Project-based interventions

Some interventions aim at supporting an individual’s pursuit of a specific life project. One example is sports medicine, which often focuses on promoting high performance instead of healing. Consider, for example, the procedure known as ‘Tommy John Surgery’, which is a common surgery performed on pitchers in Major League Baseball. The surgery reconstructs the patient’s torn ulnar collateral ligament (UCL) by replacing it with a ligament from elsewhere (either from their own body or a donor’s). This procedure is considerably more invasive than alternatives to repairing the UCL; indeed, an alternative route to repairing a torn UCL is to modify one’s activities—that is, to cease using it in precisely the way pitchers do. Of course, this is unacceptable to most pitchers who tear their UCL, so Tommy John surgery, though not medically necessary in most cases, is nevertheless the preferred option. Another example is the widespread use of cortisone injections, which allow the athlete to play by returning her to her prior performance level, but do not promote healing.22

This suggests that it is neither healing per se (nor ‘high performance’) that are distinct goals of medicine, but the values that centre around that project, that explain why the intervention is appropriate. This is also why none of Callahan’s goals capture the justification for this type of intervention. Relieving pain comes closest, but it does not capture the purpose of the intervention, which is returning the player to optimal performance as soon as possible.

Furthermore, it is questionable whether many of these treatments are in the patient’s best interest, understood objectively: perhaps the risks of the procedure to her health, or the possibility of enabling further pursuit of a risky project (eg, stunt driving, football, mixed martial arts fighting), outweigh the benefits from an outsider’s perspective. But it is the value of the project to the individual that overrides that fact.

In certain other cases, individuals opt for treatments that are otherwise not medically necessary, citing the benefits to the individual’s pursuit of a particular project. To take one example, a patient who suffers from seizures might request a resective surgery to remove the affected portions of her brain, as opposed to simply remaining on medications, because doing so will better enable her to pursue a particular career path or hobby that is important to her (eg, by avoiding certain undesirable or prohibitive side effects of the medications). It may be that this procedure would heal the patient, but it does not seem that the healing view gives a complete picture of the justification. After all, if such medically optional procedures come with significant risks, it is hard to see how we could understand this procedure entirely on the basis that it heals the patient. Both Callahan’s and Miller and Brody’s goal to treat the disease is relevant here, but it fails to sufficiently explain why the risks of the surgery could be justified over the status quo of medication. An appeal to the patient’s values is a better explanation.

Optional function interventions

A related category concerns interventions that centre on one’s ability (or requested inability) to function in a biologically typical, though strictly speaking non-necessary way. The most common area for this type of intervention concerns sexual or reproductive functions. Some patients seek prescriptions to improve sexual performance, such as Viagra. Some seek vasectomies or tubal ligation, as well as other forms of birth control (intrauterine devices, the birth control pill, contraceptive patch, etc), for reasons based in family planning rather than strict medical need.

None of these interventions promote the goal of healing. Vasectomies and tubal ligation help to prevent unwanted pregnancies, and do not serve to heal any underlying injury. One might perhaps claim that a prescription for Viagra aims to heal the patient. But this is true only if we assume that that which is to be healed is the unsatisfactory optional sexual function. This extends far beyond what defenders of the healing account typically mean when they speak of healing.

The same goes for the best interest account: it can hardly be said that these interventions are in the patient’s best interest unless one has already accounted for the patient’s own values. For example, we might say that it is in the patient’s best interest to obtain a vasectomy; but to the extent that the best interest account could make any such claim as this, it would be parasitic on the patient’s values regarding procreation and his sex life. Finally, none of Callahan’s goals are useful here.

Moral interventions

A moral intervention enables the patient to live according to her moral commitments (either obligations or supererogatory acts). Consider living kidney donation, which certainly does not heal the donor.[5] It also is clearly not in the patient’s best interest: the risks are non-trivial, and the benefits to one’s own well-being (in the sense assumed by the best interest view) are unclear. Other examples of this type of intervention include various forms of living donations (eg, tissue donations), and perhaps certain cases of surrogacy. What makes these acts morally praiseworthy is that they are other-regarding, a feature which other goals of medicine have difficulty including.

