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  Steven Joffe
  Published on: 18 May 2017
• What do patients value in their hospital care?
  Derek Narendra
  Published on: 18 May 2017

• Published on: 18 May 2017

  Authors' reply

  • Steven Joffe, Physician
  • Other Contributors:
    • Michael Manocchia, Jane C. Weeks, and Paul D. Cleary

  Dear Editor

  We thank Derek Narendra for his carefully considered response to our recent article.[1] We are pleased that our work stimulated such a thoughtful reply.

  Narendra criticises our analysis on two major grounds. First, he suggests that a survey such as ours cannot identify patients’ "considered moral judgments," and therefore that the data are not valid for the purpose we put them to. Second, he...

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  Dear Editor

  We thank Derek Narendra for his carefully considered response to our recent article.[1] We are pleased that our work stimulated such a thoughtful reply.

  Narendra criticises our analysis on two major grounds. First, he suggests that a survey such as ours cannot identify patients’ "considered moral judgments," and therefore that the data are not valid for the purpose we put them to. Second, he argues that, even if the data could lead to valid empirical conclusions, it is not clear that these conclusions should have any implications for normative theories of bioethics.

  As we articulated previously, the conceptual assumption behind our empirical conclusions was that, "if patients value a dimension of care highly, then problems in that dimension will increase the likelihood that they will report negative overall evaluations of the hospital." Narendra does not directly challenge this assumption, and he underestimates the ability of patients’ reports to illuminate the patterns of value structures that lie behind their first-order evaluations. Nevertheless, he is right that no single study or method of analysis can fully capture something so rich as "considered judgments." Our work is at best one small piece of a puzzle by which investigators, using diverse methodologies, might triangulate on patients’ deeply held views. Our findings in isolation are less important than their consistency with those obtained by other researchers using multiple different means.[2]

  Narendra’s scepticism that patients’ views should have any implications for normative bioethical theory raises a critical question about the professional role of bioethicists: do they speak on behalf of patients, of moral truth, or of some dynamic interplay between the two? We favor the latter possibility, in which case we cannot understand how ethicists might proceed in their work without listening to those they claim to represent. It would be especially ironic if those who champion respect for autonomy end up instructing patients, on the basis of first principles, about how they ought to think or behave.

  Contrary to Narendra’s interpretation, we did not link our empirical findings to normative theory directly, by suggesting that providers are morally obligated to act in ways that maximise patient satisfaction. Rather, we argued that those things that substantially impact upon evaluations of care are likely to be important (perhaps even morally important) to patients, and should therefore be taken into account in articulating normative models of health care relationships.

  Finally, we do not see respect for persons and respect for autonomy as independent and conflicting principles, but rather as closely related and substantially overlapping sets of moral norms. In our view, respect for persons has numerous dimensions in addition to the obligation to respect autonomy. If so, and these dimensions are important to patients, then they deserve greater conceptual and empirical attention than they have heretofore received.

  Differences aside, we agree with Narendra that "an exciting research itinerary" at the interface of descriptive and normative ethics lies ahead. We are flattered that, in his view, our work "takes us part of the way down that path."

  References

  (1) Joffe S, Manocchia M, Weeks JC, Cleary PD. What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics. J Med Ethics 2003;29(2):103-108.

  (2) Schneider CE. The Practice of Autonomy. New York: Oxford University Press; 1998.

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  Conflict of Interest:
  None declared.

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• Published on: 18 May 2017

  What do patients value in their hospital care?

  • Derek Narendra

  Dear Editor

  In the Journal of Medical Ethics, Joffe et al. recently published an article titled:
  What do patients value in their hospital care? An empirical perspective on autonomy centred bioethic [1]
  This empirical study evaluates whether patients’ willingness to recommend their hospital to others is more strongly associated with their belief that they were treated with...

