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May 19, 2009


You say that modern medicine is fundamentally non-utilitarian in its practices. I wonder if that isn't an oversimplification. There are a number of medical trends that are utilitarian.

For example, terminal and very elderly patients and their families are encouraged, subtly or not so subtly, to sign DNR orders and to decline other extraordinary measures. This can be rationalized as being in the interest of the patient, but it's also clearly regarded as a way of reducing the enormous medical costs frequently incurred in the last weeks of a dying patient's life.

As another example, there's been considerable discussion recently about whether patients should be tested for prostate cancer, because positive results impel patients toward treatment that may be of limited value. The focus here seems to be on societal costs and benefits of testing as opposed to the situation of the individual patients.

There is also the promotion of "best practices" as a means of bringing down the cost of health care. Once again, what's involved is a cost-benefit analysis on a macro level. In a truly non-utilitarian approach, there would be no cost-weighing. We've heard a good deal about best practices, and we'll be hearing more, especially as the Government becomes more involved with the financing of health care. That's not necessarily wrong, but let's not kid ourselves: it's utilitarian in the plainest sense of the concept.

No doubt there are trends that could be interpreted as utilitarian. My point is simply that many medical practices that society tends to view as ethical could not be justified under a strict utilitarian framework.

ISTM that war forces doctors into philosphical dilemmas that are different from peacetime practice. War involves killing and maiming large numbers of enemy soldiers, as well as civilians unlucky enough to be near some military target. A doctor who participates in the military may be using a utilitarian principle to justify her participation in so horrible an enterprise.

Go back to Dr. Lefebre's comments. If we substitute "killing and maiming enemy soldiers in battle" for "producing pain", the comment would not be controversial (except to conciencious objectors.)

The question we are left with is whether when physicians acting on behalf of a health insurer or a state comparative effectiveness board or Tom Daschle's proposed Federal Health Board decide that Treatment A may be somewhat more effective than Treatment B but not sufficiently more effective to justify its much greater cost, and therefore deny coverage for Treatment A, are those physicians acting ethically, or in Brendan's words, is "this sort of reasoning . . . chilling coming from a doctor"? It does not seem to me that the physicians would be acting unethically, even though their orientation is strictly utilitarian.

The military psychologists who advised the military on what interrogation techniques fall short of causing "prolonged mental harm" (18 USC ยง2340) did not have the detainees as their patients. Their advice seems to me neither unethical nor chilling.

War involves killing and maiming large numbers of enemy soldiers

This is a constant talking point among the defenders of torture. But soldiers on the battle field have long been recognized as falling in a different class than prisoners - the difference obviously being that soldiers in battle are both actively attempting to kill you and capable of doing so.

Prisoners are not.

Jinchi, I don't mean to defend torture, but I don't agree with your analysis. It has long been realized that the rules of war allow attacking civilians under certain circumstances. To take three examples, munitions factories can be attacked. Transportation lines can be bombed. Soldiers can be attacked even though there are civilians nearby who will be killed or maimed in that attack. It may even be acceptible to destroy a civilian target in order to motivate the other side to surrender, such as Hiroshima and Nagasaki.

In all these cases, it's acceptible to kill and maim civilians in the process of a campaign that will help win the war. It would not be acceptible to simply kill and maim random civilians (as the Palestinians do.)

This analogy suggests that it may be OK to torture prisoners if that torture will help win the war, e.g., by forcing the prisoner to reveal essential information.

Jinchi, I don't actually assert that it's acceptible to torture prisoners. My point is that your argument isn't sufficient to show why it isn't.

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