An Introductory Philosophy of Medicine

Chapter 11. Medical Axiology and Values

Values are the foundation upon which any ethic, including bioethics, is established. The values that both patients and healthcare providers hold or subscribe to influence not only contemporary medical knowledge and practice but also the use of that knowledge and its practice. Values serve fundamentally to define not only what is of proximate-but also of ultimate-worth. They "are concepts we use to explain how and why various realities matter. Values are not to be confused with concrete goods. They are ideas, images, and notions. Values attract us" (Ogletree, 2004, p. 2540). Besides values, there are also disvalues that define what is of no value. "Disvalues," according to Thomas Ogletree, "express what we consider undesirable, harmful, and unworthy about a particular phenomenon. They identify realities that we resist or strive to avoid" (2004, p. 2540).

Basically, then, values and disvalues are what under gird human behavior and are intimately associated with human need. "Behind our passions, interests, purposive actions," claims Samuel Hart, "is the belief that they are worthwhile" (1971, p. 29). Values and disvalues serve as motivating factors in promoting or inhibiting human action. For example, the value of health and the disvalue of disease can be an incentive to eat certain foods low in cholesterol and to avoid those high in it.

The study of values and of the theories used to explicate them is the part of philosophy called axiology. "Axiology," as Barry Smith and Alan Thomas define it, "is the branch of practical philosophy which seeks to provide a theoretical account of the nature of values, whether moral, prudential or aesthetic" (1998, p. 609). Although the study of values has a long tradition within western philosophybeginning particularly with the Greeks who examined such values as the good, the beautiful, or the virtuous-the programmatic or scientific study of values was not introduced until the late nineteenth century, especially by the Austro-German school (Smith and Thomas, 1998; Rescher, 1969).

The term axiology, which is derived from the Greek word, axios, meaning worth or value, did not become part of the intellectual landscape until the early twentieth century. Although axiology was marginalized during the rise of analytic philosophy, it enjoys a prominent position today is ethical theorizing (Smith and Thomas, 1998). There are a variety of values that inform the ethical stance of both physicians and patients, such as health, healing and disease prevention, helping, normality, veracity, and choice. This chapter is structured to assist in one's reflective process for deciding among the various axiological systems and their values. To that end, the values of contemporary medicine are examined only after first discussing the general nature of axiology and the primary question of what is a value.

11.1 Axiology

The programmatic study of values or axiology is concerned chiefly with the nature of value. It involves three tasks: "(1) the grounding of a genetic conception of value to provide a unified basis for the wide diversity of contexts in which the evaluation takes place, (2) the study of the phenomenology of valuation in general, and (3) the development of a system of value axiomatics codifying the universal rules of valuation" (Rescher, 1969, pp. 50-51).

The first task is divided into the objective and subjective grounds for valuation. According to objective grounding, value is like a property of an object: "Value thus has an objective basis independent of thought, emotion, and experience, with the consequence that value experiences are either appropriate (correct) or inappropriate (incorrect)" (Rescher, 1969, p. 52). According to subjective grounding, value is in the mind of the person and subject to one's desire or passion.

Another approach to the first task is the determination of intrinsic versus instrumental values. This approach is debated in terms of end-values versus means-values. The main issue is whether there is a single end-value to which all other values function as means-values. End-values are often used to demarcate major ethical systems. "What is to be valued as an end," notes Rescher, "is pleasure (the Cyrenaics), happiness (Aristotle), knowledge (Plato), virtue (the Stoics), a good will (Kant), the general welfare (the Utilitarians), and so on. These, clearly," he continues, "are all summum bonum theories that seek to found a monolithic, inverted-pyramid structure of value upon which all others are somehow means" (1969, p. 54). The problem is that some values do not easily serve as means-values, leaving open the possibility of more than one ultimate end-value.

The second task, the general phenomenology of valuation, involves determining what can be valued. The fundamental problem is that there are two possibilities to ground valuation: something is valued because it is valuable (objective valuation) or it is valuable because it is valued (subjective valuation). A general theory of valuation must resolve this quandary. Rescher (1969) collapses the problem, claiming that both possibilities function in valuation and must be taken into account. In this case, almost anything then can be valued.

Valuation is both relational, i.e. between a group of people and the thing valued, and rational, i.e. there must be a reason for the valuation. "When something is valued rationally," according to Rescher, "there exists, ex hypothesi, a reason for valuing it that constitutes a `rationale' for its positive (or negative) evaluation" (1969, p. 57). That valuation is predominantly a rational process, for values are "inextricably bound up with the question of good reasons for preferring one state of affairs to another" (Rescher, 2004, p. 25). This rational nature of valuation forms the basis for the third task of axiology.

The third task is the identification of rules for valuation. These rules can be divided into formal and material categories. "One of the chief tasks that the AustroGerman school of value theorists set for itself," according to Rescher, "was that of devising a `logic of valuation' based on the discovery of formal general rules basic to the theory of value, rules that are objective in their grounding and universal in their unrestricted applicability throughout the whole value domain" (1969, pp. 57-58). He gives examples of several of these rules, especially formulated by Franz Brentano. For instance: "When something has value, then its existence is valuable and is more valuable than its nonexistence" (Rescher, 1969, p. 58). However, these rules can be disputed as to their validity.