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  Dear Editor

  In the Journal of Medical Ethics, Joffe et al. recently published an article titled:
  What do patients value in their hospital care? An empirical perspective on autonomy centred bioethic [1]
  This empirical study evaluates whether patients’ willingness to recommend their hospital to others is more strongly associated with their belief that they were treated with respect and dignity than with their belief that they had adequate say in their treatment.[see note 1] Joffe et al. go on to suggest that confirmation of these empirical hypotheses would constitute a prescription for elevating the principle of respect for persons to the level that the principle of respect for autonomy currently enjoys in our model of the ideal patient-physician relationship ([1] p.104). In other words, they suggest that by some means empirical findings could influence our ranking of the normative principles. Earlier in the article, they make an even stronger claim about the influence of empirical data on our acceptance of normative principles. They suggest that if it were demonstrated empirically that some patients prefer to delegate medical decisions to health care professionals a serious challenge would be levied against the normative assumptions underlying the principle of respect for autonomy, at least under the mandatory autonomy view, which holds patients not only have a right but also an obligation to act autonomously ([1] p.103). In light of many recent empirical studies challenging the centrality of patient autonomy and shared decision-making in bioethical theory, I think it is instructive to evaluate the means by which empirical findings, like those offered in Joffe et al., strengthen or weaken our arguments for ethical principles. In particular, I will be interested in how Joffe et al. propose their data lead them to the normative conclusions they reach.

  In the last paragraph of their essay, Joffe et al. write, “we do not recommend that patients’ perspectives should unilaterally determine ethical frameworks. We do, however, believe that data such as those presented here can contribute to the search for reflective equilibrium in bioethics”([1] p.107). The term “reflective equilibrium,” as the authors note, was introduced by John Rawls. At least in its first instance, it refers to a way of constructing a moral theory by balancing one’s considered moral judgments against one’s moral principles, until one’s judgments and principles form a consistent set—that is, a moral theory (Rawls [2], p.288). Joffe et al.’s idea seems to be that by surveying patients’ perspectives they will be able to capture one side of this equilibrium, considered moral judgments or moral principles (they do not specify which), and in so doing contribute to the desired end: a consistent ethical framework to govern medical encounters, built (at least in part) from the principles and moral judgments of the patient community. Whatever the merits of this goal, however, Joffe et al. fail to capture either the considered moral judgments or the moral principles of those they survey and so fail to contribute to the moral theory they seek to construct.

  Rawls defines considered moral judgments as those judgments in which our moral capacities, which he considers analogous to our linguistic capacities, are “most likely to be displayed without distortion”--e.g. those offered without hesitation, given without strong emotions like fear, and made in the absence of conflicting interests (Rawls [3] p.47). The distinction between considered judgments and judgments generally is important. When constructing a moral theory for a particular community—for instance, the patient community—we want to use only those judgments that reflect the respondents’ real moral sensibilities, and not those stemming from superficial prejudices or their mood on the day they happen to respond. This raises two important questions, however, for researchers, like Joffe et al., using the reflective equilibrium: (1) precisely how considered do considered judgments have to be if they are to count, and, more practically, (2) how can a researcher know whether he or she is collecting them (i.e. what survey method, if any, is appropriate for the task)? While it is difficult to give a positive answer to these questions (and I will not attempt to do so here), some survey methods, such as the mailed questionnaires Joffe et al. use, seem particularly inadequate. Rawls suggests certain external conditions favor the formation of considered judgments: “the person making the [considered moral] judgment is presumed…to have the ability, the opportunity and the desire to reach a correct decision (or at least, not the desire not to)”(Rawls [3], p.48). Very likely, however, many of Joffe et al.’s respondents lacked the necessary ability, opportunity, or desire to reflect on their moral judgments when responding to the questionnaire they received in the mail. Furthermore, even if a number of patients did offer legitimate considered judgments, there is no way to distinguish these from those made by respondents’ who lacked the requisite ability or desire. While the size of Joffe et al.’s study is of value for its ability to more accurately reflect a population’s response to its survey questions, because of the practical limitations that come with its size, the study falls short of capturing patients’ considered moral judgments.

