THE JUST DISTANCE: A NEW BIOMEDICAL PRINCIPLE
by
PAUL QUALTERE-BURCHER
A THESIS
Presented to the Department of Philosophy
and the Graduate School of the University of Oregon
in partial fulfillment of the requirements
for the degree of
Master of Arts
December 2008
"The Just Distance: A New Biomedical Principle," a thesis prepared by Paul Qualtere-
Burcher in partial fulfillment of the requirements for the Master of Arts degree in the
Department of Philosophy. This thesis has been approved and accepted by:
Mark Johnson .D, Chair ofthe Examining Committee
IDate
Accepted by:
Dean of the Graduate School
11
© 2008 Paul Qualtere-Burcher
111
iv
An Abstract of the Thesis of
Paul Qualtere-Burcher
in the Department of Philosophy
for the degree of
to be taken
Master of Arts
December 2008
Title: THE JUST DISTANCE: A NEW BIOMEDICAL PRINCIPLE
This work argues that the principle of autonomy set forth in the Principalist theory
of biomedical ethics should be replaced by "the just distance"-a concept first suggested
by Paul Ricoeur. Beginning with the prevailing critique of autonomy in feminist
philosophy and medical ethics, the paper then explains why a principle encompassing
narrativity, relationality, and singularity would provide a better guiding standard for the
doctor-patient encounter than the current rule of "respect for autonomy". The final
chapter gives examples of how the just distance can be used in a clinical setting, and
responds to possible critiques of this new principle.
CURRICULUM VITAE
NAME OF AUTHOR: Paul Qualtere-Burcher
PLACE OF BIRTH: New Jersey, USA
DATE OF BIRTH: June 6,1963
GRADUATE AND UNDERGRADUATE SCHOOLS ATTENDED:
University of Oregon, Eugene, Oregon
University of Arizona College of Medicine, Tucson, Arizona
Boston College, Boston, Massachusetts
Occidental College, Pasadena, California
DEGREES AWARDED:
Master of Arts, 2008, University of Oregon
Medical Doctor, 1991, University of Arizona College of Medicine
Bachelor of Arts, 1985, Boston College
AREAS OF SPECIAL INTEREST:
Philosophy of Medicine
PROFESSIONAL EXPERIENCE:
Clinical Associate Professor, Oregon Health Sciences University, 2007-present
Obstetrician/Gynecologist, Peace Health Medical Group, 2002-present
v
vi
Clinical Assistant Professor, State University of New York, 1999-2002
Obstetrician/Gynecologist, University Primary Care, 1997-2002
GRANTS, AWARDS AND HONORS:
Alpha Omega Alpha, Medical Honor Society, 1990
Phi Beta Kappa, 1985
Alpha Sigma'Nu, Jesuit Honor Society, 1985
Outstanding Specialty Teacher 1998, 1999, 2000
PUBLICATIONS:
Qualtere-Burcher, Paul. "The Communal Push and its Implications for Merleau-Ponty's
Theory of Intersubjectivity". Merleau-Ponty Circle Conference Proceedings
2008. (publication pending).
Miller, William, Paul Qualtere-Burcher, et al. "AIDS Knowledge and Attitudes Among
Adolescents in the Rural Southwest". The Journal ofRural Health. 6 (1990):
246-255.
Vll
ACKNOWLEDGMENTS
I wish to thank Professor Naomi Zack for first suggesting I do a thesis that
combined my two fields ofleaming: medicine and philosophy. I am very grateful to
Professor Mark Johnson for all of his assistance as my advisor-he truly helped me
formulate my thoughts through his questions and suggestions. Finally, I need to thank my
wife Maria and family for listening to me talk about autonomy and the philosophy of
Ricoeur for over a year.
Vlll
To Maria for believing that the philosophy student could be a doctor, and then that
the doctor could again be a student ofphilosophy.
IX
TABLE OF CONTENTS
Chapter Page
I. INTRODUCTION 1
II. AUTONOMY AND ITS CRITICS IN THE PRINCIPALIST THEORY OF
BIOMEDICAL ETHICS 7
III. THE JUST DISTANCE: NARRATIVITY, SINGULARITY, AND
RELATIONALITY AS THE SOURCE OF A NEW BIOMEDICAL
PRINCIPLE 29
IV. THE JUST DISTANCE: A RESPONSE TO POSSIBLE CRITIQUES
AND ITS APPLICATION IN THE MEDICAL ENCOUNTER 45
REFERE]\J"CES 54
CHAPTER I
INTRODUCTION
Many years ago while still in training, I took care of a young woman with a
ruptured tubal pregnancy. Her evaluation showed that she had already lost a
considerable amount of blood, and she was in shock-low blood pressure, somewhat
decreased mental status. The Operating Room was not quite ready to take her, so I
and the other resident working with me began counseling her that she would need
blood. With her family beside her she replied that she was a Jehovah's Witness and
would refuse all blood products. This was quite distressing to me and my fellow
resident because while it would be fairly routine to give her blood and do a
straightforward surgery to stop her internal bleeding, it was not clear we could keep
her alive without blood products. But I saw a glance to her family that made me
wonder if we were really hearing her wishes, so while we were rolling her gurney
toward the operating room I asked her again if she was really willing to risk her life
by not receiving blood. Seemingly relieved, she responded that she did not consider
herself to be a Jehovah's Witness, but that she had not yet told her parents, and yes
she wanted blood if we thought it was necessary to save her life. She then requested
that we hide the transfusion from her family. She received several units of blood in
1
2surgery and recovery, her family was never aware of the transfusions, and she made
an uneventful recovery.