Material rules of valuation, on the other hand, pertain to the material composition of the object or item. There are several problems with these rules. One of the major problems is that these rules fail to "get at value-in-general, but only at value sui generic-the value of something as an instance of a specific kind with welldetermined characteristic properties" (Rescher, 1969, p. 59). In other words, the properties of an entity can be used to evaluate entities within that category but not another entity from a different category.

Traditionally, theories of values or axiological systems are divided into subjectivism and objectivism. "Subjectivists," according to Alan Thomas, "assert that only valuable goods are subjective states of sentient beings" (1998, p. 582). Values are based on a person's psychological constitution and do not exist independent of the person: "the sufficient conditions for the difference between one experience of value and another are wholly subjective; that is, to be found in the nature of the reaction to consciousness to whatever stimulus is present" (Lee, 1940, p. 629). Evaluation is relative in nature and represents a projection of worth or significance onto an entity or event. Value then is in the eye of the beholder and depends upon a person's feelings or emotions. One of the standard objections to subjectivism is that it makes valuation arbitrary.

Objectivists, on the other hand, claim that "there is some source or standard of value that is separate from the emotions; emotional responses to actions, character traits, or objects are prompted by, but in no way contribute to, their having value" (Halliday, 2004, p. 1536). The value of an entity or event then is intrinsic to it. There is a moderate position to this extreme form of objectivism: "Moderate objectivists would concede that value is an anthropocentric category, and that their list of good things in life must relate to human concerns. However, they would insist that these components of the good life are preferable because they are good, and not visa versa" (Thomas, 1998, p. 582). One of the problems with objectivism is that objective, sufficient conditions for identifying values are not readily palpable, which often leads to "value blindness" (Lee, 1940).

Hart (1971) provides a more refined or nuanced division of axiological systems, including axiological Platonism, axiological intuitionism, axiological emotivism, and axiological naturalism. Axiological Platonism is based on Plato's notion of idea, in which values are Platonic ideas or "the belief in values as perfect entities or essences apart from the realm of facts" (Hart, 1971, p. 37). This type of axiology had an impact on such philosophers as W.M. Urban and Alfred North Whitehead. Axiological intuitionism is based on the intuition of values through a "developed value consciousness." "Value intuitionists," according to Hart, "believe that certain actions are known to be good or bad, right or wrong, by a direct, immediate, nonin- ferential intuition of their ethical, nonnatural but cognitive qualities" (1971, p. 33). Two modern representations of this axiology are G.E. Moore and W.D. Ross. Axiological emotivism is based on one's feelings or desires and emotional attitude. A.J. Ayer subscribed to such an axiological system, in that values add nothing to the factual content of a statement but simply exhibit a person's emotional disposition. Axiological naturalism is based on a person's experience, with John Dewey as its chief advocate: "True to his spirit of naturalism, Dewey derives norms for valuative criticism from experience itself. The change from unreflective, impulsive, and customary value judgments to critical appraisals is the result of learning from experience" (Hart, 1971, p. 38).

Another important axiological naturalist, according to Hart, is Clarence Lewis (1883-1964), who was profoundly influenced by James and Pierce and published an influential work in 1946 called An Analysis of Knowledge and Valuation. Lewis divided values into intrinsic and extrinsic. An intrinsic value is that which is valuable "for its own sake," while extrinsic value is that "for the sake of something else" (Lewis, 1946, p. 392). He then divided extrinsic values into inherent and instrumental values. Inherent values refer to "those found in the experience of the object itself to which the value is attributed," while instrumental values refer to "those which are realizable in the experience of something else to which the object in question may be instrumental" (1946, p. 392). In other words, "Lewis's aim was to distinguish those things that we value because they directly give rise to experience... from those that are valued because they are means to other valued things" (Gans, 1990, p. 127). A naturalistic view of valuation then "holds that the natural bent of the natural man stands in no need of correction in order validly to be the touchstone of intrinsic value. It repudiates the conception that with respect to intrinsic values we are natively incompetent, or born into sin, and can discern then justly only by some insight thaumaturgically acquired, or through some intimation of a proper vocation of man who runs athwart his natural bent" (Lewis, 1946, p. 398).

The axiological program addresses a number of important questions concerning values and value judgments. One of these is: "Is the scientific method of inquiry applicable to value judgments?" (Hart, 1971, p. 30). Although Hart did not pursue this question, others did. For example, Robert Hartman (1910-1973) developed a well known and influential scientific axiology.' According to Hartman, axiological science is a formal or scientific system based upon what he called "the axiom of value." This axiom states that a value like the good is not a property of an entity but rather of the notion of the entity. "It allows us," claimed Hartman, "to develop a system of axiology isomorphic with the phenomenal realm of value, and thus to specify values scientifically" (1967, p. 104).

