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Ethics and the Metaphysics of Medicine: Reflections on Health and Beneficence (review)
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Ethics and the Metaphysics of Medicine: Reflections on Health and Beneficence. By Kenneth A. Richman. Cambridge: MIT Press, 2004. Pp. 222. $29.00 (cloth).

In his book Ethics and the Metaphysics of Medicine, Kenneth A. Richman explores definitions of health and their implications for clinical medical ethics. Richman's work is rooted in the tradition of the philosophers but is accessible and directed at a wider audience, ending with a chapter on "What Every Doctor Should [End Page 467] Know About Metaphysics." His first-person style is dynamic and engaging as he travels from philosophical theories of health to the ethical implications of the theories, to clinical applications for treating patients and training physicians. He provides frequent and helpful summaries of his arguments and peppers his discussion with illustrative clinical examples.

Richman lays his groundwork carefully and persuasively, if a bit too extensively, in discussing the work of prior theorists who have contributed to his "Richman-Budson theory of health." He convincingly demonstrates that health is a pejorative term with multiple and sometimes conflicting presuppositions underlying it. Whether or not we realize it, the provision of health care always involves some definition of what is normative. Biologic reductionism often fails to recognize that the medical sciences are not just involved with observation and the description of "they way things are." They invariably also involve "the way things should be" on many levels; but especially in defining what is pathologic and what is simply "normal" variation—a distinction upon which every diagnosis and every treatment is based.

Richman maintains that normative biologic processes cannot be defined statistically as clustered about the mean of a Gaussian curve. But are they then completely relative—defined only in the eye of the beholder? After critiquing other theories of health and outlining their influence on his own thinking, Richman proposes an "embedded instrumentalist" theory of health that admits both an idea of intrinsic good (à la Aristotle) but also an emphasis on individual goals. He thereby attempts to admit personal goals in a description of health while avoiding the pitfalls of relativism.

Health is an equivalence of goals and abilities with a recognized distinction between "health qua organism" (strictly biologic or physical functioning) versus "health qua person" (supra-physiologic aspects that make one a rational, moral agent). That which is beneficial for an individual in terms of physical existence and the preservation of biologic function may not always benefit a person who has beliefs and desires. The classic example is prolongation of a dying patient's mental and emotional suffering while also prolonging his life.

Richman believes health is intricately associated with quality of life and, as such, is clearly subjective and value-laden. Therefore, health qua person must trump health qua organism. Ultimately, health for an individual involves the physical and psychological ability to meet a set of appropriate set of goals. Answering the charge of relativism, Richman allows that some goals are higher or "richer" than others, and that goals may change to become richer, increasing health. Richer goals may be culturally defined but must increase the potential of an individual to act as an autonomous moral agent.

This theory leads Richman to an important ground rule for healthcare providers: "If healthy states can vary as widely as individual goals . . . [health care providers] are obligated to discuss goals with each patient" (p. 56). In essence, no provider can know that health is without knowing a patient's goals. Of course [End Page 468] this conclusion implies the need for a dramatic departure from the tradition of physician-centered medical care and is much in agreement with recent trends in the doctor-patient relationship. But it also represents a divergence from the recent trend of "evidence-based medicine," "clinical pathways," and ubiquitous "practice guidelines" that seek to eliminate variations in healthcare practice as a prima facie good (Timmermans 2005). Evidence-based treatment algorithms are becoming a measure not only of proper but also reimbursable care.

In evidence-based medicine, goals are determined by researchers, not patients (or their physicians). The "cookbook" medicine mentality does not aim at maximizing patients' health qua person, and recommended medical goals do not take into...