Although there is still a lively discussion within philosophy departments about
competing theories of ethics, in medical schools and medical specialty societies this
discussion is largely finished and a victor has been declared. My specialty board
publishes a monograph on ethics that is completely modeled after the Principles of
Biomedical Ethics by Beauchamp and Childress--eompeting theories are mentioned
in passing, and this principalist theory is said to be able to encompass and incorporate
them within its principles of medical ethics. 1 Beauchamp and Childress set out
autonomy, beneficence, non-maleficence, and justice as the four principles that one
must reason from when faced with a biomedical ethical decision.
I chose to begin this discussion of medical ethics and the worthiness of the
principle of autonomy with this case history not because of the complexity of the
ethics involved in this example, but rather because of the potential pitfalls that it
presents to a clinician well- versed in the "principalist" theory of medical ethics.
Reasoning, as I believe Beauchamp and Childress would have us do, from the
principle of autonomy we could have ethically acceded to her initial request to forgo
blood products even if it cost her life. Some have also argued that the principle of
beneficence could be invoked to override her autonomy and save her life against her
stated wishes. But how beneficent is it to disregard a patient's deeply held religious
beliefs? However, this is a false ethical dilemma because the ethical argument has
1 American College of Obstetricians and Gynecologists, Ethics in Obstetrics and Gynecology, 2nd ed.
(Washington DC: American College ofObstetrics and Gynecology, 2004).
-------- - -----------
3
proceeded too quickly from the person in need to ethical principles. Although both
inexperienced and stressed by the situation before me, the sidelong glance to her
parents reminded me that I knew nothing about her. Our relationship had begun only
minutes earlier and I did not know her story.
As long as medical ethics is guided by principles that ignore and downplay the
importance of relation and narrativity, the principle of autonomy in medical ethics
will do more to deny true respect for the selfhood of the other than stand as its
safeguard. My response to the four principles of medical ethics is not to abandon
them completely, but rather to examine and replace the principle of autonomy with a
new principle first suggested by Paul Ricoeur-the just distance-the right relation?
Just as the principle of autonomy carries with it a history of philosophy that resonates
within it, the just distance will represent a synthesis of feminist ethics and its critique
of principalist medical ethics and the narrative/relational philosophy of Paul Ricoeur.
Some feminist critiques of ethics would argue against this limited approach of
leaving the four principles intact, and merely replacing the most egregious example of
"male" abstract reasoning, but I believe this response is justified both philosophically
and pragmatically. Several feminist ethicists, including Susan Sherwin and Eva
Kittay, reject autonomy as an accurate descriptor of the human condition, but they do
not oppose principles or the normative force of their conclusions. They retain a belief
in principals as a foundation of our decision making, while discarding autonomy as a
constitutive principle of selfhood.
2 Paul Ricoeur, Reflections on the Just, trans. David Pellauer (Chicago: The University of Chicago
Press, 2007), 220.
4Sherwin argues that the principles must be tempered by the concrete, and
must reflect accurately human relations as they should be, rather than as they are, and
here she invokes the principle ofjustice in her argument:
Because feminism arises from moral objections to oppression, it must
maintain a commitment to the pursuit of social justice; that commitment is not
always compatible with preferences derived from existing relationships and
attitudes. Hence we must recognize that feminist ethics involves a
commitment to consideration ofjustice, as well as to those of caring.3
Moving the principle that informs the patient-doctor relation from autonomy to the
just distance is both an effort to accurately describe the relationality of human
selfhood and also to reform the existing understanding of the bounds of this relation.
The intent is to suggest the possibility of actual change in the behavior of
practitioners: this is also the pragmatic aspect of my project. The Principalist theory
has become and remains the primary ethical theory of clinicians since its introduction
in 1979.4 If the goal is to influence the thinking and behavior of clinicians, a revision
of the theory that has become central to our thinking about medical ethics seems more
likely successful than a complete replacement of it. Furthermore, I do not object to
the principle-based model per se-it has shown great resiliency and utility in the
sense that clinicians do often use it to reason through ethical questions confronting
3 Susan Sherwin, No Longer Patient: Feminist Ethics and Health Care (Philadelphia: Temple
University Press, 1992), 52.
4 K. Danner Clouser and Bernard Gert, "A Critique of Principalism," in Bioethics: An Introduction to
the History, Methods, and Practice, ed. Nancy S. Jecker, Albert R. Jonsen, and Robert A. Pearlman
(Sudbury: Jones and Bartlett Publishers, 2007), 153.