According to Hartman, the scientific specification of value is possible because of four scientific features of the value axiom. The first is that the axiom explicates value in logical terms, with respect to the relationship among the notion of an entity, its definition, and its referents. The next feature is that the axiom predicates values in terms of an entity's notion much like arithmetic numbers. The third feature is the axiom's "formal nature," in that the axiom "consists of variables: not of specific values but of a form which determines the specifications of all possible value" (Hartman, 1967, p. 105). The final feature pertains to value measurement. What is measured is the notion's "intension" A notion has value then in terms of the degree to which its intention is realized. Based on these features, Hartman proposed a means for specifying values formally for phenomenal experiences.'- He envisioned that the achievement of formal axiology "will lead to the building of a new society with new people, living on higher levels of awareness and possessing undreamed of insights into the subtleties and depths of moral reality" (Hartman, 1967, p. 311).

11.2 Values

Since the notion of value is difficult to explicate precisely, axiologists have proposed a number of definitions for the notion. Rescher lists nine different definitions of value compiled by a colleague Kurt Baier. These definitions range from Howard Becker's vague definition, "Values are any object of any need," to more precise definitions, such as that offered by Philip Jacob and James Flink: values are "normative standards by which human beings are influenced in their choices among the alternative courses of action which they perceive" (Rescher, 1969, p. 2). Ralph Perry (1876-1957) provided one of the better known and influential definitions of value: "a thing--any thing-has value, or is valuable, in the original and generic sense when it is the object of an interest-anv interest" (1954, pp. 2-3).

Recently, Bruhn and Henderson, in their study of medical values, define value as "an enduring that a specific mode of conduct is preferable to an opposite mode of conduct" (1991, p. 33). Rescher also proposes a definition of or formula for value. "A value," he claims, "represents a slogan capable of providing for the rationalization of action by encapsulating a positive attitude toward a purportedly beneficial state of affairs" (Rescher, 1969, p. 9). In other words, values are those "catch words" that motivate a person to action beneficially and provide a justification or rationalization for that action. Finally, Robert Halliday offers a definition that captures the complexity of the notion of value: "Relative worth, goodness, significance, or utility, attribute, or event; or, an intangible quality or attribute that has intrinsic worth" (2004, p. 1535).

A variety of different types of values have been distinguished, including "sensory values, organic values, personal values, interpersonal values, social values, cultural values, and spiritual values" (Ogletree, 2004, p. 2540). This list is certainly not complete. Organic values are particularly relevant for medicine and refer to somatic conditions, such as bodily health and integrity, while personal values include dignity and independence. Cultural values include economic, political and legal values. Social values pertain to cognitive or aesthetic interests, while spiritual values embrace various religious values such as peace and harmony.

From an ethical perspective, values are often divided into moral and non-moral. The demarcation between the two types of values is difficult except for "easy extremes: the value one places on his neighbor's welfare is moral, and the value of peanut brittle is not" (Quine, 1979, p. 473). According to Wayne Leys, "values are moral when they inspire a recognizable feeling of oughtness or approval" (1938, p. 66). Moral values, then, are often identified in terms of rights and duties, especially in terms of obligations and prohibitions (Ogletree, 2004). These are particularly important for medicine, given its moral nature (Cassell, 1991; Tauber, 1999). A physician, for example, is obligated to treat a patient to the best of his or her ability, regardless of a patient's moral status. This is especially acute when the patient is a known felon, such as a child molester (Klein, 1997).

Based on the obligatory nature of moral values, Quine divided them into altruistic and ceremonial: "Altruistic values are values that one attaches to satisfaction of other persons, or to means to such satisfactions, without regard to ulterior satisfactions accruing to oneself. Ceremonial values, as we might say, are values that one attaches to practices of one's society or social group, again without regard to ulterior satisfactions accruing to oneself' (1979, p. 474). The important feature of moral values, whether altruistic or ceremonial, is their orientation towards the other and the social structure in which an individual is embedded.

Moral values are intimately steeped in a social fabric (Quine, 1979). The moral character of a society's members is an important factor in the health and general wellbeing of that society. As a consequence, moral values must be uniform and agreed upon by society's members. "In morality," according to Quine, "there is a premium on uniformity of moral values, so that we may count on one another's actions and rise in a body against a transgressor" (1979, p. 476). Without the uniformity of moral values, a society risks moral chaos and collapse.

Because of the complexity of the notion of values and their different types, their classification is tricky business. Moreover, as evident from the above discussion, values are fluid in nature and exhibit various meanings and significance under different conditions (Ogletree, 2004). Consequently, there are various classificatory schemes for the different types of values. As noted above, Lewis divided values into intrinsic and extrinsic, with the latter divided into inherent and instrumental.

