Importance

Clarifying the goals of medicine is fundamental if certain ethical issues and clinical dilemmas in medicine are to be addressed; such as, legalized euthanasia, organ transplant lists and many others(Hanson and Callahan, 1999). If the end goals are clarified, then addressing each individual issue won’t be as divisive, since all that would have to be addressed is whether or not the proposed solutions align with said goals. With a clearer understanding of what the end goals of medicine are, healthcare practitioners’ actions and dilemmas can be guided with clear intent. Attempts to answer this question have the potential to better illuminate important mission-level ideas within medicine that would result in improved clinical and ethical decision making, thus streamlining the process for human actors in the practice of healthcare.

The Hastings Center Goals of Medicine project presented three reasons why people should be invested in the goals of medicine. (1) It makes no sense to discuss financing of the organization of health care systems if we do not understand their purpose. (2) Rapid advances of modern medicine have created many large ethical, cultural and legal problems that “turn on what it is thought right or wrong, good or bad, for medicine to do for people in the name of preserving or improving their health.” (3) Modern science and medicine have elevated some goals (e.g., an intent to save and extend life) over other, also important goals (e.g., the intent to relieve suffering or the pursuit of a peaceful death). Thus, it is helpful to make sense of goals and how they fit together (Anderson, 2007).

Questioning and determining the goals of medicine is also important because it reframes therapeutic efforts in terms of how it can best help patients. If clinicians or bioethicists lack a framework highlighting the goals of medicine, the resulting ambiguity may compromise patient care as a disparity develops between what the patient desires, what the physician thinks is best advised, and what an ethics committee deems to be the correct course of action. In determining a set of goals, the ambiguity is clarified, and more consistent patient care will be nurtured.

The question also addresses the important aspects of emotional and empathetic support and its influence on the responsibility a provider has to their patients. By better understanding what the field of medicine is aiming to accomplish, providers will be better prepared to afford the appropriate importance to a patient’s will (e.g., if they’d prefer a longer life or to maintain better quality of life prior to terminal illness running its course).

It’s clear that medicine and healthcare are beneficial to society, which makes the discussion of its goals so important. What do people want to get out of the healthcare system? In the surgical community, many are now reconsidering how surgery impacts the elderly, and if the harms outweigh the benefits, which is the subject of a 2018 NPR article. The conversation around death with dignity has become more prevalent in recent years. Americans have actually been shown to have a strong support for Euthanasia, displayed by the fact that72 percent of Americans surveyed believe that euthanasia should be legal in the US (Brenan, 2018).

Furthermore, the question regarding the goals of medicine is important because for the first time in recent history, the average lifespan of people in the U.S. has decreased [citation needed]. Thus, should we be more focused on addressing people’s quality of life rather than aggressive, end of life treatments? Compared to treatments, substantially less research has been done on end-of-life care and death in the medical community (Higginson, 2016).

There is a tangle of issues that come to light in pursuit of the answer to the main question. As stated, the broad answer seems to be to do whatever the patient desires. However, this answer assumes some clear definitions of what “patient” means and how this definition relates to the choices healthcare practitioners make. This section includes questions about this relationship in order to make clear the complexities one faces in attempting to answer the big question of this paper. These complexities include, but certainly are not limited to questions such as:

• Who gets to be recognized as the patient?

• What is best for the patient with regards to their death?

• When is the unequal treatment of patients permissible?

• Who determines what is best for the patient?

Who gets to be recognized as a patient?

Determining who has legitimate claim on receiving healthcare, and hence having the status of “patient,” seems vital to address before we can fairly consider the question “What is best for the patient?” Norman Daniels, a bioethicist at Harvard University, argues that an argument for a right to healthcare can be derived from Rawlsian justice theory, specifically, the principle of “Fair Equality of Opportunity'' (FEO). Daniels centers his argument around the idea that equality of opportunity is a right, and that this must include healthcare. The fundamental concept behind this idea is that “disease and disability restrict the range of opportunities that would otherwise be open to individuals'' (Daniels, 2017). Since medicine’s general goal is to maintain bodily functions as close to normal as possible, and receiving healthcare can minimize the risk and effects of diseases and disabilities, then denying healthcare is denying opportunities and violates the principle of FEO. Therefore, a healthcare system should protect its constituents. However, there is a balance point [citation needed]. A healthcare system that promises the top of the line healthcare, with no regard for resource scarcity or technological development, to all of its constituents is simply nonrealistic [citation needed]. However, it is argued that a minimum right must still be acknowledged [citation needed]. So, a just healthcare system is one that protects its constituents within the bounds formed by resource scarcity and technological development (Daniels, 2017).

What is best for the patient with regards to their death?