------------------------------
5
them in their practice. Returning to the case history, a principle of right relation
would not argue against the respect for her autonomous choices, but it would go
beyond this limited dimension to asking the larger question of whether we knew her
well enough to understand what her answer really meant.
Beauchamp and Childress acknowledge the possibility of revision to their
theory. 5 They also see the principles as pluralistic and non-hierarchical, so changing
one principle does not negate the others---although the conclusions of any particular
case may now change as the balance between the principles has now shifted.
I begin with a discussion of the Principalist theory, and the principle of
autonomy as it is understood in this setting, and then move to the state of current
critique in feminist and medical ethics regarding the Principalist theory. The second
chapter will discuss the philosophy ofRicoeur and explain why the just distance is a
principle that correctly characterizes the doctor-patient relation. This is the
groundwork for the third chapter which will continue to argue for a replacement of
the principle of autonomy with the principle of respect for the right relation, as well
as discuss possible critiques of the just distance. The goal is to remain within a
principle-based theory of bioethics but to move from the "one size fits all" principle
of autonomy to guide the physician-patient relation to the just distance-a principle
that carries with it a recognition of both narrativity and the particularity of each
person and therefore each relation. The answer for what is the appropriate relation-
what is the correct "distance" between the physician and the patient must be found in
5 Tom L. Beauchamp and James F. Childress, Principles a/Biomedical Ethics, 5th ed. (Oxford:
Oxford University Press, 2001), 398-399.
each encounter. The myth of respecting patient autonomy is in part that there is one
correct answer to this question. Ricoeur's response is that there can never be only
one answer, and that the relation itself carries in it the information to determine how
to proceed. To this end, while Beauchamp and Childress begin with a principle that
cannot be universalized to every patient encounter," respect the autonomous choices
of persons,,,6 because not every patient can fulfill the ideal of having the capacity to
make autonomous choices, the just distance can impose a directive that is always
appropriate-find the right relation in this encounter, with this person, at this time.
6 Beauchamp and Childress, Principles a/Biomedical Ethics, 57.
6
7CHAPTER II
AUTONOMY AND ITS CRITICS IN THE PRINCIPALIST
THEORY OF BIOMEDICAL ETHICS
When Thomas Percival wrote his treatise on medical ethics in 1803, he argued
for an essentially principle-based theory of medical morality, but there were only two
principles that a doctor needed to abide by in making medical decisions: beneficence
and non-maleficence. l The doctor was expected to determine what was best for the
patient, and the patient was expected to passively follow this advice. The years
between Percival's medical ethics and the beginning of medical ethics as a discipline
saw the abuses of the Tuskegee experiments and the eugenics movement, and both of
these examples provide support to a principle of patient autonomy. The long tradition
of what is now understood as "paternalistic medicine" was already coming to an end
when the first edition of Beauchamp and Childress's Principles ofBiomedical Ethics
(PBE) was published in 1979. This text of biomedical ethics established a principle-
based theory that gave equal standing to the principles of autonomy, beneficence,
non-maleficence, and justice as the foundations for judging biomedical ethical
questions and dilemmas.
1 Tom L. Beauchamp and James F. Childress. Principles a/Biomedical Ethics. (Oxford: Oxford
University Pres, 2001), 12.
8Even critics of the principle of autonomy as described in PBE agree that it has
had a beneficial effect in moving clinicians away from a role in which they empower
only themselves in the medical decision-making process? It is worth remembering as
this critique proceeds that one possible perspective on the use of autonomy as one of
the four basic principles of medical ethics is that it served a useful function in time,
but that it can now be replaced by a more nuanced understanding of the physician-
patient relation without any threat of returning to paternalism. To judge this, we must
first understand both how autonomy is described in PBE and also say something
about its use and understanding among other ethicists and clinicians.
The four principles are grounded in "common morality" which Beauchamp
and Childress define as:
We will refer to the set of norms that all morally serious persons share as
common morality. The common morality contains moral norms that bind all
persons in all places; no norms are more basic in the moral life. In recent
years, the favored category to represent this universal core of morality in
public discourse has been human rights, but moral obligation and moral virtue
are no less vital parts of the common morality.\Italics original)
Their justification for beginning in common morality is in part based upon a concern
that ethical systems grounded in a particular theory--deontology or utilitarianism, for
example, can be negated by challenges to the underlying theory. They argue that by
2 Albert R. Jonsen. "A History ofBioethics as Discipline and Discourse." in Bioethics: An
Introduction to the History, Methods and Practice eds. Nancy Jecker, Albert Jonsen, and Robert
Pearlman. (Boston: Jones and Bartlett Publishers, 2007), 13.
3 Beauchamp and Childress. Principles ofBiomedical Ethics, 3.
9beginning in common morality rather than a moral theory they avoid this potential
source of annulment of the ethical principles that are then derived from this source.
