Clear and concise, Ethics and the Metaphysics of Medicine makes an important contribution to bioethics by providing a systematic framework for the traditional principles of beneficence and autonomy, applying them fruitfully to issues concerning advance directives and physician/patient relationships. Part I forms the theoretical framework in terms of what he calls the Richman-Budson theory of health.  These two chapters are quite technical, including detailed critical analyses of the literature in a number of philosophical areas, including the fact-theory distinction, theories of health and views on personal identity. These chapters will be of interest primarily to scholars and advanced students of the philosophy of medicine.  Part II (chapters 3-5) is the application of this theory to resolve the conflict between (medical) beneficence and (patient) autonomy and is recommended to teachers of biomedical ethics as well as practicing bioethicists.   In Part III Richman discusses advance directives and patient/physician communications in the light of his theory.  The general reader, as well as health care providers should find these chapters relevant and enlightening.

The Richman-Budson theory of health is the heart of the book. An "embedded instrumentalist theory it defines health as a state which allows one to strive for one's goals. Richman distinguishes two sorts of health:  biological and personal. Individuals are biologically healthy when they function according to biological norms which Richman maintains may be explained "by reference to some desired future state" (p.33), that is, functions are to be understood in terms of goals. Less problematically, individuals are personally healthy when they are able to pursue their various goals and plans for their lives. This thoroughly teleological concept of health has problems which Richman attempts to answer, though not, I think satisfactorily.  That people have personal goals would seem to be uncontroversial, but Richman recognizes that goals may be problematic in a number of respects: they may be physically impossible to achieve, or inconsistent with other goals, or immoral. Richman adopts an ideal observer view in which the relevant goals will be the "individual's core wants and values.." (p.45)  This view, in common with many theories of agency, presupposes that people are much more reflective and self-aware than the empirical evidence supports.  If the notion of personal goals has problems, the idea that final causes have not been banished from biology is even less plausible.  Richman himself recognizes that what he calls the "new biology" (by which he means molecular biology, including cell biology, genomic science and  developmental biology) is no longer distinct from chemistry (p.17)  He believes that biological norms are still crucial to biological explanation though the idea of a biological norm can no longer be made precise, given, for example, that single genes have variants which may all be normal or when having two copies of a gene is abnormal while one copy is protective (e.g., the so called cystic fibrosis or sickle cell gene).  A second way in which Richman defends the uniqueness of biological explanations, by an appeal to the importance of epidemiological studies in which a "…causal network" may cite factors using the language of physical, chemical, genetic, psychological or environmental science." (p.18)   While epidemiological studies continue to provide evidence of correlations  (e.g., between estrogen supplements and breast cancer occurrence), they are not treated as fundamental explanations,  but are themselves the subject of explanation — in this case, in terms of  molecular receptors on cancer cells and the presence of  the BRCA1 or BRAC2 mutations (among others).  The development of molecular biology encompassing not only cell biology but developmental biology and genetics is a revolutionary change in biological science which is transforming medical science as well.

Despite significant reservations about the Richman-Budson theory of health, when Richman uses his theory to address three important issues in biomedical ethics, the results are praiseworthy.  The first issue is the supposed conflict between medical beneficence and patient autonomy which has provided so much of the content of bioethics.  According to Richman's theory, the apparent conflict can be replaced by unity of goals.  Medical beneficence is not limited to promotion of biological health, but must include personal health as well.  Generally improved biological health will result in improved personal health, but when it does not, it is the physician or Health Care Provider (HCP) who has conflicting duties, the duty to promote biological health and the duty to promote personal health.  Richman argues that because personal health is based on goals which are crucial to one's personal identity and that personal identity is the expression of the individual's moral status as an agent, personal health should have priority over biological health, although there may be exceptions. Medical beneficence thus requires respect for patient autonomy. 

The second issue Richman addresses is that of advance directives, the inadequacies of which as guides to proper medical treatment have long been noted in the literature.  They tend to be both too general, providing little explanation of the conditions under which the advance directive should be applied and too specific, limiting the patient's ability to state their wishes in terms of the rejection of particular treatment options.  The importance of personal health in the Richman-Budson theory supports a broader view of what an advance directive should include exemplified by a "…Values History [which]  allows patients to express their preferences in terms grounded in choices that they have already made as they have built their lives." (p.144) Richman should have recognized that family members can often be a source of the kind of information a Values History is designed to elicit, and they should be recognized as a valuable, if fallible, source.

The third issue to which Richman applies his theory of health is that of the patient/physician relationship.  The dual nature of health requires a HCP (or at least a primary care provider) to practice patient-centered care.  Richman argues persuasively for the need to train physicians how to discover the relevant personal goals of their patients.  He emphasizes the need to obtain authentic responses from the patient.  "Treatment based on inauthentic responses or misunderstanding of patient preferences will not promote health or autonomy" (p..176)   How physicians are to find the time to obtain the sorts of information essential to fulfilling their duties to their patients is the obvious response to Richman's ideal .  He suggests that "One way to do this is to move some of the work to a professional or paraprofessional patient advocate.  Such a person could help patients begin the process of articulating what they want from the encounter with the physician." (p.164)

Bioethics has been well-served by the Belmont Principles of beneficence, respect, and justice but neither they nor the moral theories which justify them are adequate as a framework for understanding the problems facing the ever changing practice of medicine. Some kind of framework, a philosophy of medicine or perhaps of medical practice is needed.  Whether this framework will be derived from the Richman-Budson theory of health, or from the Gert-Culver-Clouser theory of malady or from some other idea remains to be seen.  That even a flawed framework such as the Richman-Budson theory of health can provide a systematic argument for better health care is an achievement to be admired.                   

© 2007 Hannah M. Hardgrave

Hannah M. Hardgrave, Ph.D, Department of Philosophy, Wake Forest University, Winston- Salem NC.

Categories: Ethics, Philosophical