Aesthetic interventions

Some interventions aim to change the appearance of an individual without any clear medical need. Consider cases of elective surgery, such as breast enhancement, facial rejuvenation or body contouring. Clearly, such surgeries are not in pursuit of healing, nor are they necessarily in the patient’s best interest. This category is more controversial, as some people do object to physicians focusing on elective procedures when there is nothing medically wrong with the body.17 23 Nevertheless, cosmetic surgery is still widely accepted as legitimate medicine in many such cases, and it has been defended by appealing to social and cultural values.24 Aesthetics can also play a role in the other direction. A routine procedure that most others would accept might be refused by someone whose values—being a model, say—make the procedure too risky because of his values.

Additional cases

In addition to the cases that fall relatively neatly into one of these four categories, there are also other examples that defy simple categorisation. One such example is elective abortion. It is not hard to imagine certain cases of abortion fitting within many, or perhaps even all, of the above categories. And while some people object to the permissibility of elective abortion on general morality terms, few object to abortion falling within the scope of medicine.

But again, it is not clear that the other accounts of the goals of medicine apply here. While it may be that one of the many factors relevant to a decision to obtain an abortion might be concerns about one’s health, the intervention is not centrally concerned with healing. (There are, of course, cases in which an abortion is medically necessary to protect the life or health of the pregnant person, hence our use of the qualification ‘elective’ here.) Moreover, it is not clear that an abortion aims at a proper goal of medicine only when doing so is in the best interest of the individual. Indeed, it is not clear how a physician would go about determining this. It is much clearer that abortions are legitimate medical practice because they are autonomously requested by the patient—that is, because they align with her values.

Another example is gender confirmation surgery, which can be very important to many transgender people for reasons ranging from having the body type and characteristics that best align with their gender identity to their self-presentation and self-understanding—that is, reasons that fall under the categories of project-based, optional functioning, and aesthetic interventions, at least. Here again, healing and best interest do not seem to give an adequate account of why such procedures conform to the goals of medicine.

Gender confirmation surgery also demonstrates the role of values in assessing the risk of harm. Physicians, acting out of a concern for the welfare of their patients, can err by enforcing their own values about what constitutes appropriate risk. Trans writer Andrea Long Chu makes this point in a discussion of her then-upcoming gender confirmation surgery:

The medical maxim ‘First, do no harm’ assumes that healthcare providers possess both the means and the authority to decide what counts as harm. When doctors and patients disagree, the exercise of this prerogative can, itself, be harmful. Nonmaleficence is a principle violated in its very observation. Its true purpose is not to shield patients from injury but to instal the medical professional as a little king of someone else’s body.25

Chu goes on to advocate for a version of a value promotion view in her discussion of gender confirmation surgery:

I […] believe that a surgery’s only prerequisite should be a simple demonstration of want. Beyond this, no amount of pain, anticipated or continuing, justifies its withholding.25

To be clear, on our view, it is not the patient’s mere demonstration of want that justifies medical intervention. For one thing, as we have already noted, the all-things-considered judgement may require reference to other factors, such as justice. Furthermore, the justification question is distinct from the goals of medicine question. Nevertheless, Chu’s general point still applies: by enforcing a standard of harm that is not sensitive to the patient’s own understanding of what aligns with her values and what risks are acceptable to her, the principle to do no harm is self-effacing.

Too inclusive

One possible objection to our view is that it seems to allow for doctors to perform interventions in a range of cases that might seem intuitively impermissible. This objection is strongest when considering the most extreme examples. Consider a patient who requests that the physician surgically remove his legs for aesthetic reasons, or a patient who requests a prescription for a drug that might cause significant damage to his health. The value promotion account seems to say that the physician promotes a goal of medicine—and thus acts permissibly—by acceding to these requests. But is this right?

First, when considering extreme cases, we must be cautious not to inadvertently build in assumptions that run counter to the value promotion account’s actual commitments. Recall that values are not simply requests; promoting requests per se does not aim at a goal of medicine. Thus, if a patient undergoing a psychotic episode requests that her legs be amputated, the physician does not promote a goal of medicine by acceding to this request. (The same can be true when an incapacitated patient, such as someone in a delirium, is refusing treatment for which the benefits clearly outweigh the costs. In such cases, the mere refusal might not be sufficient to justify accepting it.) We must also be careful not to assume that the patient is properly informed about the intervention. If the patient is unaware that the prescription he requests will cause significant damage to his health, then the physician does not promote the patient’s values by prescribing this medication.