Hartman also used the categories of intrinsic and extrinsic, as well as a third categorysystemic. Intrinsic value is a "singular concept" in that it represents the individual or unique entity and is measured in terms of the Gestalten. He seldom referred to intrinsic value in terms of that which is valuable for its own sake. Hartman provided an example of intrinsic value with the statement "I am in pain" (1967, p. 255). Extrinsic value refers to the value of being a member of a particular class and is measured in terms of predicates. Hartman's example was two people suffering in pain, with one suffering more than the other. Here, "two pains are judged as members of the class of pains and compared" (Hartman, 1967, p. 256). He seldom referred to extrinsic value in instrumental terms, as a means towards an end.' Systemic value is the most abstract in nature and is measured with respect to specified terms. His example was a patient in a particular hospital room suffering from referred pain in the sternocleidomastoid. The pain in this example is "not of a person but of a certain physiological and medical entity, a unit in a certain hospital room with a certain pathological symptom. Here pain is precisely determined within a network of relations and belongs to systemic value language" (Hartman, 1967, p. 256).

Besides these common classificatory schemes, Rescher (1969) identifies six additional schemes. The first is based on "subscribership" or who holds the value. Values are categorized in terms of the individuals or the various social groups who hold them. For example, an individual's value may be intelligence while a group's value may be justice. These values are subject to the "domain of applicability," in that justice can also be attributed to individuals. The next scheme is based on the features of the object valued. For example, an object may be valued in terms of its beauty or goodness.

The third scheme is based on "the nature of the benefit at issue-that is, according to the human wants, needs, and interests that are served by their realization" (Rescher, 1969, p. 16). The benefit ranges from the material, such as health, to the sentimental, such as love. The next scheme is predicated on the purpose value serves. For instance, deterrent values serve the function to dissuade others or oneself from acting in a particular fashion while persuasive values serve to recruit others to one's point of view.

The fifth scheme is based on the relationship between the subscriber and the beneficiary. The relationship may be between the subscriber and the subscriber's self or others. Values are egoistic in terms of the former relationship and they reflect disinterestedness in terms of the latter. The final scheme is the relationship among values themselves. Values are classified as either self-sufficient or primary, or subordinate or secondary. Primary values are intrinsic or end values, while secondary values are instrumental or means values.

Besides the different types and classifications of values, there is also a hierarchy of values. "Hierarchy," according to Risieri Frondizi, "should not be confused with a classification. Classification does not necessarily imply order of importance" (1971, p. 11). However, hierarchy does involve an ordering of values with respect to importance. Max Scheler (1874-1928) identified five criteria to rank values based on "a special act of value-cognition: the act of preferring" (1973, p. 87).s The first criterion is endurance: "A value is enduring through its quality of having the phenomena of being `able' to exist through time" (1973, p. 91). The longer a value lasts the higher it is: "the lowest values are at the same time essentially the ,most transient' ones; the highest values, at the same time `eternal' ones" (Scheler, 1973, p. 92). The next criterion is divisibility, i.e. higher values do not loose their value or their value is undiminished upon division.

The third criterion is foundation: "a value B is the `foundation' of a value A if a certain value A can only be given on the condition of the giveness of a certain value B" (Scheler, 1973, p. 94). A founding value is always the higher value, since it is not dependent or minimally dependent on other values. The next criterion is depth of contentment, not in terms of pleasure but rather in terms of "an experience of fulfillment; [contentment] sets in only if an intention toward a value is fulfilled through the appearance of this value" (Scheler, 1973, p. 96). The final criterion is relativity, especially in terms of a value's proximity to absolute values. According to Scheler, the closer a value is to an absolute value the higher it is.' Based on these criteria, Scheler ranked the value categories accordingly: "the modality of vital values is higher than the agreeable and the disagreeable; the modality of spiritual values is higher than that of vital values; the modality of the holy is higher than that of the spiritual" (1973, p. 110).

Finally, Hartman (1967) also ranked values, especially in terms of the notion of "richness" The systemic, extrinsic, and intrinsic value categories, "constitute a hierarchy of richness, intrinsic being richer in qualities than extrinsic value, extrinsic richer in qualities than systemic value" (Hartman, 1967, p. 114). The hierarchy is important in terms of the development of values, especially with respect to enrichment. Thus, through enrichment one moves from systemic to extrinsic to intrinsic values, with intrinsic values representing a limit. "General human value capacity, at present," according to Hartman, "does not seem to reach beyond the intrinsic-to experiences where infinities are piled up upon infinities, experiences of mystic exaltation, of higher and higher, wider and wider expansion of awareness" (1967, p. 224). In terms of the example of pain, then, the worst pain is the one I have (intrinsic value), while the second worse is the pain you or others have (extrinsic value), while the least painful "axiologically, is the one constituting, or constituted by, a system" (systemic value) (Hartman, 1967, p. 257).

11.3 Medical Axiology and Values

According to the biomedical model, medicine as a science is a value-free discipline. Values, being subjective in nature, have no place in either medical knowledge or practice, which mimic the knowledge and practice of the natural sciences. "Accepting the natural science approach to medicine," according to Paul Hoehner, "presupposes that physicians should be value neutral, i.e., completely objective, in order to prevent their therapeutic plans, diagnoses, and relationships with patients from being influenced by values, beliefs, feelings, and other `unscientific' biases" (2006, p. 341). Traditionally, the natural sciences, if they exhibit any values, exhibit the values of objectivity and neutrality, as mentioned in the previous section.