But how do they arrive at four principles as the guideposts for all possible decisions
and situations in bioethics, beginning as they do in "common morality"-a set of
norms that all "morally serious persons" could agree upon? Interestingly, it is the last
chapter ofPBE that explains and defends common morality theory. This is consistent
with their view that any medical ethics grounded on a true ethical theory is made
vulnerable by attacks to this underlying justification. Their response is to emphasize
elaboration of the four principles as guideposts for bioethical thinking and to de-
emphasize defending the basis for these principles, other than to claim they are easily
derivable from common morality.
The claim is that by beginning in common morality they are not grounding the
principles in a theory at all-that the linkage to common morality is less assailable
than principles derived from deontological or utilitarian reasoning:
We cannot reasonably expect that a contested moral theory will be better for
practical decision-making and policy development than the morality that
serves our common heritage. Far more social consensus exists about
principles and rules drawn from our common morality ... than about theories.
This is not surprising, given the central social role of the common morality
and the fact that its principles appear in some form in all major theories.4
4 Beauchamp and Childress. Principles ofBiomedical Ethics, 404.
10
While this contention is itself arguable, my focus is on the principle of
autonomy itself, not its derivation. However, since this project seeks not a total
dismantling of the four principles, but rather a modification, we will need to return at
the end and ask whether we are justified in our new principle in seeking support from
common morality. If not, we have created an untenable hybrid, rather than a better
statement of principles.
Beauchamp and Childress begin their description ofthe principle of autonomy
by delimiting it and setting it apart from a directly Kantian sense of autonomy.
"Respect for the autonomous choices of persons" is their initial statement of the
principle, and they then quickly add that they see autonomy as being neither a
rejection of the "social nature of individuals," nor a principle "focused on reason". 5
The acknowledgement of the social nature of humans would seem to be more a
concession to critics than an intrinsic aspect of their understanding of autonomy
because the analogy they use to describe their sense of autonomy is in fact quite
individualistic:
Personal autonomy is, at minimum, self-rule that is free from both controlling
interference by others and from limitations, such as inadequate understanding,
that prevent meaningful choice. The autonomous individual acts freely in
accordance with a self-chosen plan, analogous to the wayan independent
government manages its territories and sets its policies.6
5 Beauchamp and Childress. Principles ofBiomedical Ethics, 57.
6 Beauchamp and Childress. Principles ofBiomedical Ethics, 58.
11
A major aspect of their conception of autonomy is the realm of "informed consent"-
the choice made by an autonomous individual in health care must be both non-
coerced and well informed. The transformation of the physician's role into teacher
and communicator is without question part of the "benign influence" of the emphasis
on patient autonomy present in PBE.? But Beauchamp and Childress are clear that
they do not accept a "shared decision making" model of autonomy-the doctor
conveys information, but just as in a business contract, the decision rests solely in the
patient's realm. The patient declines or agrees to a procedure or treatment after being
adequately apprised of its risks and benefits. Beauchamp and Childress describe the
patient role as "authorizing," but only after the patient is informed enough to judge
what the options truly represent. 8 This authorization is dependent upon both non-
coercion and adequate information. The ability to give consent, and therefore the
validity of the consent, also rests upon a determination ofcompetence of the patient.
In a clinical setting, a determination of competence actually precedes the
process of giving informed consent: if a person is judged to be incompetent then the
giving of authority falls from them, and the process of informed consent occurs with a
surrogate decision-maker. Although Beauchamp and Childress discuss the
controversy surrounding the concept of competence, they throw their support to a
rigid demarcation between competence and incompetence without resolving which
standard is the best for determining where this line is to be drawn. Nonetheless, the
7 Albert R. Jonsen. "A History of Bioethics as Discipline and Discourse," 13.
S Beauchamp and Childress. Principles o/Biomedical Ethics, 78.
12
effect of their position is an acknowledgement that the principle of autonomy will not
apply in all situations-to be incompetent to make a medical decision is to no longer
have autonomy, that is, to no longer be respected and treated as an autonomous
individual in one's medical choices.
Beauchamp and Childress recognize another limit to the principle of
respecting autonomy based upon the patient's own response to this principle, which
in tum is often predicated upon the patient's age, social status, or ethnicity. They
make a clear distinction between respecting or offering autonomous choice to every
patient (every patient judged to be competent) and actually requiring autonomous,
informed choice of every patient. They acknowledge that many patients do not want
this role, or feel incapable of carrying it out, even though they meet a technical
standard of competence. Beauchamp and Childress are responding to critics and
empirical studies that have shown that patients may not wish to have autonomous
choice and may perceive the choice as a burden. Furthermore, as they explain, in
Navaho culture, the giving of information about a procedure and any discussion of its
risks is viewed as detrimental to the patient's chances of a successful recovery
because the mere saying ofthe risks makes them more real or probable.9 They end
this discussion with a nuanced response to criticisms against the principle of
autonomy as a possible encumbrance foisted upon some unwilling patients:
A more adequate interpretation of respecting autonomy will put these
problems to rest. There is a fundamental obligation to ensure that patients
9 Beauchamp and Childress. Principles ofBiomedical Ethics, 61-63.
13
have the right to choose, as well as the right to accept or to decline
infonnation. Forced information, forced choice, and evasive disclosure are
inconsistent with this obligation...Health professionals should always inquire
in general tenns about their patient's wishes to receive information and to
make decisions, and they should never assume that because a patient belongs
to a particular community, he or she affinns that community's world view and
values. The fundamental requirement is to respect a particular person's
autonomous choices. 1o
Although Beauchamp and Childress are right to respond to their critics by
acknowledging that respect for autonomy is an ideal that can be inappropriate in a
particular situation or with a particular patient, the effect of this is to limit even
further the applicability of their first principle. As a system of principles intended to
cover every bioethical question or encounter, it is odd that the first principle, and the
only principle that deals directly with the relation between caregiver and patient, has
such a narrow scope. If we must treat only substantially autonomous persons
autonomously, how do we then treat everyone else? Beauchamp and Childress offer
no principle for the rest ofhumanity. Furthermore to the extent that illness, age and
injury can all substantially impair autonomy, it would seem that many specific
medical encounters may lack the preconditions of autonomy, even in a previously
autonomous person when not in need of health care. The young woman in a serious
car accident is substantially autonomous until the event that leads to her need for care.
10 Beauchamp and Childress. Principles a/Biomedical Ethics, 63.
14
There is a dynamic between autonomy and the need for health care that can work
counter to each other: those in greatest need are often the least autonomous at their
time of need. PBE offers no guidance for a substantial portion of clinical encounters.
Beauchamp and Childress devote much space in PBE explaining how the four
principles are to be understood and used in bioethical reasoning, but two aspects of
this discussion are relevant for this paper. The first is that the principles are non-
hierarchal-none takes precedent over another. Conflicts between two principles
must be decided in view of the actual case. For example, if a psychiatrist decides to
warn the police that her patient is contemplating and planning a murder, she has
decided in this instance that non-maleficence is the more important principle
(outweighing autonomy of the patient). This decision does not imply that non-
maleficence is always the ascendant principle; it only decides their order in this
circumstance. This leads to the second aspect of their use of principles already
evident in this example: principles can be ethically violated-they are prima facie
but not absolute. 11
However, some supporters ofthe principalist theory have argued against
Beauchamp and Childress that autonomy does, and should, receive greater weight
than the other three principles, and that autonomy should only be violated in rare
circumstances, if ever:
.. .I personally am inclined to see respect for autonomy as primus inter
pares-first among equals. Firstly, autonomy-by which in summary I
11 Beauchamp and Childress. Principles ofBiomedical Ethics, 14.
15
simply mean deliberated self rule ... is what makes morality-any sort of
morality-possible ... Secondly, beneficence and non-maleficence to other
autonomous agents both require respect for the autonomy of those agents. 12
Alfred Tauber, a physician and philosopher agrees that clinicians place autonomy first
among the principles in actual practice, but unlike Gillon he worries that the effect of
this has been to transform the patient-doctor relation into a market model where the
patient "chooses" independently what she wishes from a range of choices offered to
her. 13 He is critical of the effect of autonomy on the doctor-patient relation, and seeks
a return to "responsibility"-on the part of the physician-as a founding principle in
this relation. He also argues against the benefits of the principle of autonomy in that,
"so called rituals of trust (the informed consent process) have emerged as substitutes
for organic truSt.,,14 This, he argues, makes medicine contractual, and therefore
allows doctors to shift responsibility to the patient. The doctor provides terms of the
agreement, and the patient either refuses or enters into the contract. If the patient was
informed of the risk, how can she blame the doctor for an outcome that was described
as possible? Tauber argues that the principle of autonomy has undermined the
physician's sense of responsibility and has been one factor in transforming medicine
into a commercial model from a service/caring one based primarily in trust and
responsibility. He ends his discussion of autonomy with the plea that autonomy must
12 R Gillon, "Ethics needs Principles-Four can Encompass the Rest-and Respect for Autonomy
Should be 'First among Equals,'" Journal ofMedical Ethics 29 (2003): 310.
13 Alfred 1. Tauber, Patient Autonomy and the Ethics ofResponsibility, (MIT Press: Cambridge, 2005),
61.
14 Tauber, Patient Autonomy and the Ethics ofResponsibility, 59.
16
be understood as relational, a critique that started with the feminist critique of
autonomy and principalism.
Beginning with Carol Gilligan, feminist writings have objected to an
atomistic, individualistic view of self, and have therefore challenged the validity of
autonomy as an accurate descriptor of human agency. If we are created and sustained
by relation, can autonomy be a useful concept in healthcare, or for that matter, in any
realm? Tauber argues for a new understanding of autonomy rather than a
replacement of the principle:
... substituting a relational understanding of selfhood for a narrowly atomistic
notion fundamentally shifts the definition of autonomy from the exercise of
moral choice by a fully independent agent to one who is embedded in
relationships, which of themselves confer identity. "Relational autonomy"
then becomes a more complete and honest depiction of the doctor-patient
relationship, because it more accurately describes the agency of each party.