Since death is an inherent component of medicine, the ethics of issues surrounding and including death ought to be called into question as well. What is best for the patient with regards to their death? Is there more value in merely extending a patient’s life for as long as possible, or in ensuring that a life is as comfortable as possible? Who decides when it is time to die? Healthcare professionals generally default to the previous broadly stated answer of allowing the patients to decide and use the principle that it is the patient’s wishes that come first as the primary support for default. However, this invites the issues associated with patient autonomy [citation needed].

Questioning the bounds of patient autonomy with regards to patient death naturally leads to the subject of euthanasia (i.e., physician assisted suicide). The primary line of questioning surrounding the ethics of euthanasia concerns the conflation of “killing” and “letting die”. Suppose a terminally ill patient is well informed, sound of mind, refuses treatments, and still wants to die. Is letting the patient die the same as killing them?

The common point brought up in rebuttal to any argument in support of euthanasia is that the Hippocratic oath, the oath taken by physician before they start practicing, says, “do no harm.” However, Hippocrates, considered by many to be the father of medicine as an institution, argued that early physicians should not treat those who are “overmastered by their disease,” and warned about the power of medicine and the need to understand its limits. From the Hippocratic corpus The Art: “If a man demands from an art a power over what does not belong to the art, or from nature a power over what does not belong to nature, his ignorance is more allied to madness than to lack of knowledge. For in cases where we have the mastery afforded by a natural constitution or by an art, there we may be craftsmen, but nowhere else. Whenever a man suffers from an illness which is too strong for the means at the disposal of medicine, he surely must not even expect that it can be overcome by medicine” [Citation needed].

Those who raise this point hold the physician accountable to this oath, and thus feel the physician is obligated to ensure that no harm befalls a patient as a direct result of their actions. Since death can be assumed to be undesirable in most cases, and things that are undesirable can be considered harmful on some level, it follows that letting a patient die is doing harm. However, a quick rebuttal to this could be that the “harm” in question is harm done to the patient, and on the same level of relativity that psychology is on, this harm is relative to the patient. If the patient decides that the side effects of treatment are worse than succumbing to a disease, then shouldn’t the patient’s wishes be upheld to the best of the healthcare provider’s abilities? If the patient simply wants to die and forego the side effects of a treatment, those who argue for euthanasia would argue that ensuring the patient’s comfort and adhering to the patient’s values take priority [citation needed].

Take the instance Diane, a patient of Dr. Timothy E. Quill, a distinguished Professor of palliative care, and professor of medicine, psychiatry, medical humanities and nursing at the University of Rochester School of Medicine (URMC). Diane was diagnosed with acute myelomonocytic leukemia, for which the treatment consisted of induction chemotherapy, to which 25 percent of patients do not respond. Those that do respond next undergo consolidation chemotherapy, for which a further 25 percent of patients are non-responsive. The survivors then receive bone marrow transplants, and only 50 percent of patients respond to this last treatment. Diane was informed of all the options and her possible treatment path and was stated to have “had a remarkable grasp of the options and implications'' (Quill, 2017) of refusing treatment. She refused to undergo treatment, as she did not believe that taking the risks were worth it and would rather spend her days "in control of herself and her own dignity” (Quill, 2017). To Diane the harm of treatment exceeded that of the harm death posed. Quill honored her wishes and let her maintain the degree of control and dignity she desired. This account shows the emotional component that seems to be inherent in the Physician-Patient relationship [citation needed]. Quill recognized this component and took it into consideration when working out the moral action to take. In the instance just presented a physician was able to talk to his patient and learn the patient’s wishes first. Quill was treating a patient who was informed of the possible options, she was deemed to be of sound mind, and could clearly convey their wishes to Quill. However, there are instances where this is not the case.

There are four categories of euthanasia that seem to be in the focus of current bioethicists: active voluntary, active non-voluntary, passive voluntary, and passive non-voluntary (Vaughn, 2020). The first distinction that should be made is between non voluntary and involuntary euthanasia. Involuntary euthanasia is “bringing about someone’s death against her will or without asking for her consent while she is competent to decide” (Vaughn, 2020). Contrasted with non-voluntary, which is bringing about someone’s death when they are not competent enough to convey their wishes, nor did they make them previously known. Voluntary euthanasia is bringing about someone’s death when they are competent and it is what they desire. Active voluntary euthanasia is what is commonly known as mercy killing, when a physician directly ends the life of a patient in accordance with the patient’s wishes. Active non voluntary is similar, but the patient is unable to convey their wishes. Passive voluntary euthanasia is what occurred in the Quill case presented. A physician withheld possible life-saving treatment in accordance with the wishes of the patient. Once again, passive non-voluntary euthanasia is similar, but the patient is unable to give consent. The issue then tying all these together and to the

When is the unequal treatment of patients permissible?