The result of the values objectivity and neutrality for the medical sciences and clinical practice, especially in terms of medical ethics, is impartiality on the physician's part or emotional distance between the physician and patient. The physician remains aloof but still concerned to the patient's illness experience and focuses only on the disease or on the diseased body part itself. These two values certainly fueled the material success of the natural sciences, as well as of the medical sciences, especially in terms of controlling and manipulating natural phenomena such as disease and dysfunction; but, they are also responsible, in large part, for the current quality-of-care crisis in modem medicine.

Although medicine depends on science and science is traditionally a value-free discipline, medicine itself, especially the clinical practice of medicine, is not a value-free discipline, according to the proponents of humanistic or humane medicine. In fact, medicine is imbued with subjective values and is moral at its core (Cassell, 1991; Tauber, 1999, 2005). The role of subjective values in medicine is as an important component of good medical knowledge and practice (Bruhn and Henderson, 1991; Cassell, 1991; Gracia, 1999; Hoehner, 2006; Napodano, 1986; Pellegrino and Thomasma, 1981b, c; Tauber, 1999, 2005; Wright, 1987).

There are values, as well as virtues and principles, which "are central to the practice of a healing profession. In my view," opines Rudolph Napodano, "these are as much a part of the practice and theory of all of the disciplines of medicine as are the activities of diagnosis and treatment. These are the basis for the physician's conscience as it relates to his professional actions with patients" (1986, p. 52). "Physicians must engage all the values they hold," advises Hoehner, "when developing their relationships with patients. A truly value-neutral doctor," he claims, "would have no patient-physician relationship of significance" (2006, p. 342).

Pellegrino and Thomasma distinguish three ways in which values function in medicine: "in being aimed at the good of health, in being a cognitive art evaluating towards that good, and as a manifestation of a virtuous disposition concerning that good" (1981b, p. 5). As for the first function, health itself is a value that guides medical knowledge and practice, especially in terms of healing. As for the next function of values, medical theories are "value-laden" such that medicine is not concerned exclusively with a "correct" decision vis-n-vis the medical sciences but also with a "good" decision concerning a patient's (and a physician's) value structure. The final function involves medicine as virtue, since its aim is health as the good. Based on these three values, Pellegrino and Thomasma identify three value-principles to guide medicine as moral practice: "it is good to be healthy," "individual persons have intrinsic value," and individuals represent "a class-instance of human bodies" (1981b, pp. 9-10).

Besides health, there are a number of values, as well as disvalues, which inform medical practice. For example, Napodano lists the following "generic" values for the medical profession: "A genuine interest in, and commitment to, helping people who are sick and suffering," "Truthfulness," "Beneficence and primum non nocere," "Moral agency in professional activities," "Respect for life from beginning to end," "A faith in self," "Lifelong study, inquiry, and scholarship," "An equilibrium between altruism and self-interest," "Personal health," "A mature and full appreciation of society and the larger, real world," and "A willingness to give good-quality care for all who are sick and suffering" (1986, pp. 53-55).'

In this section, the notion of health and wellbeing as values and the disvalues of pain and suffering associated with disease and illness, respectively, are discussed. As Cassell so aptly observes: "Definitions of health and illness always include value judgments by a society and its individuals about what constitute acceptable dysfunctions, pains, or disfigurements" (1991, p. 154). Diego Gracia also makes the same point: "health and disease are not, as people and physicians generally thought, objective temporal facts, but cultural and historical values" (1999, p. 88).

11.3.1 Health and Wellbeing

Health, as a value, is defined in a number of different ways, especially in terms of the biomedical model. For example, Kurt Goldstein (1878-1965) defined health as a value with respect to self-actualization: "the individual's capacity to actualize his nature to the degree that, for him at least, [health] is essential" (1959, p. 183). Goldstein also considered health a "prototype of value," in that it is "the value, from which all other values experienced under special conditions become comprehensible. It acquires this significance," he claimed, "because it guarantees man's self-realization" (1959, p. 188). Bruhn and Henderson also define health as "a significant positive value because it provides the means by which persons can achieve what is essential and meaningful to them" (1991, p. 33). Finally, Gracia defines health in terms of happiness: "health is not only the absence of disease, that is, biological integrity, but a biographical status directly related to one's values and one's own idea of happiness" (1999, p. 95). These definitions of health as a value often focus on the physical and at times on the mental or psychological.

Robert Downie, Carol Tannahill, and Andrew Tannahill (1996) claim that health is both a utilitarian value and a value "for its own sake" As a utilitarian or an instrumental value, health is chosen because it promotes or is advantageous in obtaining other goods that a person values. But the problem is defense or justification of health as a value ipso facto. They defend the latter claim based on several reasons. "One obvious reason for valuing health for its own sake is," claim Downie and the Tannahills, "that disease, illness, sickness, or disability are likely to be painful or unpleasant, whereas there are positive pleasures, glows of fitness and so on, which accompany the peak of health, and a sense of well-being accompanying more ordinary good health" (Downie et al., 1996, p. 174). Another reason involves the fulfillment of a divinely appointed plan for the person as embodied. In other words, God created humans and their bodies to be healthful and so health is a primary value. A related but secular reason: "It might be said that it is incumbent upon us as human beings to make our human nature flourish" (Downie et al., 1996, p. 175). Health then is to be valued for its own sake vis-d-vis the innate forces of growth and maturity. Finally, "the idea that health is a value," claim Downie and the Tannahills, "involves an aesthetic view of health... health is an ideal design with which we should try to make our bodies conform" (Downie et al., 1996, pp. 175-176).