  Any empirical approach, like Joffe et al.’s, using reflective equilibrium faces a second challenge: why do we want peoples’ considered moral judgments to influence our ethical theories in the first place? In his influential critique of reflective equilibrium, DW Haslett writes, “given the wide differences between people’s considered moral judgments, and given that these differences are, as we know, largely just a reflection of differences in upbringing, culture, religion, and so on, it would appear that, far from having a reason for giving people’s considered moral judgments initial credibility, we have instead a reason for initial skepticism”.[4] If moral judgments are liable to reflect superficial prejudices, one could argue, considered moral judgments are liable to reflect deep-seated ones. Surely this prejudice is something ethicists would like to overcome, not codify. While I do no think this challenge is insurmountable, [see note 2] it does demand that researchers justify the inclusion of considered judgments in ethical theory before using the method of reflective equilibrium. Joffe et al. have failed to do this.

  Joffe et al.’s study is susceptible to a second line of critique. Even if the study’s use of mailed surveys is appropriate, the study fails to capture either patients’ considered judgments or principles, because, put simply, it doesn’t ask for considered judgments or principles. Instead, it asks patients whether providers respected their person or respected their autonomy, and then tests patients’ responses to these questions against whether they report being satisfied with their care. If a provider’s acting with respect for persons is a better predictor of patient satisfaction than her acting with respect for autonomy, Joffe et al. conclude that the principle of respect for persons should be assigned as much importance ethically speaking as the principle of respect for autonomy. As should be clear, this conclusion does not follow from Rawls’s conception of how one constructs a moral theory. In a Rawlsian view .[see note 3] , a moral theory requires knowing which principles patients hold, not whether those principles are associated with patient satisfaction. Joffe et al. seem to be operating with an underlying utilitarian assumption to the effect that what we ought to do ethically speaking is whatever will lead to the greatest patient satisfaction. Though there may be reasons for accepting this utilitarian assumption (which Joffe et al. do not provide), certainly there are others for rejecting it. For instance, though patient satisfaction may give a hospital a very good reason to change a policy, we probably do not want to say this reason is a good ethical reason. It is just good business sense. This is an especially important point given the principles that Joffe et al. evaluate. Respect for autonomy and respect for persons are traditionally viewed deontologically--that is it terms of duties or rights, which are valued for their own sake rather than the consequences (e.g. patient satisfaction) that they produce. In any case, these utility considerations take us far from patients’ actual moral views, the very things Joffe et al., by invoking Rawls’s reflective equilibrium, propose to capture.

  Lastly, there is a question of their instrument’s validity. As I have been arguing, Joffe et al. claim to assess whether patients are treated according to the principles of respect for autonomy and respect for persons. Yet, their single item assessing respect for autonomy - the question, "do you feel you had your say?" - does not do the principle justice. The principle of autonomy not only requires that the health care provider ask the patient for his opinion, but also that she act on the patient’s opinion. Their instruments are similarly inadequate for the principle of respect for persons, which, they suggest, includes "autonomy, fidelity, veracity, avoiding killing, and justice" as well as "respect for the body, respect for family, respect for community, respect for culture, respect for the moral value (dignity of the individual), and respect for the personal narrative"(104). How are we to know whether patients had all or any of these in mind when they answered the question, “did you feel like you were treated with respect and dignity while you were in the hospital?” Joffe et al. acknowledge that these ethical concepts are a bit unwieldy for a survey of manageable length. However, these practical considerations should be used not only to excuse the study but also to question its ability to clarify the ethical concepts it claims to assess. They should prod us to ask, regardless of the survey’s scale and the limitations its size produces, does this survey really address what we mean by the principles of respect for autonomy and respect for persons?

