Best interests

Reader Bob Hunt, commenting on Abortion and execution clarifies his position regarding a physician's interaction with a patient:

You defined the matter in terms of the patient's best interest "in the patient's own terms," not the physician's. That's a big wrench to throw into the equation. ... Obviously, a physician would judge a treatment as contrary to his or her conscience because he or she believes that it would not be in the patient's best interest, even if that means disagreeing with the patient on what is in the patient's best interest.

Mr. Hunt's position brings up a critical question for all utilitarian ethical accounts, including subjective accounts: on what basis do we determine any individual's best interests in a fundamental way? Determining an individual's best interests is an issue for all ethical situations, not just specifically medical situations, but an examination of medical situations can, I think, provide important insights.

(Whether a fetus has its own "best interests," interests that a physician is obliged to consider, is an interesting and profound question (albeit a question with one good answer), but it is a completely different question than the issue under discussion in this post. We are, per Mr. Hunt's explicitly stated position, discussing the methodology a physician uses to determine the patient's best interests, not which patients the physician must determine the best interests of.)

On an objectivist utilitarian account, we can, at least in principle, determine an individual's best interests without taking into account her specific subjective mental characteristics, indeed we can determine best interests without taking into account any person's or group of person's subjective accounts. I'm aware of no serious objectivist account that takes into account any external non-mental contingencies (e.g. the phase of the moon or the price of tea in China); we may confidently conclude that an objectivist account of "best interests" is therefore a universal account: all people in the same objective, physical circumstances would therefore have the same best interests.

On a subjectivist account, an individual's best interests does substantively depends on her specific subjective mental states, or the mental states of some person or group of persons. In other words, the truth of any statement of best interests is, on a subjectivist account, relative to the subjective state of some person or persons. Since we cannot directly observe anyone's mental states, we must somehow infer those states.

Ordinarily, we infer a person's mental states by asking her or listening to her speak. If someone says, "I want a hamburger," we infer that she presently has the mental state of "wanting a hamburger." Such an inference is the simplest explanation to account for the facts, in this case the fact of the utterance.

Sometimes determining all the mental states relevant to a particular circumstance is non-trivial. People sometimes have conflicting desires and preferences: a person might desire a tasty hamburger, but not desire the consequences of the fat and cholesterol. Most desires must be fulfilled through the objective, material world: if (all things considered) a person wants to eat a hamburger, there are definite, bounded ways she must interact with the material world to actually eat a hamburger. People sometimes have false beliefs about reality; they might believe that if they want a hamburger, the best way to satisfy that desire is to go to Taco Bell.

A subjectivist account of best interests, then, entails that we ask the individual to speak, make the best scientific inference as to the corresponding mental states, and determine the best interests that correspond to those mental states.

In medicine specifically, it's clear that there is a strong subjectivist component to account for the best outcome, and an strong objectivist account for the best treatment to achieve that outcome. For example, if some treatment is especially risky or entails significant side effects, it is the patient's choice whether to face those risks or endure the side effects, or leave the underlying condition untreated. Affording this choice is determining the patient's best interests as corresponding to her subjective mental states. Indeed even if a physician believes the patient has an exaggerated subjective evaluation of undesirability of the risk or the side effects, the physician cannot simply override the patient's subjective evaluation; she must persuade the patient to accept the risk: she must attempt change the patient's subjective state and thereby change the patient's subjectively defined best interests.

On the other hand, if a patient desires a particular outcome (e.g. having her cancer cured), it is a matter of objective truth that there is a well-defined bounded set of actions scientifically known to achieve that outcome, and a well-defined bounded set of actions scientifically known to not achieve that outcome. A patient's subjective desires regarding treatment are indeed irrelevant precisely because efficacy and risk are matters of objective truth.

A pregnant woman comes to a physician seeking an abortion. It's uncontroversial on any account that the physician must, of course, ensure that the woman really does want to be not pregnant: He* must determine that not being pregnant really is in the patient's subjectively defined best interests. Once he has determined that she really does want to be not pregnant, it is a matter of uncontroversial scientific truth that there is a specific set of procedures one of which must be performed to achieve that end, that are known to achieve that end, and have known risks and side-effects comparable to other routinely condoned and performed medical procedures.