Once autonomy is configured as achieved in cooperation, the defensive and
distorted moral posture of the patient may be replaced with ... the healing
encounter: the recovery of independence and a sense of self-authority. 15
There is a tension perhaps to the point of breaking in Tauber's new definition
of autonomy. Although Beauchamp and Childress give a nod to the relational aspects
of our selfhood, they maintain a "self-rule" version of autonomy that would be at
odds with Tauber's attempted compromise. Tauber in my view has the correct view
15 Tauber, Patient Autonomy and the Ethics ofResponsibility, 122.
17
of selfhood, but he fails to recognize that this is simply not consistent with the history
and usage of "autonomy," and he would do well simply to describe the doctor-patient
relation as an encounter that involves the relational selfhood of both parties, because
in fact both sides share an identity composed in relationality. But this relation is in
tum only one aspect of each self that extends to and is defined by other significant
relations offamily, friends, and as we will discuss later, dependency relations. Each
of these relations is taken into the doctor-patient encounter, and each of them may
become crucial in a particular decision or choice.
Much of the feminist critique of both autonomy and the doctor-patient relation
does take this additional step and jettison autonomy as a useful descriptor of human
selfhood and relations. Susan Sherwin's No Longer Patient is both a feminist critique
of healthcare and a plea to move beyond an autonomy-based system of medical care
and medical ethics. 16 Although Sherwin and Tauber both seek to move beyond the
traditional conception of autonomy, they make different moves in regards to the
doctor-patient relation based upon their differing projects.
Sherwin traces the historical development of feminist ethics, beginning with
Carol Gilligan's work that demonstrated women's tendency to solve ethical problems
with relational thinking rather than the principle-based theories that men were more
inclined to use. Gilligan's conclusion was that both methods ofthought were
valuable and that women's relational thinking had been undervalued in traditional
16 Susan Sherwin, No Longer Patient: Feminist Ethics and Healthcare, (Temple University Press:
Philadelphia, 1992).
18
ethical philosophy. 17 Sherwin sides with Gilligan over the "pure" care ethicists such
as Nel Nodding and Virginia Held, who reject any justice, principle- based ethics in
favor of a "feminine" ethics centered in the virtue of care with maternal care as the
paradigm. While Sherwin largely agrees with the desire to bring care to the forefront
of ethics over abstract principles, she argues that without principles there is no way to
determine when care is inappropriate, and how to deal with the other for whom care is
not the suitable mode of relation. Her claim is that care is an appropriate mode of
relation only where there is already justice in the social sphere-without justice we
must relate to others in ways that promote justice but are not necessarily characterized
by care. A woman must not care for her abuser. A victim of oppression only furthers
the oppression by entering into a caring relation with her oppressor.
Sherwin distinguishes between "feminine ethics" and "feminist ethics" on the
basis of whether there is a political response to the oppression of women. Feminine
ethics recognizes the relational aspects of female ethics, but it is feminist ethics that
pushes also for the social change that would allow a true emergence of feminine
values. While Gilligan, Nodding and Held are all responding to the oppressive male-
centered ethics, Sherwin worries that an ethics based solely upon care will not
necessarily further the cause of women:
Within the existing patterns of sexism, there is a clear danger that
women will understand the prescriptions of feminine ethics to be directing
them to pursue the virtues of caring, while men continue to focus on
17 Sherwin, No Longer Patient, 46-48.
19
abstractions that protect their rights and autonomy.. .In a society where the
feminine is devalued and equated with inferiority, it is not easy to perceive
men embracing a moral approach described as feminine. Because the world is
still filled with vulnerable, dependent persons who need care, if men do not
assume the responsibilities of caring, then the burden for doing so remains on
women. IS
For Sherwin care must be not a virtue of exclusively women, and only justice and
care can together lead to an ethical theory that is comprehensive. But justice must
address in a systematic way the causes of oppression in society:
Feminist ethics focuses instead on the need to develop a moral analysis that
fits the world in which we live ... that is not to say that feminist ethics involves
no concern with principles. It encompasses theories that are committed to
concerns about social justice, because it demands criticism of the various
patterns of dominance, oppression, and exploitation of one group of persons
by another. 19
She conceives ofjustice as changing the oppressive power structures and bringing
about the transformation that she envisions, where care can then be a primary but
shared virtue among women and men. It is this political agenda that separates her
critique from Tauber. It also a tension within her thought on autonomy as well.
