Patient Preference Absolutism

I venture that most clinicians would find Minerva's suggestion quite astonishing that it is ‘plausible that some patients may request interventions aimed at changing their features in a way that the surgeon might consider against a patient's best interest’, but that this does not necessarily ‘provide them [the surgeon] with a good reason to refuse to perform it’.1 ,ⁱ The idea that a surgeon must do something which he judges not to be in a patient's best interest simply because the patient requests or prefers it I call Patient Preference Absolutism (the reciprocal concept to Conscience Absolutismⁱⁱ, which Minerva criticises explicitly in another paper2). There are good reasons to doubt it. First, it overlooks an important distinction regarding patient autonomy; second, it risks severely undermining the concept of beneficence and the place of clinical expert judgment in medical practice.

A missed opportunity

The subject of cosmetic surgery in relation to CO provides an opportunity to explore the distinction between professional and moral judgment. Unfortunately, Minerva's assumption that a request has prima facie priority simply because it expresses preference obscures this, as well as the common-sense distinction between the respective goals of cosmetic surgery and medicine more generally. This is a double missed opportunity.

First, because, as suggested above, there is a significant difference between refusal on moral grounds and refusal on grounds of clinical judgment. The clinical judgment of an expert is not the same sort of thing as his moral concerns. Not satisfying patient preferences often has more to do with clinical judgment than ‘moral permissibility’.1 Not all objection is strictly moral. Patient Preference Absolutism cannot account for this; it does not engage with the matter. The belief that moral/CO cannot be admitted does not necessarily entail anything about clinical objection. It is regrettable that this important distinction remains unexplored by Minerva, for it has been mostly ignored in the literature so far.^viii It would be interesting to consider the possible analogy between clinical judgment and ‘moral’ judgments in clinical medicine.

Second, there is a distinction between medicine in general and cosmetic surgery which has not yet informed the CO debate. Their goals are very different: the restoration and maintenance of health for the former and the enhancement of appearance for the latter.^ix Hence, one can argue that there is something specific to what a doctor qua doctor must do, which is not necessarily identical to what a cosmetic surgeon does (though the craft of the latter presupposes similar expertise to the former). The things which a doctor does qua doctor are not necessarily to be directly equated with what a doctor does, for doctors can apply their craft to evil ends as well as good ones.^x If a procedure does not conform to the goals of medicine, then it is unclear that it is a medical practitioner's duty to do it. Even if female genital mutilation were a routine procedure (as some envisage9), it would not be a doctor's duty to perform it, for the intentional mutilation of genitals does not conform to the goals of medicine. Whether his refusal is moral or not is largely irrelevant, since he is merely refusing to do something which he has no professional duty to do. The same reasoning might apply to ritual circumcision, body enhancements and active euthanasia. It is regrettable that current literature on CO largely overlooks its relation to the goals of medicine. Minerva's paper is another missed opportunity in this regard.