NORMS EMBEDDED IN ORDINARY MORALITY (ACCORDING TO VEATCH)

• (NHB) The Norm of Beneficence and Non-maleficence: Benefit and do no harm to others.
  • (NH) Do no harm to others.
  • (B) Benefit others.
• (A) The Norm Protecting Individual Freedom (Autonomy): Respect and protect the individual freedom of others; respect their autonomy.
• (D) The Norm of Respect for Human Dignity: Respect and protect human dignity.
• (V) The Norm of Veracity: Tell the truth and keep your promises.
• (J) The Norm of Respect for Justice: Respect human rights including the right to proper compensation for past injustice.

Veatch does not make completely clear how to distinguish (A) from (D). Actions that might elucidate the difference would have to involve two elements: 1) informed rational consent of participants and 2) some undignifying activity. The behavior of some guests and their hosts on some TV-shows may, perhaps, illustrate the points. yet they would have to be undignifying. Perhaps what the g We may envisage, however, some actions that

MAIN DIFFERENCES BETWEEN VEATCH , BAYLES, AND ELLIN

• Veatch develops models for medical professionals; Bayles develops models for professionals in general. However, Veatch's models may be generalized to all professions. Similarly, Bayles models may be used to illustrate the relations between doctors and their patients.
• Veatch develops four models; Bayles proposes five different models.
• Ellin discusses several models. The most important one is his fiduciary model. This model is different that Bayles' version of fiduciary model

SOME COMMENTS

THE ENGINEERING/AGENCY MODELS

• The main advantage of this model is that the professional are "value free" (or as value free as possible). That is, the client (patient) makes all the choices; a professional/physician respects these choices. He or she simply brings about what the patient had chosen.
• The same is the main problem of this approach, First, it's not clear it is logically possible to act in a "value free" way.
  More importantly, even if it were possible, it would be morally wrong. "[E]ven if the physician logically could eliminate all ethical and other value considerations from his decisions making... it would be morally outrageous for him to do so. It would make him an engineer, a plumber making repairs, connecting tubes and flushing out clogged systems, with no questions asked... (Veatch, p. 89)"

THE PRIESTLY (OR PATERNALISTIC) MODEL

• The patient makes no choices and a physician makes all the choices.
• Physicians are guided in their choices by NHB principle (do no harm and benefit).
• Paternalism: Any intervention that constrains someone for his or her own good.
• Problems: Except for NHB, this model ignores all other ethical considerations.
  In particular, it gives no weight at all to the respect for autonomy (Unmitigated paternalism is frequently wrong.)

THE COLLEGIAL MODEL

• "The patient and the physician work together as colleagues pursuing the common goal of eliminating the illness and preserving the health of the patient. The physician is the patient's ‘pal'... trust and confidence play the most crucial role" (Veatch, p. 91).
• Problems: There is no "real basis for the assumption of mutual loyalty and goals [or] of common interests..." (p. 91). It is unrealistic to suppose that patients and physicians have generally enough in common to be pals.

THE CONTRACTUAL MODEL

• Veatch's favorite model
• The patient and the physician are constrained by a contract or covenant analogous to marriage.
• Both parties preserve their autonomy and integrity.
• Problem (pointed to by Bayles): it is not realistic to suppose that a client and a professional can really enter into a real contract as equals; the client's knowledge is too limited.

BAYLES FIDUCIARY MODEL

• Bayles' favorite model (different from Ellin's fiduciary model)
• The professional has a special obligation to his/her clients
• The professional proposes various courses of action
• He/she suggests which one is the best choice, is in the best interest of the client
• The client consents to the proposed courses of action
• This consent must be rational and well-informed.

ELLIN'S FIDUCIARY MODEL

• The professional has a special obligation to his/her clients
• The professional proposes various courses of action
• He/she suggests which one is the real interest of the client (as professional alone understands this interest)
• It's not clear whether the client consents to the proposed courses of action
• Client may fail to have some relevant information. Deception is allowed.
• Hence, even if the client "agrees" to some form of action, this may fail to be fully informed consent".

BAYLES AND ELLIN ON FIDUCIARY MODELS

BAYLES	ELLIN
A client and a professional are constrained by a special kind of "contract".	A client and a professional are constrained by a special kind of "contract".
The professional has special obligations to the clients; she must ensure that she deserves the trust.	The professional has special obligations to the clients; she must ensure that she deserves the trust.
The professional acts in the best interest of the client.	The professional acts in the real interest of the client as the professional alone understands this interest.
The client determines what is (or is not) in his or her best interest.	The nature of their relationship determines what this real (or relevant) interest is.
The professional proposes the possible courses of action and informs the client which course is the best for the client.	The professional proposes the possible courses of action and informs the client which course will fulfill the client's interests.
The client gives rational informed consent to this course of action	It is not clear whether the client consents to this course of action. (At best, a client gives a hypothetical consent just in virtue of entering the relationship with the professional.)
The client has all the relevant information.	The client may, or may not, have all relevant information (deception is possible and allowed for therapeutic causes).

TWO CONTRASTING APPROACHES TO RELATIONS BETWEEN PROFESIONALS AND THEIR CLIENTS 

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OLD FASHIONED ("AUTHORITARIAN")	MODERN ("RESPECT FOR AUTONOMY")
Ethics is authoritarian (based on authority and not necessarily on reasons)	Ethics is antiauthoritarian (based on reasons not on arbitrary prescriptions and prohibitions imposed by some authority)
Ethics is a list of obligations and prohibitions	Ethics is a study of reasons that underlie professional obligations
Professionals decide what their obligations are	Ethics is fundamentally rational activity. By studying reasons for and against, anyone can discover what the professional obligations are (because anyone can discover the underlying reasons)
Ethicists and philosophers have nothing to do, there is no role for them to play	The role of a moral philosopher is to study the reasons underlying the professional obligations and permissions; philosophers contribute to protecting the public against professional abuses
The client determines what is (or is not) in his or her best interest.	The nature of their relationship determines what this real (or relevant) interest is.
Professionals have almost complete (total) authority over the treatment of their clients	Clients make important contributions to the decisions that concern them
Professionals need not give us any reasons for, or explanations of, what they do	Professionals must give us good reasons for what they do; they must explain and justify their actions.
In the context of medical ethics, the primary ethical principle is (NHB): "do not harm and benefit"	Harms and benefits for the clients are important reasons; but there are other important reasons stated in principles other than (NHB)
Informed consent is not crucial (or even relevant) for this approach	Fully informed consent is the most crucial for this approach
Professionals can lie and deceive if it is good for their clients	Professionals must not lie or deceive; lies and deceptions are assaults on the client's autonomy

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