18 Sherwin, No Longer Patient, 51.
19 Sherwin, No Longer Patient, 55.
20
Sherwin begins like Tauber with a rejection of a conception of self that is
individualistic and that denies our relational grounding:
We must reconceive the concept of the individual, which has been taken as the
central concept of ethical theory in Western thought. People have historical
roots; they develop within specific human contexts, and they are persons, to a
significant degree, by virtue of their relations to others like themselves ...We
cannot speak of the individual as the central unit of analysis, however, without
considering that persons only exist in complex, social relationships.2o
Unlike Tauber, Sherwin sees this conception of selfhood as inconsistent with previous
western philosophy that enshrined atomistic autonomy at its center, and she makes no
attempt to reconcile relationality and autonomy. But the doctor-patient relation for
Sherwin remains problematic even after abandoning autonomy as a regulating
principle. This, in turn, relates to her concerns about the history of medicine as an
oppressive force against women that may yet again be enacted in a new patient-doctor
encounter. Where Tauber will suggest a non-paternalistic relation of care and
responsibility as a model of the relation, Sherwin seems clear that women must keep
their distance from doctors, seek counsel but remain quite separate in their decision-
making:
... the historical and continuing records of women's experiences within
medicine indicate that medical practice directed specifically at the health
20 Sherwin, No Longer Patient, 53.
21
needs of women serves medical interests, and it is, too often, harmful to
women.
Hence we should be aware of the complexity of the values that
underlie the medical services provided to women. This awareness makes it
clear why women must regain control over the determination of their health-
care needs and over the delivery of health-related services. Because
paternalism encourages patients to trust and not question the authority of their
physicians, it should not be accepted as common medical practice?l
Sherwin, on the one hand, affirms the relational nature of selfhood, while she
expresses concerns about too close a relation in a physician-patient interaction.
Where Tauber, Beauchamp and Childress declare the death of paternalism twenty
years before the writing of Sherwin's critique of medicine, she still fears paternalism
as an active behavior that women must guard themselves against in a physician
encounter. Tauber takes a stance that stands in almost direct opposition to Sherwin-
his fear is that the relation has become too constrained and commercial in form, and
that the principle of respect for autonomy has been part of this unfortunate
transformation that has pushed patient and doctor apart.
But Sherwin remains suspicious of the doctor-patient encounter given the
unreformed nature of medicine in general, so although she is affirming of caring
relations, she does not characterize physician-patient relations as such. The defensive
posture that she maintains is in fact quite similar to the one Tauber decries as the
21 Sherwin, No Longer Patient, 153.
---------- - ----
22
nature of the relation today, and his objection that this prevents a more therapeutic
interaction carries no merit for Sherwin:
Medical practice should be oriented to maximizing patient's ability to make
reasonable, informed decisions about their health care. Hasty imposition of
authoritarian, paternalistic intervention is more likely to inhibit than support a
patient's recovery of independence. Moreover, when paternalistic
intervention is called for, the person authorized to act on the patient's behalf
should be someone who can be counted on to return authority to the patient as
soon as there is sufficient recovery to allow effective participation in the
decision-making process. Ordinarily, this person will not be the patient's
physician.22
The irony here is that having abandoned autonomy as a philosophical descriptor of
persons, she then demands respect for autonomy (without calling it this) in her
interactions with physicians, because she does not believe the profession can be
depended upon to create a caring relation founded upon trust and responsibility as
Tauber would have it.
Sherwin does not deny the existence of trustworthy, caring practitioners of
medicine; she is critiquing the profession as a whole. Although I believe Tauber is
correct that paternalism as a physician behavior has been largely replaced with a too
distant, defensive posture on the part of physicians who are only to happy to layout
the choices in a patient's care and have her both decide and then bear the
22 Sherwin, No Longer Patient, 154.
23
responsibility for the outcome of the decision, Sherwin's critique rings true at several
levels as well. She rightly expresses concern that physicians too often consider
interests that are not in the interest of their patients-although I would place time
constraints and financial concerns over the maintenance of dominance that worries
Sherwin. This is not to deny the history of oppression of women or the role medicine
has played in it. Furthermore, physicians have been slow to take up progressive
causes such as universal health care, because they fear the impact of such reforms on
their income and status. If physicians are to regain some modicum of trust from
critics such as Sherwin, they will need to be more politically progressive and truly
champion the causes of the oppressed and underserved, whether this arises from
gender, race or class. Physicians will not regain trust at an individual level; it must be
as a profession. The American Medical Association's support of more universal
healthcare coverage is a recent move in this direction.23
Both Tauber and Sherwin reject the traditional formulation of the principle of
autonomy as described in PBE, but they differ in their response to this void. Tauber
wants physicians to re-embrace an ethics of responsibility in a new non-paternalistic
fashion, whereas Sherwin places responsibility and decision-making squarely back
with the patient out of her distrust of the medical profession. I argue that this leaves
her in a place that differs little, from a practical standpoint, from the position of
Beauchamp and Childress that she initially criticizes since she returns to supporting
23 AMA Health Care Policy Group, Expanding health Care Coverage: The AMA Proposal for
Reform, editors Valerie Carpenter and Robert D. Otten, www.ama-
assn.org/amal/pub/upload/mm/363/ehilO12.pdf .
24
patient autonomy without ever acknowledging it as such. But where both in their
differences are alike is that they seem to replace the principle of respect for autonomy
with another somewhat monolithic answer-responsibility in the case of Tauber, and
patient independence (or doctor-patient non-relation as it could be better described) in
Sherwin's case.
