14 - Dependency: the foundational value in medical ethics

Summary

In this chapter I am seeking to correct a rank order of moral principles which seems to have crept into the literature of medical ethics over the past two decades, almost unobserved. There has developed a presumption in favour of individual self-determination or autonomy, and an implied or explicit criticism of the beneficent approach to the health care relationship as being second best, or justified only in certain strictly demarcated circumstances. Examples of this ordering of principles are not hard to find in the standard works in contemporary medical ethics. A notable counterbalancing of this prevailing view-point has been Pellegrino and Thomasma's For the Patient's Good: The Restoration of Beneficence in Health Care. To some extent this chapter can be seen as an elaboration of some aspects of their argument. But my central point is perhaps more controversial than theirs. I want to assert that the fundamental character of human life is one of dependency, and that therefore a medical ethics which seeks to overemphasise the independence of the individual is in danger of being a de-humanising and inadequate account of the therapeutic relationship. I have already stated this fundamental assumption about the dependent nature of human existence in my book, Moderated Love. Writing about the ‘wisdom’ upon which medical interventions must be based, I described the following features of the ‘creatureliness’ which constitutes human life:

To be a creature is to be born of others, to know ourselves through them, to depend upon them and create dependency, to know the pain of losing them and finally to be the instance of that pain to others.