VALUE AND HEALTHCARE

Bioethics is concerned with values insofar as they are identical to universal or objective goods (benefits) and evils (harms). There is a use of value such that it refers to whatever any person happens to value, but this sense of value has no normative implications. What value refers to in this sense is completely determined by empirical research; it is a purely descriptive sense. There is a related sense of value such that it refers to what a large number of people value. This is the sense that seems to be important in economics. Economically speaking, something has value or is valuable if there are many people who value it, it can be transferred from one person to another, and there is not enough of it for all of the people who value it. How valuable something is on this understanding is also a completely empirical matter with no normative implications. However, there is another sense of valuable where what is valuable is what leads to less harms being suffered or more benefits gained, regardless of whether or not people are aware of this. This is an instrumental sense of valuable, and is objective. Modern healthcare, as a whole, is valuable in this sense, but some kinds of healthcare are not valuable, even though misinformed people value them.

Basic Values

Whether something has instrumental value is determined by whether it leads to a decrease in universal or objective evils or an increase in universal or objective goods. These goods and evils are the basic values because all other values in a normative sense are derived from them. Positive basic values have been called intrinsic goods, and negative basic values, intrinsic evils, but the phrases intrinsic goods and intrinsic evils are misleading, as they suggest that whether something is an intrinsic good or evil is independent of the attitudes of rational persons. However, an account of basic values that does not relate them to the attitudes of rational persons cannot explain why all rational persons avoid evils and do not avoid goods.

The following definition of basic evils (harms) and basic goods (benefits) acknowledges the necessary connection between basic values and rationality. "In the absence of reasons, evils or harms are what all rational persons avoid, and goods or benefits are what no rational person gives up or avoids" (Gert, 1998, ch. 4, p. 92). On this account of the basic values, there are five basic evils: death (permanent loss of consciousness), pain (including mental pains and other unpleasant feelings), disability (including loss of physical, mental, or volitional abilities), loss of freedom (including loss of freedom from being acted on as well as the freedom to act), and loss of pleasure (including loss of sources of pleasure). There are four basic goods: consciousness, ability, freedom, and pleasure.

These basic values are central to healthcare. Healthcare is primarily concerned with the prevention and cure of maladies, and with the relief of the symptoms of maladies that cannot be cured. Maladies, which include both diseases and injuries, have as an essential feature, that a person with a malady is suffering one of the basic harms, or has a significantly increased risk of suffering one of them (Gert, 1997, ch. 5). It is almost a truism that healthcare is primarily concerned with preventing, as far as possible, death, pain, and disability. Although not mentioned quite so commonly, healthcare is also concerned with treating those conditions of persons that would result in their suffering a loss of freedom or pleasure. Those in healthcare might rank the basic values differently from people outside of healthcare; physicians generally rank preventing evils as more important than promoting goods, and view death as the worst evil. However, no one in healthcare would challenge any of the items on the list of basic goods and evils, that is, the basic values.

Values and Rationality

Given that the definition of good and evils is based on the actions of rational persons, it may seem as if, without empirical research, nothing could be said about what counts as evils or harms, or what counts as goods or benefits. However, such research is impossible to carry out, for it requires examining what all rational persons avoid and do not avoid. A list of the basic goods and basic evils has already been provided, however, so there is a seeming inconsistency. It is important to clarify the definition so as to remove this problem. To say "In the absence of reasons, evils or harms are what all rational persons avoid, and goods or benefits are what no rational person gives up or avoids," means "In the absence of reasons, evils or harms are what all rational persons, insofar as they are acting rationally, avoid, and goods or benefits are what no rational person, insofar as he is acting rationally, gives up or avoids." Almost all rational persons sometimes act irrationally. This happens when they are in a very frightening situation or are overcome by some other strong emotion. What they happen to avoid or not avoid at these times is not relevant to the account of objective values.

Making clear that basic values are determined only by the behavior of rational persons insofar as they are acting rationally introduces a new problem. How is it determined that a person is acting rationally? This is a crucial question. Most philosophers, as well as most economists and political scientists, answer this question by providing a formal answer, one that has no universal or objective content. With various modifications, the standard answer to the question "What is it to act rationally?" is "It is to act in a way that maximizes the overall satisfaction of your desires." On the formal account of rationality under consideration, persons are acting rationally if and only if their actions are consistent with maximizing the satisfaction of their desires, regardless of the content of those desires.