In order to ground medical ethics on a philosophy of medicine, Pellegrino and Thomasma make health the primary value both for the practice of medicine and for medical ethics. "As a fundamental need of living organisms," according to Pellegrino and Thomasma, "health can be said to be an absolute, intrinsic value, common to all class-instances of living bodies" (198 lb, p. 8). Health then is normative, in the sense that it is the "evaluative factor" by which all other values in medicine and medical ethics are arranged hierarchically. "Even though health is subject to a variety of interpretations," admit Pellegrino and Thomasma, "the principle that it is good to be healthy could function as a norm in medical ethical decisions" (1981b, p. 8). To that end, as noted above, they derive three axioms and discuss three implications of them in grounding ontology for medical ethics.

In reaction to Pellegrino and Thomasma's position, Kazem Sadegh-zadeh (1981) developed an alternative theory of values for medicine. He claimed that health is not an absolute value but a relative one. Sadegh-zadeh proposed what he calls an "antithesis" to Pellegrino and Thomasma's universal thesis of health: "Health cannot be said to be a universal human absolute value and a universal human intrinsic value" (1981, p. 111). He gave two proofs, taken from his own clinical experience, for his antithesis. The first was a number of patients who simply wanted to die and refused treatment. The second proof consisted of a poll of 25 persons, with two who were ill, in which the participants were asked to determine whether health as a value for them was extrinsic, intrinsic, relative, or absolute. Only the two ill persons choose health as an intrinsic value. Health as a value, as for any value, then is relative to a person's circumstances: "That something is a value or disvalue of any kind or value-free for a person at a given time, is subject to value kinematics caused by any change in her/his states of affairs space, action space, epistemic space or deontic space. Thus a human's values, disvalues and value neutralities cannot be separated from the particular history and context of her/his life. The valuation of health is no exception" (Sadegh-zadeh, 1981, p. 112).

In response to Sadegh-zadeh's critique, Pellegrino and Thomasma (1981c) claimed that their original intention was not to defend health as an absolute value for all occasions. To that end, they explicated health as a value utilizing Hartman's distinction of value as intrinsic, extrinsic, and systemic or systematic, along with the distinction of absolute and relative:

(1) As absolute intrinsic value: health as a bodily need of a living organism, the good of a body qua body, without which the body cannot function or survive.

(2) As a relative extrinsic value: health as a comparative value ranked by agents among other valued state of affairs...

(3) As absolute extrinsic value: health as an end of the physician-patient relationship, the best interests of the patient, the good end sought by those who are ill and promised in the act of profession by the physician.

(4) As relative systematic value: health as one value ranked by a decent society among other goods to be procured.

(5) As absolute systematic value: health as a norm or standard to be achieved by public health programs or hospitals, or in scientific judgments about disease (Pellegrino and Thomasma, 1981c, pp. 339-340).

As Pellegrino and Thomasma acknowledged, this health scheme is artificial and that these definitions of health as values overlap in the real world. Ultimately health is a moral value, since it can be measured in terms of the good.'"Within the context of medicine," concluded Pellegrino and Thomasma, "health functions as a value in several distinct, inter-related ways that influence what is, or is not, morally justified behavior for patient, physician, and society" (1981c, p. 340).

For the humanistic or humane models of medical practice and ethics, wellbeing and its associated notion wellness serve as a, if not the, primary value. Wellbeing includes not only physical health as a basic need but also psychological and social health. "Health," according to James Griffin, "is always... a necessary condition of living a good life" and therefore an important component of wellbeing (1986, p. 296). But health is only one component, as he recognizes.' Other values may intercede, especially as desires that trump a basic need. Moreover, people may lead a good life or have over all wellbeing even though they suffer from disease and physically healthful people may suffer from unrecognized illness. All these scenarios are possible because wellbeing is of greater value than simple physical health, even a positive notion of health. The value of wellbeing depends upon the subjective values to which a person subscribes. The notions of wellness and subjective wellbeing are two models for capturing the larger notion of a good life as the primary value.

The notion of wellness, as a value, is based on a subjective model of health (Larson, 1991). Halbert Dunn (1896-1975), for example, championed wellness as a more expansive notion, which includes the holistic and spiritual as well as the preventive or positive, compared simply to physical or mental health. He coined the phrase "high-level wellness" to achieve this aim. Dunn defined high-level wellness accordingly: "an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable, within the environment where he is functioning" (1977, p. 9). Wellness is a dynamic concept as opposed to the standard notion of health and is applicable not only to an individual but also to society. Dunn envisioned the emergence of a social "personality" and a world culture.

