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Confessions of a Medicine Man: an Essay in Popular Philosophy
  1. Matthew Clayton
  1. Department of Government Brunel University

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    Alfred I Tauber, Cambridge, Mass, The MIT Press, 1999, 159 + xviii pages, £17.50 (hb).

    Tauber's book outlines a philosophy of medicine that sees an ethos of caring as the central imperative of a doctor. Three broad claims are defended in the text. First, Tauber is sceptical of conceptions of medicine that treat physicians as primarily scientists or the agents of profit-makers or administrators. For such conceptions fail to consider the patient as a whole or his/her personalised suffering as demanding empathy.

    Second, he criticises conceptions of medical ethics that emphasise personal autonomy. After a brief account of how, he thinks, the ideal of autonomy was invented and developed in Western thought, Tauber questions the significance of autonomy in medicine. Because of the complexity of medical problems and uncertainty of favourable results, patients often lack the means to make autonomous decisions and this means that the doctor-patient relationship cannot be one of equality. In contrast to autonomy-based ethics that stress patient self sufficiency but which, in fact, Tauber argues, lead to patient isolation, he outlines a relational ideal in which the physician is primarily an authoritative healer who the patient trusts and to whom he surrenders his autonomy to a degree.

    The third important theme that runs throughout the book concerns the foundational significance of Tauber's relational ethic. First, he claims that his approach to ethics, once fully developed, can be extended to deal with the full range of moral problems that clinicians face. Second, he argues that medical schools should place this philosophy at the heart of a medical training such that other values, such as scientific detachment, can be seen to be subordinate to the need for doctors to heal the ill.

    As Tauber describes in the introduction, these claims emerge from, and are intermingled with, an account of recent US medical history, personal anecdotes, and a brief survey of the notion of selfhood in Western thought. The anecdotes often illustrate his views nicely, and the critical appraisal of a dehumanised medical market in American is instructive. Less persuasive are his account of selfhood in moral philosophy and medicine, and his objections to autonomy-based medical ethics. The notion of selfhood is multiply ambiguous connoting for example, character, personal identity, or the relationship between different individuals. Tauber proceeds without clearly distinguishing the different questions various conceptions of selfhood are answering. At times this leaves the reader perplexed as to the point of the discussion. In addition, the contrast between autonomy-based and so-called relational medical ethics is perhaps a little crude. The book would have benefited from a detailed analysis of one or two autonomy-based conceptions. I, for one, doubt that a plausible account of autonomy would emphasise notions of self sufficiency and the separation of the individual from the community, upon which Tauber's principal worries about the view rest. Indeed, many would claim that autonomy-based ethics are themselves, in part, relational ideals that are compatible with a fiduciary role for doctors. Finally, one might doubt that the relationship between physician and patient is the proper foundational focus of medical ethics. Issues concerning the kinds of need that should be met by the health service, or the rationing of medical resources, seem to be problems of justice which cannot adequately be addressed by appeal merely to an ethos of care.

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