On this account of rationality, there is no particular kind of thing that all rational persons act to avoid and not avoid, and thus there are no basic values or objective goods and evils. There are only values in a sense that has no normative implications. It might be thought that, at least, pleasure and pain would remain as goods and evils, but this is not so. The formal answer cannot restrict itself to persons who are not suffering from mental disorders. When people with serious mental disorders are included, it is not true that all persons acting rationally, defined as acting in a way that maximizes the overall satisfaction of their desires, act to avoid pain and act so as not to avoid pleasure, even in the absence of reasons. The maximizing satisfaction account of rationality results in values being defined as whatever people value. So defined, values have no normative implications. People determine for themselves what is good or evil and so pain and disabilities can be goods to some people, and pleasure and abilities, evils to them.

The Inadequacy of Formal Accounts of Rationality

Many attempts have been made to handle this problem, none of them satisfactory. Insofar as rationality is defined in purely formal terms with no limit on content, it loses its normative implications. It will always be possible to come up with an example that will categorize someone as acting rationally when no one would ever recommend that any person for whom they are concerned act in that way. For example, suppose a person's desire to kill himself in the most painful possible way is stronger than all of his other desires put altogether, even after full consideration. On the maximum satisfaction of desire view, he would be acting rationally to consult Consumer Reports, read biology books, etc., in order to achieve his goal. Once this consequence of the maximum satisfaction of desire view is made explicit, it is clear that this account of rationality has no normative force. Given this sense of rationality, it makes perfectly good sense to ask, "Why should I act rationally?" Many people would respond that on some occasions you should not act rationally.

In the normative sense of rationality, the one with which philosophers are properly concerned, no persons who are regarded as a moral agents, i.e., who are held responsible for their actions, would ever recommend to anyone for whom they were concerned, including themselves, that they ever act irrationally. They would never seriously ask, "Why shouldn't I act irrationally?" If it makes perfectly good sense to ask, "Why shouldn't I act irrationally?" then it is not important to determine whether rationality supports morality or anything else. The normative sense of rationality, like the normative sense of values, evils (harms) and goods (benefits), requires that there be universal agreement among moral agents on what kinds of things are harms and what kinds are benefits. All persons who are regarded as responsible for their behavior agree that they would always recommend to anyone for whom they were concerned, including themselves, that they act rationally and they would never recommend acting irrationally.

This agreement is what allows for clear counter-examples to all of the formal definitions of rationality. Everyone agrees that death, pain, disability, loss of freedom and loss of pleasure are evils. In the absence of reasons, all of us would recommend to anyone for whom we are concerned that he act in such a way as to avoid these harms. Likewise, in the absence of reasons, all of us would recommend to anyone for whom we are concerned that she not act so as to avoid the goods of consciousness, ability, freedom, or pleasure. Indeed, if, in the absence of reasons, persons do not act so as to avoid any of these harms or act to avoid any of these goods, they are regarded as acting irrationally. If they act in these ways for an extended period of time, they would be classified by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM IV) as suffering from a mental disorder. Having objective values (objective goods and evils), and having an account of rationality with content necessarily go together. Healthcare presupposes these objective values. Medicine aims at avoiding and relieving the basic evils that are the result of a condition of the person being treated.

Reasons

As pointed out in the previous paragraph, people are regarded as acting irrationally if, in the absence of reasons, they do not avoid the evils and do avoid the goods. This correctly suggests that the primary function of a reason is to make some otherwise irrational action rational. Since irrational actions are those in which, in the absence of reasons, a person does not act to avoid an evil or acts to avoid a good, reasons must be facts about avoiding evils or gaining goods. Only such facts can make it rational not to avoid an evil or to avoid a good. It is rational to amputate my right arm if that is necessary to avoid the spread of a cancer that will kill me. It is not rational to amputate my right arm simply because I want to do so, or because I correctly believe that doing so will make me asymmetrical. If desires are taken as reasons that can make an otherwise irrational action rational, then it could be perfectly rational not to avoid an evil or to avoid a good simply because of a desire to do so.

All reasons must involve one or more of these basic goods or evils that are involved in the account of an irrational action. Of course, not all reasons will be adequate to make all otherwise irrational actions rational. An adequate reason must be one that involves a good or an evil that is viewed by a significant number of otherwise rational persons as compensating for the evil suffered. Otherwise rational persons are persons who, in the absence of reasons, avoid evils and do not avoid goods. Rational people can, within limits, differ in their rankings of the goods and evils. What one person regards as an adequate reason for not avoiding a given evil, another person might not. But there are limits. It is irrational to commit suicide to avoid going to the dentist. However, it is not irrational to commit suicide when suffering from an incurable illness that is sufficiently painful or disabling. Although rational persons can, within limits, differ on which good counts as better and which evil counts as worse, they do not disagree on what counts as an evil or as a good. There is complete agreement on the basic values even though there is limited disagreement concerning their ranking.