It is also important to recall that the goals of medicine question does not settle the further question of what is permissible all things considered. For one thing, in both versions of the cases as presented in the previous paragraph, even if our view did allow that acceding to such requests aligned with the goals of medicine—which, to be clear, is not our view—one could still hold that performing these interventions would be impermissible by virtue of the lack of autonomy in the former case, and failure to properly inform the patient in the latter. As a general matter, however, our view is compatible with the possibility that there may arise cases in which a physician promotes the patient’s values—and so acts in accordance with a goal of medicine—and yet acts impermissibly overall. Thus, it is important to identify the source of the implausibility in the objection. It does not follow from the fact that the intervention is impermissible that the source of the concern lies with the account of the goals of medicine.

Once these factors are fully accounted for, however, we see much less reason to be troubled. Some patients wish to promote values of theirs that many of us might struggle to understand. But our inability to understand certain values should not stand in the way of patients and willing physicians who seek to promote them. Patients with body integrity identity disorder (BIID) may seek to have their appendages amputated in order for their physical body to conform to their self-image.23 ,26 Many of us cannot begin to understand the value this has for patients with this condition. But when such requests are truly autonomous and reflective of one’s sincerely held values, we see little difference from certain other widely accepted interventions, like gender confirmation surgery, vasectomies and tubal ligation, and various forms of elective plastic surgery.

Of course, given that such requests can be so unfamiliar, coupled with the significance and irreversibility of their effects, they might require additional support before performing them is morally justified. For example, perhaps patients who request elective amputation should consult with psychiatrists, and should be required to show that their request is stable over time. But again, these are constraints on what it is permissible to do, not on whether the intervention aligns with the goals of medicine. This point is not distinctive of the value promotion account; all other accounts of the goals of medicine allow for this possibility.

Perhaps some will remain sceptical. If the scepticism rests purely on differing intuitions on hard cases such as those just mentioned, then we are willing to bite the bullet. As we have argued, the importance of promoting patient values is clear. But one might object that values are already an important part of medicine, so there is no need for the account we are defending. We turn to this point now.

Defending the status quo

According to the previous objection, the value promotion view is flawed because it permits interventions that should actually be impermissible. In other words, it allows too much. According to an objection from the other side, a defence of the value promotion view is unnecessary because patient values are already incorporated into current practice. A defender of this objection could appeal to the rise of person-centred care, which involves elucidating and acting on patient values. If this objection succeeds, there is no need for a defence of values because it is the world we already inhabit.

This objection has an element of truth. Patient values play a larger role in clinical practice than they used to, and this is for the best. There are far fewer physicians who will appeal—at least explicitly and in front of a clinical ethicist—to pure paternalism to justify their actions. In this sense, patient values are not new.

However, as the rest of our discussion has made clear, we favour a different and expanded role for value promotion. The sense in which value promotion will be different on our account is that some procedures, including controversial ones such as physician-assisted death, can be justified based on this goal of medicine, whereas they are often rejected through appeals to other goals. The sense in which the role of values will be expanded is by direct appeal to values in many clinical situations. It is more parsimonious to defend vasectomy, tubal ligation or kidney donation on the grounds that the patient has a consistent, stable value that is promoted by the procedure.

Currently, values are given the following role: once the physician has decided the procedure that is most clinically indicated (usually based on healing), he recommends it (or perhaps a couple alternatives). The patient can then either choose the option that best promotes her values or she can refuse all care. The values only matter within the scope of what the physician deems acceptable based on other goals of medicine. To use the language we introduced above, on the current model, the patient’s values are a constraint on permissible care. On our view, values influence the care more centrally.

The rise of person-centred care makes it all the more strange that no account of the goals of medicine directly appeals to value promotion. If our arguments are successful, value promotion does a better job than other views at justifying currently accepted care, and it also shows how medicine should adjust its approach to include other types of care frequently taken to fall outside its scope.

Physicians’ value judgments

One might object that the value promotion account requires physicians to make value judgments about which lives are worth living, or which values are worth respecting. This point has been made most forcefully by Daniel Callahan in the context of expanding euthanasia:

Apart from depression (the main statistical cause of suicide), people commit suicide because they find life empty, oppressive, or meaningless. Their judgment is a judgment about the value of continued life, not only about health (even if they are sick). Are doctors now to be given the right to make judgments about the kinds of life worth living and to give their blessing to suicide for those they judge wanting? What conceivable competence, technical or moral, could doctors claim to play such a role? Are we to medicalize suicide, turning judgments about its worth and value into one more clinical issue?27

He goes on to say that

It is not medicine’s place to determine when lives are not worth living or when the burden of life is too great to be borne. Doctors have no conceivable way of evaluating such claims on the part of patients, and they should have no right to act in response to them.27

Applied to the value promotion view, the objection goes roughly like this: value promotion as a goal of medicine would allow physicians to promote patient values via their distinctive expertise, which would require that they are able to assess competently what these values are. But such assessments fall well outside the physician’s realm of expertise: physicians either cannot or should not make such assessments. Thus, the value promotion account is mistaken.

