Diagnostic Success, Therapeutic Failure


Doctors' Dilemmas: Moral Conflict and Medical Care, by Samuel Gorovitz, New York: Macmillan, 1982, 225 pp. $14.95.

For whom will you wait enduringly until called, undress when requested to do so, allow exploring hands to seek out each crevice of your body? Whose encouraging remarks will elevate your spirits; whose passing frown, dash them? And on whose judgment will you so rely that you will often allow it to supersede your own? A lover perhaps. Or, more likely, your physician.

Doctors ply a craft that is both inherently dramatic and charged with a level of intimacy unique among the professions. It is therefore unsurprising that medical ethics inherits some of the glamour that attaches to medicine itself. Surely no other area of applied philosophy has attracted so much attention from the general public. From the prospects of in vitro fertilization and abortion that precede birth to the lingering life-in-death of Karen Quinlan, the moral dilemmas that abound in medical practice have become as conspicuous on front pages as in learned journals.

Samuel Gorovitz has been in the forefront of the past decade's burgeoning concern for issues in medical ethics. His contributions to scholarship have been impressive, and equally so have been his efforts on behalf of the teaching of medical ethics within medical schools and the liberal arts curriculum. In Doctors' Dilemmas he tries to address a wide and variegated audience, urging through the consideration of a representative range of problems associated with medical practice that philosophy can offer genuine help to those on whom falls the burden of making hard choices.

Philosophy can help by clarifying the nature of the values at stake in a choice situation and by guiding one toward the general area within which maximum resolution of differences can be attained. Philosophical analysis will not by itself uniquely determine a solution for each moral dilemma, Gorovitz admits, but it is nonetheless a significant resource for the decisionmaker. "I am willing to respect it for what it can do instead of lamenting what it cannot."

His success in demonstrating the achievements of philosophical reflection is, however, mixed. Gorovitz does an able job of spelling out the nature of moral problems that emerge in medical practice. And he shows how they derive from the clash of values each of which merits respect but which cannot be jointly realized in a recalcitrant world.

Delineating what the problems are is one thing, though; moving them toward resolution, another. Gorovitz's success as a diagnostician is juxtaposed with frequent failures as a therapist. The positive arguments he offers more often than not disappoint. One example is his discussion of abortion, where he argues that the attainment of sentience by the fetus is a morally crucial line of demarcation. "Surely the concept of a person involves in some fundamental way the capacity for sentience," he writes, and goes on to conclude that aborting a presentient embryo cannot be considered the killing of a human person.

One's guard ought to be up when a philosopher prefaces a claim with surely. At least it ought to be up here. For if sentience is a necessary condition for personhood, then someone even temporarily comatose is not a person and can be dispatched with impunity! Gorovitz entirely omits consideration of this rather obvious objection to his suggested criterion.

No useful response is liable to be forthcoming, though. Were he to maintain that those temporarily comatose have the potential to attain to sentience and will usually do so in the course of time, he would be saying something true. But it is a truth that also characterizes most zygotes. If one enjoys a right to life as a potentially sentient being, so does the other. Moreover, if mere sentience is morally crucial in this context, must we not recognize a right to life in puppies or even earthworms? These sorts of difficulties are commonly noted in the philosophical literature on abortion; it is mysterious why Gorovitz is oblivious to them here.

Why are these and other arguments presented in so conspicuously vulnerable a state of disrepair? An answer would be more easily forthcoming had Gorovitz not previously demonstrated that he is a competent philosopher. In other contexts he has exhibited a markedly more professional standard of argument. I suspect that it is precisely because he wants to reach an audience of nonprofessionals that he strives for what appear to be "moderate" positions, that he sweeps along without a nod toward likely objections, that he offers sketches of arguments rather than the bona fide article.

The goal of exhibiting the worth of moral philosophy to nonphilosophers is laudable. The strategy adopted, though, is counterproductive. A reasonable response is: if this is the best that philosophical analysis can bring forth, it is a frail reed indeed. Doctors' Dilemmas would have done better to try decisive surgery more often and to prescribe fewer placebos.

Loren Lomasky is a visiting research associate at the Center for Study of Public Choice, Virginia Polytechnic Institute.