Healthcare and Values

Healthcare is primarily concerned with preventing or treating those conditions of persons that cause or significantly increase the risk of death, pain, and disability and, to a lesser extent, the loss of freedom and pleasure. Healthcare is less involved with gaining any of the goods, but still has some concern with these matters. Those in healthcare might have a unique ranking of values, with the avoidance of death, pain, and disability, being ranked higher than they might be by people not in healthcare. However, English philosopher Thomas Hobbes (1588–1679), who was primarily concerned with politics, not with healthcare, also took death, pain, and disability to be of primary importance. Indeed, like many doctors, Hobbes seemed to view death as the worst of the evils. When the rankings of individual healthcare practitioners are not the same as the rankings of their patients, patients need not accept the rankings of their healthcare practitioners. On the contrary, healthcare practitioners must accept the rational rankings of their patients, for it is the patients that will actually be suffering the evils.

In addition to the basic values, there are also moral values. Moral values are the moral virtues, such as kindness, fairness, trustworthiness, and honesty. Moral values, like the basic goods and evils, are objective values. Kindness, fairness, trustworthiness, and honesty, are traits of character that all impartial rational persons want everyone to have because having these traits of character increase the probability that less harm will be suffered by all people affected. Indeed, a trait of character counts as a moral virtue only if its general practice increases the probability that less harm will be suffered than its not being generally practiced. There are other virtues of character such as courage, prudence, and temperance that all rational persons want for themselves because they increase the probability that the person himself, or those he cares for, will suffer less harm and gain greater benefits. These are personal virtues and although they are necessary in order to have the moral virtues, they are, as Hobbes and German philosopher Immanuel Kant (1724–1804) pointed out, traits of character that make immoral persons even more dangerous.

It should now be clear that there are no unique values in healthcare, either unique basic values or unique moral values. Since the moral values in healthcare cannot conflict with the moral values in the rest of life, it is not even plausible that there are any unique moral values in healthcare. There are duties that are unique to those in health case, but there are duties that are unique to those in every profession. But none of these duties exempt those in healthcare from the requirements of common morality. As in any profession, a physician may have duties that are in conflict with some other moral rule, but in all of these cases they must be willing for everyone to know that everyone is allowed to violate this other moral rule in circumstances with the same morally relevant features.

Although it may seem that some values such as kindness take on more importance in healthcare, there is no unique ranking of moral values. There are no moral values that are unique to healthcare. The importance of recognizing that there are no values, including moral values, that are unique to healthcare is that it makes clear that, as long as two persons know the facts of a situation equally well, it makes no difference to the validity of their judgments whether or not one is a practitioner of healthcare and the other not. Of course, those involved in healthcare usually know more of the relevant facts better than someone not involved in healthcare. However, the relevant facts should be made available to people outside the field as well as to those within. The advantages in moral evaluation and moral decision making about healthcare matters that those in healthcare have over those not in healthcare, in addition to greater knowledge of the facts, is greater experience and practice. These are not insignificant advantages.

Ethical Relativism

Anthropologists investigating a society previously unknown to them are very wary of criticizing any aspect of that society, even when that aspect involves a harmful practice. At one time, this reluctance to criticize was based upon a kind of naïve ethical relativism. They believed that each society had its own morality, but they believed that their own morality required tolerance, which they took to require that they not judge any practice in another society on the basis of their own moral standards. They did not even care whether the harmful practice was based on false beliefs about the empirical world. That the people of that society, or more commonly the dominant group in that society, accepted a certain practice, was all that was important. For various reasons, these views changed. Partly this was due to a great increase in the number of women anthropologists, and the widespread practice of female circumcision or genital mutilation in many societies being studied by anthropologists. However, even though many anthropologists now consider the practice of female circumcision to be immoral, they do not thereby immediately criticize that practice and try to get the society to stop practicing it. The reason for this is that they realize that this practice is tied into many other beliefs and practices, so that it is not clear how this practice can be changed or eliminated without doing greater harm to the people of that society.

