- Asymmetrical Applications, General Norms and Specified DutiesA Commentary on Tapper and Millet’s “Is Professional Ethics Grounded in General Ethical Principles?”
In their article, Alan Tapper and Stephan Millett focus on the apparent logical difficulty of applying general principles (especially autonomy and beneficence) to medical contexts, because there are “symmetrical” implications of such principles for both professional and patient that require “missing” premises in order to make sense of the priority of patient autonomy and physician beneficence in the typical clinical encounter. They do not deny these usual normative priorities in medical ethics; instead, in their words, they offer “an argument against an argument for certain conclusions, not an argument against the conclusions themselves.”
According to Tapper and Millett, general ethical principles are meant to govern the behavior of everyone. It follows that, all else being equal, the general ethical principles of beneficence and respect for autonomy would seem to be equally binding on both professionals and patients, which is clearly not how they are typically weighted in clinical medicine. As a broadly theoretical point, their claim here about the symmetry of principles seems uncontroversial. Indeed, Thomas Beauchamp and James Childress, in their influential Principles of Biomedical Ethics, would likely agree with such implications at the most general and formal level of what they call “the common morality” (2013, pp. 3–5). At the same time, Beauchamp and Childress focus the implications of general principles by invoking Henry Richardson’s notion of specifying norms (Richardson, 1990). Beauchamp and Childress note that specification is not a process of producing or defending general norms, because general norms (including the four basic principles [End Page 81] of respect for autonomy, nonmaleficence, beneficence, and justice) are assumed as a normative framework rather than functioning as a general ethical theory. Instead, specification narrows the scope and adds concreteness to general norms by “spelling out where, when, why, by what means, to whom, or by whom [an] action is to be done or avoided” (Richardson, 1990, p. 289, quoted in Beauchamp & Childress, 2013, p. 17). If specification is indeed successful, Tapper and Millett’s central concern about formal symmetry appears to be somewhat misplaced. The broadly symmetrical implications of beneficence and respect for autonomy as general norms will be altered or reordered in the light of certain core features of the clinical encounter, which invariably involves asymmetries of power and knowledge between physician and patient. As Beauchamp and Childress insist, “Specification . . . does not merely analyze meaning; it adds content” (2013, p. 17). Thus, “to say that a problem [including the apparently symmetrical implications of beneficence and respect for autonomy] . . . is resolved or dissolved by specification is to say that norms have been made sufficiently determinate in content that, when cases fall under them, we know what ought to be done” (2013, p. 19). For example, the physician’s medical knowledge provides context and content to the specified meaning(s) of beneficence in the clinical encounter. Such knowledge will distinguish the physician’s expertise from that of a lawyer or a clergywoman or a financial adviser. At the same time, one will expect to find family resemblances across the various professions in the structural asymmetries of expertise, power, and relative need between the professional and those whom she serves. Such asymmetries will serve to clarify the ways in which general norms will vary in their content, scope, and comparative stringency between physician and patient (or professional and client in other settings).
Consider, for example, Tapper and Millett’s discussion of the comparative risks faced by doctor and patient. To suggest that the norms of autonomy and beneficence formally entail duties that are equally incumbent on both physician and patient seems to overlook the obvious—the patient’s medical need for the physician is specific, focused, and may often involve an immediate vulnerability (e.g., life-threatening illness or accident). Those circumstances do not correspond to any immediate medical need on the physician’s part. To be sure, a range of needs will motivate a doctor in seeing patients: the need to make a living, to support a family, to [End Page 82] develop a reputation, to repay student loans, and so forth...