  With any empirical study in bioethics, there is a gap between the empirical hypothesizes the study confirms and the normative conclusions its authors would like to draw from it. In their article Joffe et al. hoped to bridge this gap by invoking Rawls’s notion of the reflective equilibrium. As I have explored, however, Joffe et al.’s study does not contribute to either side of the reflective equilibrium they imply, and, thus, they fail to demonstrate how their findings challenge the centrality of autonomy and shared decision-making in bioethics.

  Joffe et al.’s failures are instructive, however, in so far as they suggest how we might better bridge research and theory. The use of the reflective equilibrium in empirical research has promise, provided researchers are clear about:
  (1) how to define considered moral judgments and/or principles,
  (2) how their methodology capture these judgments and/or principles reliably,
  (3) how the inclusion of considered moral judgments strengthens rather than weakens bioethical theory, and
  (4) how their instruments are valid for the judgments or principles they mean to assess.

  In addition, empirical research can contribute to bioethics by questioning the assumptions implicit or explicit in our normative views. Joffe et al. try to do just this when they argue that patients’ desire to delegate decision-making challenges the mandatory autonomy view, in the introduction of their paper ([1] p.103). However, if empirical findings are to defeat a particular normative principle, the assumption those findings challenge must be logically necessary for our holding that principle. For instance, without showing patients’ desiring autonomy is necessary for our holding the mandatory autonomy view, the studies that Joffe et al. cite, even if valid, can be interpreted variously as devaluing the mandatory autonomy view or as recommending that we better educate patients on the value of autonomy. This normative question cannot be settled empirically.

  Empirical researchers have the potential to contribute substantially to bioethics, but their work needs the kind of philosophical and empirical rigor that comes from truly interdisciplinary collaboration and must be informed by a careful reflection on the proper relationship between descriptive and normative ethics (Sulmasy and Sugarman).[4] Joffe et al. take us part of the way down that path. An exciting research itinerary lies ahead.

  References

  (1) Joffe S, Manocchia M, Weeks J C, Cleary P D. What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics. J Med Ethics 2003; 29:103-108.

  (2) Rawls J. The independence of moral theory. In: Freeman S, editor. Collected papers / John Rawls. Cambridge, MA: Harvard University Press, 1999. p.286-302.

  (3) Rawls J. A theory of justice. Cambridge, MA: Harvard University Press, 1971.

  (4) Haslett DW. What is wrong with reflective equilibria? The Philosophical Quarterly 1987; 36(148):305-311.

  (5) Sulmasy DP, Sugarman J. “The many methods of medical ethics (or, thirteen ways of looking at a blackbird).” In: Sugarman J, Sulmasy DP, editors. Methods in Medical Ethics. Washington, D.C.: Georgetown University Press, 2001.

  (6) Delden JJM, Thiel GJMW. Reflective equilibrium as a normative-empirical model in bioethics. In: Burg W, Willligenburg T, editors. Reflective equilibrium: essays in honour of Robert Heeger. Dodrecht: Kluwer Academic Publishers, 1998. p. 251-259.

  (7) Rawls J. Political liberalism. New York: Columbia University Press, 1993.

  Notes

  Note 1:
  Joffe et al. also evaluate whether patients’ reporting they had confidence and trust in their health care providers significantly predicted whether they would recommend their hospital to others. For simplicity’s sake, I only address Joffe et al.’s treatment of the respect for persons and the respect for autonomy principles in this response.

  Note 2:
  See, for instance, Delden and Theil,[6] in which the authors convincingly argue that a reflective equilibrium-like methodology may be valuable for capturing the norms of health care providers and that knowledge of these norms may guide individual providers.

  Note 3:
  I say “a Rawlsian view” rather than “Rawls’s view” because in his Theory of Justice Rawls advocates balancing a single person’s considered moral judgments (e.g. Rawls’s or his reader’s) with a single person’s moral principles (Rawls [3]p.50). Although he later gestures towards reflective equilibrium a an exercise that involves the considered moral judgments of others (Rawls [7], p.8), it is probably safest to say “Rawslian.”

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  Conflict of Interest:
  None declared.

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