Let us begin with the suggestion that physicians cannot determine what the patient’s values are (or whether they are sincere, informed, etc). It is of course true that this will sometimes be difficult for physicians to do, particularly when the patient’s request is of an unfamiliar and uncommon sort (eg, patients with BIID requesting limb removal). But it is surely false that physicians are wholly incapable of assessing patients’ values—indeed, it is a frequent part of their job. Physicians are regularly tasked with assessing patient competence, whether their choices are autonomous, and whether they are fully informed. This occurs in both high-stakes and low-stakes settings: consider the variety of procedures that patients opt in and out of in the course of a pregnancy, during palliative care or in myriad other circumstances.

Furthermore, being a good physician requires aligning care with values. This is the lesson from person-centred care, which teaches that the constant pursuit of healing is often the wrong approach, especially in end-of-life care.28 To be sure, certain physicians might question their ability to assess patients’ values in some cases. But we should not conclude from this that the task is impossible, and thus that the value promotion account is mistaken. For one thing, in certain unorthodox or high-stakes cases, physicians ought to supplement their judgments with those of other physicians. (Indeed, it is a common feature of legal physician-assisted death policy that multiple doctors are consulted prior to granting the request.) Moreover, it is important not to forget the role of the clinical ethicist, whose training and expertise in elucidating patients’ values is a valuable supplement to the physician’s own assessment.

One might still object that physicians ought not to make such judgments. This seems to be the heart of Callahan’s worry. But here again, we reply by noting that physicians do commonly make such judgments in the course of their work, and few of us are deeply troubled by this fact. It is, perhaps, only troubling when one looks to marginal cases, such as euthanasia or other frontiers of accepted medical practice. But at this point, we have circled back to the question of what are the proper aims or goals of medicine. We are therefore sceptical that the objection that physicians ought not to make judgments concerning patients’ values can avoid begging the question against our view.

Scalpels for hire

A related objection takes issue with the implications for the value promotion view on the medical profession. On this general worry, Leon Kass writes the following:

At what should the medical art aim? What is the proper end—or the proper ends—of medicine? Continued confusion about this matter could bring about, more directly than any other cause, the demise of the profession […] For without a clear view of its end, medicine is at risk of becoming merely a set of powerful means, and the doctor at risk of becoming merely a technician and engineer of the body, a scalpel for hire, selling his services on demand.9

While Kass is concerned with a lack of specification of the goals of medicine, his point applies equally to a view like ours. That is, the value promotion account seems to make physicians into ‘scalpels for hire’ insofar as it views physicians as possessing a distinctive expertise that can be put to the service of patients’ ends.

It is a bit unclear precisely what his concern is. If it is that physicians will be obligated to perform any procedures that patients request, then this is clearly not entailed by our view. If it is that physicians will be justified in doing anything for which their services are requested, then this too is false on our view, since our view does not centre on requests as such but requests in line with values; and, furthermore, the question of the goals of medicine does not settle what it is all things considered permissible to do, since other concerns (eg, justice) factor into that judgment. But if the concern is that the physicians’ role will be reconceived in an unpalatable way, then this is either false or else a bullet worth biting. It is false for reasons canvassed above: there are already many interventions where physicians aim at the goal of promoting patient values. Thus, the professional role is not so much reconceived and expanded as better understood for what it already is. But if one still finds this perceived expansion to be problematic, then we are happy to bite the bullet. As we have stressed throughout this essay, there is significant value in respecting and promoting patients’ values. When physicians have the tools and resources to do so, and they opt to provide this service, we should see this as a good, rather than troubling, expansion of their role. Instead of calling physicians ‘scalpels for hire’, which, on our view, risks oversimplifying and obscuring the nature of their role, we might instead think of them as ‘value-promoters for hire’. But this, we submit, is not an unwelcome title.