*I'll use the male pronoun only to easily disambiguate the physician from the patient; the latter being in this context always female.

What, however, are we to make of a physician whose domain of practice includes abortion, but seeks an exemption from ever performing that procedure? We must ask: on what basis does he seek the exemption? What are the overall effects of privileging the principle of allowing individual physicians to make medical decisions on that basis?

The physician must be referencing the ends (not being pregnant), since the relevant characteristics of the means (the various procedures for performing an abortion) are matters of uncontroversial, settled scientific truth. The physician therefore must have either an objective or subjective basis for objecting to the ends.

If a physician has an objectivist objection to the ends, he is saying in effect it is objectively true that it is never in a pregnant woman's best interests to not be pregnant. But if this is his position, basing this position on conscience is inept: Matters of objective truth — at least in medicine — must be settled by scientific inquiry, not individual opinion. Furthermore an objectivist position implies a universal position: any other physician who disagrees with him must be mistaken, since there is by definition exactly right answer to yes-or-no questions about objective truth. If this were truly his belief, then he has a moral obligation not just to personally abstain, but to do everything in his power to correct the mistake of his colleagues. Seeking only a personal exemption should be seen as nothing but moral cowardice.

Lacking an objectivist objection, the physician therefore must have a subjectivist objection. There are only three general subjectivist bases to object: the patient's own subjective state, the physicians own subjective state, or statistical, collective properties of the subjective states of the members of the community, culture, society or state.

We can eliminate the latter: the Supreme Court in Roe v. Wade determined that — all things considered — the state (and therefore the community, culture and society) does not have a collective opinion relevant to the desirability of having an abortion in the first trimester; abortion may neither be compelled nor prohibited on this basis.

An objection based on the patient's subjective state poses the same problem. The process of inferring an individual's subjective state is a scientific process. A physician must state that we never infer a woman's relevant subjective state to be those that correspond to the best interests of being not pregnant. To make this statement, however, the physician must propose and defend a definite scientific, evidentiary methodology to support such a statement; an appeal to conscience is not a scientific methodology. Alternatively, a physician could propose that there are no subjective states at all that correspond to the best interests of being not pregnant. Again, he must put forth some sort of logical or philosophical argument for such a determination; personal conscience is no more a philosophical argument than it is a scientific methodology.

(The physician could also assert that every pregnant woman who desires to be not pregnant is ipso facto insane, in the same sense that we determine that everyone who wants to die (and who is not terminally ill) is insane. I don't think anyone serious advocates this position, so I will waste no more ink rebutting it.)

There is simply no basis for relying on a physician's "expert judgment" in determining a patient's subjective states in a general, when the actual determination is substantively different from the ordinary method that most everyone is competent in employing: querying a person and taking their answers (more or less) at face value. If we use the ordinary methodology for determining subjective states and determining the corresponding best interests, is is uncontroversially the case that millions of pregnant women's subjective states and the corresponding best interests are to be not pregnant. Not only must a physician offer a better reason than "conscience" to make a different determination, but also there are no better reasons a physician can rationally offer.

So we're left with the physician's own subjective state. But if the previous constructions are merely unreasonable, the idea that the best interests of the patient are dependent on and relative to the subjective state of the physician is so wildly counter-intuitive as to verge on the ridiculous.

When the scientific truth of the efficacy or safety of some procedure is equivocal, ambiguous or not well-established, I would certainly trust a physician's more-or-less subjective judgment on the desirability of some specific procedure to achieve the typically desired end of good health. If one physician considers an experimental procedure to be worth trying, but another considers it too risky relative to its efficacy, and the current state of scientific knowledge is objectively ambiguous, there's no objection to permitting one physician to perform the procedure and another to refuse it.

There is no basis, however, other than insufferable arrogance or blatant irrationality on which a physician could determine, when a patient is in possession of all relevant scientific knowledge and is demonstrably sane, that the patient is incompetent to determine and articulate her own fundamental best interests. Such a physician should not only be drummed out of the medical profession, but earns our contempt as a human being.