's values. In order to act in the patient's best interests, or the patient's good, the physician and patient must discern what that good is. This knowledge is gained only through a process of dialogue between patient and/or family and physician which respects and honors the patient's autonomous self-understanding and choice in the matter of treatment options. This emphasis on a dialogical discernment of the patient's good rejects the assumption long held in medicine that what is considered to be the medical good is necessarily the good for this patient. In viewing autonomy as a necessary condition of beneficence, the authors move beyond a trend in the medical ethics literature which identifies beneficence with paternalism. In their analysis of beneficence, the authors reject the current emphasis on rights- and duty-based ethical systems in favor of a virtue-based theory which is grounded in the physician-patient relationship. This book's provocative contributions to medical ethics will be of great interest not only to physicians and other health professionals, but also to ethicists, students, patients, families, and all others concerned with the relationship of professional to patient and patient to professional in health care today.
PART I: The Delineation of Beneficence1. Paternalism, Autonomy, and Beneficence in the Patient-Doctor Relationship2. Limitations of Autonomy and Paternalism: Toward a Model of Beneficence3. Why Good Rather than Rights?4. Beneficence-in-TrustPART II: The Implications of Beneficence for the Doctor and Patient5. Health and Ethical Norms6. The Good of the Patient7. Quality of Life Judgements and Medical Indications8. The Good Patient9. The Good PhysicianPART III: The Consequences of Beneficence10. The Common Devotion: A Reconstruction of Medical Ethics11. Making Decisions Under Uncertainty12. Making Decisions for Incompetent Patients13. The Role of Physicians, Families and Other Surrogates in Decisions Concerning Incompetent Patients14. The Physician as Gatekeeper15. Beneficence-in-Trust: How It Is Applied16. A Medical Oath for the Post Hippocratic Era