For achieving wellness, Dunn dissected human nature into five areas and lists 12 needs that must be fulfilled, including survival, communication, fellowship, growth, imagination, love, balance, environment, communion with the universal, way of life, dignity, and freedom and space (1977, p. 12).1° "The challenge posed by the concept of high-level wellness," Dunn concluded "is how to achieve its ends within everyday living and for mankind as a whole" (1977, p. 16). To that end, a journal called Health Values: Achieving High Level Wellness was inaugurated in the late 1970s to promote Dunn's ideas."

Wellness became a fad in the 1970s that continues today, especially in terms of lifestyle changes with respect to eating healthfully and exercising regularly. Part of the appeal of the "wellness revolution," according to Peter Conrad, is its moral underpinning particularly in terms of being a chief value for the virtuous: "In modern society, where health is such a dominant value, the body provides a forum for moral discourse and wellness-seeking becomes a vehicle for setting oneself among the righteous" (1994, p. 398).12

Ed Diener and colleagues have also recently championed another notion of wellbeing, subjective wellbeing (SWB), as one of the chief values for health: "we believe that subjective well-being is one value among many, but one that is widespread because it allows people to judge their own lives based on their own values and standards" (Diener et al., 1998, p. 36). Diener and his associates polled people in terms of their evaluations of what constitutes a good life. "We believe," opined Diener and colleagues, based on their data, "that subjective well-being results from people having a feeling of mastery and making progress toward their goals, from one's temperament, immersion in interesting and pleasurable activities, and positive social relationships" (Diener et al., 1998, p. 34).

From a review of the literature, Diener (2000) identified three key factors involved in SWB. The first and most important is adaptation. Several studies reveal that the majority of people adapt to either positive or negative events and return to a base line SWB. The next factor is personality or temperament. Studies show that a person's SWB is to a large extent dependent upon heredity. The final factor is goals or expectations, which are influenced by one's environment. Moreover, the more flexible a person is with respect to goals and expectations the greater his or her SWB. In conclusion, Diener called for more research into the nature and state of SWB in order to "create a better society where happiness is ubiquitous" (2000, p. 41).

Downie and the Tannahills critiqued SWB, claiming that it relies too much on subjective feeling and not on objective criteria. SWB "may arise from influences which are overall detrimental to an individual's functioning or flourishing, and/or to society" (Downie et al., 1996, p. 18). They gave the example of narcotic administration to elevate a person's mood. Furthermore, a critical objective analysis of wellbeing must take into account "the basis of feelings of well-being. We argue that true well-being involves and reflects a quality which we shall refer to as empowerment" (Downie et al., 1996, p. 19).

Empowerment or autonomy entails four values: self determination, self government, sense of responsibility, and self development (Downie et al., 1996, pp. 164-165). Empowerment provides a structured notion of wellbeing in contrast to SWB, especially in terms of achieving the "good life" or a life of flourishing. Unfortunately, SWB is part of the biomedical model's attempt to provide a quick fix for health problems, as opposed to the health promotion model that Downie and the Tannahills advocate: "the biomedical approach to health tends to involve the subjective sense of well-being since it can be drug-induced, whereas the health promotion approach, with its stress on `being all you can be', must assume the... `good life' sense" (Downie et al., 1996, p. 20).

11.3.2 Disease and Illness

Biomedical practitioners define disease and its associated pain in terms of facts, i.e. the material and physical, with little if any reference to values. Disease and pain are value neutral or if there is any value to them it is inconsequential. Humanistic or humane practitioners, on the other hand, consider illness and its associated suffering to be value-laden or disvalue-laden terms. "Physicians," according to Leon Eisenberg, "have been taught to conceptualize diseases as abnormalities in the structure and function of body organs and tissues. But," he continues, "patients suffer illnesses; that is, experiences of disvalued changes in states of being and in social function" (1988, pp. 198-199).

Illness and the suffering that results from it are social terms and ideas that depend upon the values society places upon them. It is this evaluation then that a person learns and that thereby influences the response of an individual to his or her condition. Recently, however, philosophers of medicine argue that just as health and wellbeing are values that motivate people to act in certain ways, so are the disvalues of disease or illness and pain or suffering. These disvalues are moral in nature with respect to the bad, just as health is a moral value in terms of the good. In other words, disease and illness are negative evaluations of bodily conditions.

Traditional interest in the notion of disease and the language to articulate this notion are "mainly concerned with epistemological and metaphysical questions such as the nature of disease and the status of disease language in clinical practice and medicine science... The problem of disease and disease language thus has taken on [in contemporary discussion] a predominantly ethical coloring" (Agich, 1983, p. 27). Agich works out this ethical dimension in terms of the role of values in articulating the nature of disease. Ethical values are important for determining the very nature of disease itself, especially in terms of illness and sickness.

