Bioethics, with all its practical importance, has grown in the past 30 years or so to the point that it is increasingly recognized as an academic field in itself. As ethics is a field within philosophy, one would expect that bioethics would naturally be seen as a field within a more general philosophy of medicine that explores, in addition to ethics, the particular epistemological, metaphysical, logical, and aesthetic realms of medicine. Philosophers, however, have been reluctant to recognize the philosophy of medicine as a field within philosophy. Nonetheless, a handful of those who call themselves bioethicists and others who eschew the title have recognized the importance of studying the philosophical foundations of bioethics and the practice of medicine. Some even dare to identify themselves as philosophers of medicine and have contributed to a rich academic discourse on the philosophical foundations of medical science and practice.
Kenneth A. Richman calls this eleventh volume in MIT Press's Basic Bioethics Series a book about the philosophy of medicine, and it is a welcome contribution to one of the central discussions in the philosophy of medicine: the concepts of health and disease. Richman's aims are both metaphysical and ethical: to present a theory of health and to draw out the ethical implications of the theory. Framing the question in this way shows that Richman is alert to the foundational importance of the philosophy of medicine. In a relatively short book, Richman concisely but substantively addresses a wealth of metaphysical and ethical matters relating to health and health care.
A theory of health, Richman rightly claims, ought to accord generally with our intuitions about health. Furthermore, a theory of health has important implications for guiding decisions about medical care and medical research (5). The theory defended in this book was first offered in a paper coauthored with Andrew E. Budson (Richman and Budson Reference Richman and Budson2000). Richman situates this theory in a family he refers to as “embedded instrumentalist theories.” These theories, the best known of which is that of Lennart Nordenfelt, take health to be “whatever state allows the person to reach or strive for his or her goals” (27). A state, then, can be objectively evaluated as healthy or unhealthy even while it takes into account the actual value-laden goals of individuals. The Richman-Budson version of embedded instrumentalism is new insofar as it makes a distinction between health qua organism and health qua person. Richman claims that this distinction better characterizes the evaluations made by patients and health care providers than does the more common distinction between disease, which has to do with biological explanation, and illness, which has to do with the subjective experience of disease (28).
Perhaps the most serious challenge faced by preference-satisfaction theories of health comes from the individual whose goals are unrealistic or even inconsistent. A human who cannot meet a goal of flying, for instance, is obviously not unhealthy. Furthermore, people who are unhealthy because they cannot strive for their chosen goals might instantly become healthy upon readjusting their goals. Richman's solution to the problem of incompatible goals is to appeal to an ideal observer, as some theories of ethics have done, to make judgments about whether goals are properly chosen (45). This, however, is unlikely to settle difficult cases. There are serious doubts about whether such a position of ideal observation exists, or whether it could possibly be known even if it does exist. One might plausibly argue that an ideal observer would likely reduce reasonable health goals to something like a set of basic vital goals, and thus the theory would look very similar to that of Nordenfelt.
Health care providers necessarily encounter ethical dimensions in helping patients achieve a state that will enable them to pursue their goals. In the second part of the book, Richman singles out the ethical principles of beneficence and autonomy as especially relevant to preference-satisfaction theories of health. Beneficence is aimed at helping persons strive for their goals, but faces the problem of distinguishing true health preferences from quality of life preferences. Autonomy provides a philosophical foundation for respecting persons and their goal choices. In discussing autonomy, Richman makes much of Kant's notion of respect for the person, but one must wonder whether Kant would see heteronomy rather than autonomy in the striving for one's own preferences. Richman's theory really employs autonomy in the sense that it is used in typical bioethical discourse: freedom to pursue one's own goals.
The final section of the book discusses the ethical implications of this theory of health by singling out two issues: advance directives as expressions of autonomous goal choices; and education of medical students as communicators who can effectively come to know and evaluate patient goals. The former involves an interesting foray into the metaphysical issue of personhood and its continuity over time, and the latter a discussion of the physician-patient relationship in general.
If one accepts the distinction between health qua organism and health qua person, there can be conflicts between one's health as an organism and one's health as a person. For instance, Richman points out that a person with untreated bipolar disease may find a hypomanic state useful in pursuing chosen goals and thus be healthy as a person, but untreated bipolar disease is clearly unhealthy for the organism. He makes it clear that he considers health qua person primary, and health qua organism merely instrumental to the primary notion of health (111), but in a discussion of treating incompetent patients whose wishes are unknown, he claims it is a virtue of his theory that in such situations we can take the “fallback approach of promoting health of the patient qua organism” (153). In the end, one is left wondering whether such a dual conception of health really is in accord with our most basic intuitions about health and whether such a dual conception can be of much practical help. Nonetheless, this book interrelates many basic problems in the philosophy of medicine in a scholarly and thought-provoking way and makes a noteworthy contribution to the field.
