While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)

Mainstream epistemology is a highly theoretical and abstract enterprise. Traditional epistemologists rarely present their deliberations as critical to the practical problems of life, unless one supposes—as Hume, for example, did not—that skeptical worries should trouble us in our everyday affairs. But some issues in epistemology are both theoretically interesting and practically quite pressing. That holds of the problem to be discussed here: how laypersons should evaluate the testimony of experts and decide which of two or more rival experts is most (...) credible. It is of practical importance because in a complex, highly specialized world people are constantly confronted with situations in which, as comparative novices, they must turn to putative experts for intellectual guidance or assistance. It is of theoretical interest because the appropriate epistemic considerations are far from transparent; and it is not clear how far the problems lead to insurmountable skeptical quandaries. This paper does not argue for flat-out skepticism in this domain; nor, on the other hand, does it purport to resolve all pressures in the direction of skepticism. It is an exploratory paper, which tries to identify problems and examine some possible solutions, not to establish those solutions definitively. (shrink)

Abstract.This paper critiques particular aspects of the published UK government Department of Health’s proposal to promote ‘The Expert Patient’ as a way of enhancing patient autonomy and reducing reliance on limited health care resources. Although the broad aims of the report are supported the detail is criticised on the basis that lack of clarity over key terms, including ‘expert’ ‘illness’ and ‘disease’, means that there is no clear focus for action and threatens to undermine the effectiveness of the proposals.

: The way patients make health care decisions is much more complicated than is often recognized. Patient autonomy allows both that patients will sometimes defer to clinicians and that they should sometimes be active inquirers, ready to question their clinicians and do some independent research. At the same time, patients' active inquiry requires clinicians' support.

A common philosophical account of expertise contends that (a) the good of expertise lies in the fact that it is grounded in reliably true beliefs or knowledge in a domain and (b) rejecting this truth-linked view threatens the authority of experts and opens one to epistemic relativism. I argue that both of these claims are implausible, and I show how epistemic authority and objectivity can be grounded in the current state of understanding and skill in a domain. Further, I argue (...) that what I call a ‘cognitive systems’ approach is consistent with this domain-linked account of expert authority, is empirically supported, and provides a philosophical foundation for both empirical and conceptual work on the nature and scope of expertise. (shrink)

Abstract.This paper responds to the Expert Patient initiative by questioning its over-reliance on instrumental forms of reasoning. It will be suggested that expertise of the patient suffering from chronic illness should not be exclusively seen in terms of a model of technical knowledge derived from the natural sciences, but should rather include an awareness of the hermeneutic skills that the patient needs in order to make sense of their illness and the impact that the illness has upon their sense of (...) self-identity. By appealing to MacIntyre’s concepts of “virtue” and “practice”, as well as Frank’s notion of the “wounded story-teller”, it will be argued that chronic illness can be constituted as a practice, by building a culture of honest and courageous story-telling about the experience of chronic suffering. The building of such a practice will renew the cultural resources available to the patient, the physician and the rest of the community in understanding illness and patient-hood. (shrink)