Values function not only in the actual diagnosis of the patient's diseased state but are also important in the illness the patient may suffer or the sick role society confers on the diseased or ill person. "The language of disease," according to Agich, "necessarily involves evaluation and value judgment about what compromises the proper and desirable human conditions. Essential to this condition is freedom; hence," he concludes, "values are both implicitly and explicitly implicated in the common use of disease language" (1983, pp. 37-38). Given that freedom is the main value concerning the human condition, the disvalue then of disease, illness, or sickness is the loss of freedom. One of the chief disvalues of illness is the loss of freedom to act in a familiar world (Toombs, 1993).

A key component to the notion of disease and illness as primary medical disvalues is the notion of human dignity. Daryl Pullman (2002) divides human dignity along two poles of a continuum. At one pole is basic human dignity, which is inherent to every person. This sense of dignity represents a moral absolute that cannot be diminished by disease or illness. At the other pole is personal dignity, which "is tied to personal goals and social circumstances, to a sense of who one is as an individual in the social world" (Pullman, 2002, p. 76). This sense of dignity then is subjective in terms of personal feelings and contingent upon external factors. Both disease and illness in terms of compromised integrity detract from a person's overall dignity, especially in terms of both a person's health and overall wellbeing. The pain associated with an acute disease and especially the suffering of chromic illness cripples the person and robs him or her of the ability to achieve his or her maximum potential qua human being.

A sense of dignity is based on a notion that choice defines human dignity (Pullman, 2002). Loss of choice is then equated with loss of dignity: "in a society that values independence and self-sufficiency the life of dignity, as defined by this culture, is often lived alone.. .On this view the dignified response in the face of suffering is to go it alone. Those who lose their independence or the control of bodily functions, are often viewed with disgust by both themselves and others" (Pullman, 2002, p. 89). In contrast, human dignity should be based not on choice and independence but on an aesthetic of meaningful and loving relationships: "The beautiful life-the life of dignity-is expressed in the caring relationships we share with one another" (Pullman, 2002, p. 89).

Paradoxically, disease and pain can be positive values for a person. After all, it is pain that is an adaptive mechanism alerting a person as to a somatic problem and it alerts the person to present danger that may lead to further pain and damage. In some respects disease and illness are more a primary (dis)value of medicine than health or wellbeing, in that disease or illness is what motivates a person to seek medical attention in the first place.

Gotthard Booth also interprets disease as a positive value from a psychosomatic perspective. He claims that disease is a message or as one commentator claims, "disease is a message of the whole person" (Slater, 1981, p. 100). "Psychosomatic medicine," according to Booth, "suggests that disease has a positive, spiritual aspect, too. It is an unconscious self-revelation of the limitations of individuality... In this respect, each case of disease must be considered not only an evil to be fought, but also a reminder of the purpose of life. By this I mean," he continues, "that that all human actions and efforts aim toward something which transcends the achievements in this world" (1951, p. 18).

Booth later articulates the positive value of disease and its treatment in terms of what he calls "a psychotherapeutic maxim: Do not overvalue your spontaneous idiosyncratic image of the world. The more you live in a too one-sided fashion, the more you are likely to be forced by disease to sacrifice your over-differentiated function" (Booth, 1962, p. 315). In other words, disease keeps us humble before the mystery of the world and counsels us not to excess.

11.4 Summary

Pellegrino and Thomasma claim that "the axiology of medicine is in too primordial a state... Clearly, one task of the philosophy of medicine is the formal and extended elaboration of value theory" (1981c, p. 340). To the establishment of a medical axiology, Pellegrino proposes the following goals: "[Medical axiology] would deal with the tensions in human values created by the progress of medicine itself; it would define how medicine might contribute to restructuring and resynthesizing a value system for contemporary man. And," he concludes, "it would define those values which should determine the social and personal behavior of every physician" (1979a, p. 211). Although Bruhn and Henderson's enumeration of the various values that animate medicine goes a long way to developing the field, it fails to provide the needed theoretical basis for further development of a medical axiology. The question arises as to whether medical knowledge and practice are unique enough to warrant a specific axiology. The consensus seems to be that they are, although there is certainly dissent concerning that position.

"Health," according to Gracia, "is a moral enterprise, exactly because it is not a natural predicate but a value" (1999, p. 95). The important question then is whose moral terms and values are to be used to determine the nature of health and disease. He distinguishes between two levels at which values function: the private and the public. Health begins with private values, especially in terms of what constitutes the ideal health for the individual. "Health," argues Gracia, "is an ideal, a moral ideal that everyone must achieve in accord with his or her own system of values" (1999, p. 98). He identifies the private values with the ethical principles of autonomy and beneficence and the public values with the ethical principles of justice and nonmaleficence. Although health and the moral life begin with these private values, these values can be trumped by public values if and when conflict between them arises. Society must apply its public values across the board to achieve equity, otherwise injustice results. He concludes: "the question is whether or not we must understand the crisis of the concept of health as a crisis of our system of values and of our moral ideals" (Gracia, 1999, p. 99). It is that crisis of health and ultimately of values that contributes to the larger quality-of-care crisis. In the remaining chapters, the crisis of care is examined with the crisis of values in the background.



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