Realization that objective evaluation of a society's practices is legitimate should lead to a more careful examination of the complex interrelationships between the practices in that society. It is not appropriate to criticize a practice and attempt to change or eliminate it until reasonably sure that changing or eliminating that practice will not result in even worse consequences. Caution is in order before trying to get a society to change or eliminate any of its practices. This is true not only of the practices of other societies, but also of a person's own society. Nonetheless, when encountering a harmful practice, it is now recognized that it is morally acceptable to try to find out what can be done to lessen the amount of harm, without causing even greater harm. A harmful practice should always give rise to an investigation about what can be done to change or eliminate that practice without resulting in greater harms. Anthropologists came to realize that the basic harms were universal. They also understood that a practice could be recognized as harmful even though it might not yet be known how to eliminate that harm without causing even greater harms.

Relativism and Unique Values in Healthcare

If healthcare is thought to have unique values, then people outside of healthcare, e.g., philosophers, might be in a position like those anthropologists who held ethical relativism. Evaluation by outsiders who did not share these unique values would be inappropriate. However, if healthcare shares the same values as all other areas of life, then all that outsiders need to know is what the facts are. However, similar to the situations of anthropologists, knowing all the facts is not an easy matter. Consider the following example; a philosopher claims, with some justification, that the process of providing information as practiced by the overwhelming number of doctors, is not adequate. On an ideal or philosophical level, a patient ought to be provided with all of the information that any rational person in that situation would want to know. This would include not only any significant risks and benefits of the proposed treatment, of alternative treatments, and of no treatment at all, it would also include information about which hospitals and doctors are most successful in providing those treatments.

Everyone agrees that patients are deprived of some freedom to make rational decisions if they are not supplied with all of this information. Thus the current practice of not providing this information is a harmful practice. In the absence of adequate justification, it would seem that this failure to provide all of this information is not morally acceptable. However, it does not follow that this practice should be changed and that doctors should be required to provide all of this information. It might be that, unless many other practices are also changed, requiring doctors to provide all of that information will require so much time, with so little change in outcome, that the costs, human as well as financial, make it undesirable to require physicians to provide that information. Perhaps healthcare practitioners already know that. But if we know that a practice is harmful, we should be trying to see if something can be done to change that practice without thereby causing even more harm. There should be consideration of other methods of providing this kind of information to patients.

Summary

Healthcare accepts the same basic and moral values that are accepted by all rational persons. Death, pain, disability, loss of freedom and loss of pleasure, due to conditions of person, are the focus of healthcare. Those in health case might rank the basic values differently, they may even rank the moral values differently, but even if they do, it is quite likely not a uniform difference. It is only that more individuals in healthcare might rank avoiding death higher than avoiding pain than most people not in healthcare. Sometimes, however, as in end of life care, these differences in rankings can be very important. Although there are no unique values in healthcare, there is a unique experience. Those who are healthcare practitioners know more about what actually happens and how different practices are related to one another. Anyone not in healthcare who has not studied what actually goes on in healthcare should, like anthropologists confronting a new society, be very wary of suggesting changes in the way healthcare is practiced, even when confronted with what seem like clear cases of harmful practices. But those in healthcare should recognize that when all the facts are known and appreciated, the rankings of values by those in healthcare do not have any privileged status, rather the rankings of those who will suffer the evils carry the most weight.

bernard gert

SEE ALSO: Autonomy; Care; Casuistry; Communitarianism and Bioethics; Compassionate Love; Consensus, Role and Authority of; Contractarianism and Bioethics; Emotions; Freedom and Free Will; Human Rights; Obligation and Supererogation; Principalism; Utilitarianism and Bioethics; Value and Valuation; Virtue and Character

BIBLIOGRAPHY

Gert, Bernard. 1998. "Goods and Evils." In Morality: Its Nature and Justification, p. 92. New York: Oxford University Press.

Gert, Bernard; Culver, Charles M.; and Clouser, K. Danner. 1997. "Malady." In Bioethics: A Return to Fundamentals. New York: Oxford University Press.

Gruzalski, Bart, and Nelson, Carl, eds. 1982. Value Conflicts in Health Care Delivery. Cambridge, MA: Ballinger.

Hobbes, Thomas. 1991. Man and Citizen, ed. Bernard Gert. Indianapolis: Hackett.

Humber, James M., and Almeder, Robert F., eds. 1997. Biomedical Ethics Reviews: What is Disease? Atlantic Highlands, NJ: Humana Press.

Kant, Immanuel. 1981. Grounding for the Metaphusics of Morals, tr. James W. Elington. Indianapolis: Hackett.

Kopelman, Loretta M., ed. 1999. Building Bioethics, Coversations with Clouser and Friends on Medical Ethics. Dordrecht: Kluwer.

Nathanson, Stephen. 1994. The Ideal of Rationality: A Defense within Reason. Chicago: Open Court.