It is all too often that we hear the phrase “everyone should be treated equally”. However, this seems to be an astonishingly broad claim. When faced with multiple patients, how should the healthcare practitioner prioritize treatment? Affording treatment to one patient potentially means diverting some manner of resources and time away from another, which then begs the question, when is the unequal treatment of patients allowed? When there are multiple patients needing treatment, who gets “the best”? This is one of the most prevalent issues raised in response to the main question.

Take the example of an elderly patient, 70 years old, and a younger patient, age 20. Both patients require the same treatment, the only relevant difference between the two patients is their age, and there are only enough resources to provide care to one patient. Should both be treated equally in a situation where one gets treatment and the other does not? Perhaps, many would say that the younger patient deserves treatment as they potentially have longer to live after treatment relative to the elderly patient. If age is the primary factor in deciding the allocation of treatment, the answer to the questions posed in the previous paragraph are to default to younger patients’ needs. However, is it morally permissible for healthcare practitioners to deem elderly individuals as deserving less or lower priority care since they are more likely to be closer to death than the young? If the end goal of medicine is to extend the life of a patient, is there a group of patients that deserves preferred treatment in order to extend life?

Discrimination of care based on aged has become known as “ageism.” The most common arguments against ageism call upon anti-discriminatory rhetoric. Why should the elderly suffer discrimination? They have contributed to society, worked jobs, and possibly have families just as any younger person has. Yes, the old are more likely to be weak, handicapped, and require protection; but this is no different from young children (Shaw, 1994). Those against ageism say that any form of discrimination is unjust and therefore should not be tolerated.

The main argument in favor of ageism can roughly be stated to say older people have already had the chance to live and enjoy life. Furthermore, they most likely have less left to enjoy than younger patients. Younger patients should get the chance to live the lives that their elderly counterparts have already gotten. Several points are argued using this main point as support (e.g., The need for rationing medical services boils down to the inescapable fact that not every patient can be treated). There are only a certain amount of resources, and ageism is one possible solution to this problem. Those who support this argument believe that the default approach should be that younger patients deserve preferred allocation of health care, and that nuances should only be considered after taking this approach as fundamental (Shaw, 1994).

Who determines what is best for the patient?

An ongoing debate in medicine concerns how those who practice medicine are to understand the focuses of their disciplines. Should the primary focus be determined by objective criteria of illness, injury, or disease, or should it be determined by what the patient wishes. This section poses the question “Who determines what is best for the patient?” Eric J. Cassell, Emeritus Professor of Public Health Weill at the Medical College of Cornell University, provides a number of case examples in his volume exploring suffering and the goals of medicine. He argues that the “nature of the moral problem [of withholding or advancing care] depends on the details of the case” (Cassell, 1991) What can be concluded from his case examples is that the actions [or inaction] of the physician — that are most effective from the patient's perspective — can become opaque or blurred at best. Specific scenarios often involve prioritizing the social and cultural values of the patient over keeping the person biologically alive. The example of honoring the rights of a Jehovah’s Witness to reject blood transfusion is a well-known medical reality as a more familiar example found in the US.

Like most debates in medicine, this one is often traced back to The Hippocratic Oath. It is similar to debates in U.S. politics which tend to rely on the Constitution for finding answers and is known to divide people into one of two camps: the traditionalist, who sees the original doctrine as complete and irrefutable, and then those that believe the doctrine is a living document, meant to be reframed as ethical theory does [citation needed]. Notably, the Hippocratic oath states that a physician will apply all measures necessary. Therefore, some may argue that not focusing on extending life or even assisting with death is a violation of a sacred oath (Anderson, 2015).

Two extremities of this debate are made up of those who see value in specific applications of the artificial termination of human life and those that assign some inherent sanctity to status of living. Those who are pro-euthanasia, such as the World Federation of Right to Die Societies and Death with Dignity would argue that the goal of medicine should not be to extend life. Conversely, there are numerous groups that hold the view that Radical Life Extension (RLE), the notion that aging and death by aging can be eliminated via medical practices is an attainable goal that just needs the appropriate technological fix to accomplish (Mercer and Maher, 2009). Some examples offered here include Google’s Calico Longevity Lab and People Unlimited. The aim of these labs is to research human aging in the pursuit to extend life. This movement (or movements) may not be viewed as viable or taken seriously by most conventional physicians, but are included here as the most extreme counterpoint to this discussion. Those in support of this point would argue that ageism ought to never play a factor in medical decisions since it is possible age will not be a factor in the longevity of an individual’s life.