In one sense, Sherwin's critique is an answer to why Tauber's project cannot
be successful: some patients will not want the physician to assume the close relation
that he believes is ideal for healthcare, and some encounters may have to continue in
the absence of trust as their foundation. Similarly, Sherwin's answer is hopefully not
the stance toward healthcare that we should all adopt. Perhaps trust should be
developed over time, rather than assumed, but long term doctor--patient relations
should, I believe, always move in this direction or be replaced by a better match
between two people. If Sherwin had a politically progressive feminist physician
would she still believe it necessary to place so little trust in that person's
recommendations?
Tauber and Sherwin's objections to autonomy center on its meaning as
atomistic "separateness." Sherwin argues that none are truly autonomous, although
men may seek autonomy out of fear of relation. Eva Kittay' s critique of autonomy is
an empirical extension of Sherwin's argument. A substantial portion of the
population, she explains, is either directly dependent due to age or disability, or
indirectly dependent and therefore non-autonomous because they labor as dependence
workers. Dependence workers, largely women, do the unpaid or poorly paid
25
unskilled labor of caring for dependent persons. All of us are dependent persons
during some time in our lives, so to refer to persons as autonomous is to ignore or
marginalize those who are not, and those who can never be, because they are either
permanently dependent or dependency workers. Dependency workers lack autonomy
because their roles place demands upon them that cannot easily be unburdened, and
because their lack of payor poor pay make them financially dependent on others.
This can be a direct threat to autonomous choice in medical care as a dependency
worker may be unable to choose a surgery or treatment she may otherwise need
because she cannot afford the time off, or be able to find a replacement during her
own recovery. Kittay argues that too many people lack autonomous choice out of
their life circumstances to make it a useful principle:
By excluding this dependency from social and political concerns, we have
been able to fashion the pretense that we are independent-that the
cooperation between persons that some insist is interdependence is simply the
mutual (often voluntary) cooperation between essentially independent
persons. The argument of this book is that our mutual dependence cannot be
bracketed without excluding both significant parts of our lives and large
portions of the population... 24
Sherwin, Tauber, and Kittay together describe the prevailing critique against a
principle of autonomy in a principle-based system of biomedical ethics. Both
Sherwin and Tauber argue that conceiving of the person as an independent, self-
24 Eva Feder Kittay, Love's Labor: Essays on Women, Equality, and Dependency, (New York:
Routledge, 1999) xii.
26
ruling entity is simply not an accurate representation of how we are constituted. Who
we are is largely defined by our relations; our place in the world integrated into
families, friends and work relations. These relations not only define us, they also
delimit us-the relations we have constrain our choices in ways that make autonomy
a myth that only a few can possibly believe describes their place in the world. Both
Sherwin and Kittay argue that only successful white males actually believe they are
autonomous, but even they are forgetting their own periods of dependence, or the
dependency relations around them that may contribute to their sense of autonomy.
Although these three authors converge in their critique of autonomy, they see
different implications for the doctor-patient relation. Sherwin has too little trust in the
medical profession to even see the possibility of the physician-doctor relation
becoming a source of relationality that could lead to better decision-making and care
of the patient. Instead, she focuses on the way patients need to bring their important
people with them into medical encounters to protect them from the ulterior motives
that physicians take into the exam room. The relations of friendship, family, and
dependency are taken into the exam room, and to forget this is part of the myth of
autonomy.
The case presentation at the beginning of this paper showed a woman who
saw her family relations as so central to her life that she was willing to risk her life
rather than jeopardize them, even for a religious idea that she no longer shared with
them. The centrality of autonomy ignores that people do not, or cannot, make medical
choices in a vacuum apart from their lives, which are in tum defined by their
27
relationships. While Beauchamp and Childress acknowledge that a person's choice
may be impacted by their relationships, what they miss is that no one makes choices
independently. Whether the relationships are empowering or constraining, or both, to
affirm "self-rule" is a grave mistake about who confronts a physician in an exam
room.
But Sherwin also has a political vision that can be extrapolated, I believe
fairly, to the doctor-patient relation. She argues that the problem with care is that it is
a feminine attribute, and that justice demands that care be universalized as an ethic if
it is to be valorized. Care can and should be central to any healing relation, and
Sherwin is right that the modem medical relation often lacks it. Yet the healing of the
doctor-patient rift that she describes is exactly the antidote to autonomy-driven
medicine. The relationship between the patient and the doctor need not be as lasting
or significant in a person's life as their familial or friendship relations, but Tauber is
right that without trust and physician responsibility it is also not likely to be
therapeutic.
Whether medicine can reform itself sufficiently so that its critics such as
Sherwin can trust it enough to allow a closer, non-paternalistic relation to emerge is a
question, or problem, that will not be solved entirely at the level of individual
encounters-it is ultimately a larger political question that is tied to other institutions
that have a history of domination and repression as well. I wish to acknowledge this
larger political context before returning to the individual encounter and focusing on
what can be done to reconceive this relation in a way that will promote the care and
healing that should be at its center.
28
29
CHAPTER III
THE JUST DISTANCE: NARRATIVITY, SINGULARITY, AND
RELATIONALITY AS THE
SOURCE OF A NEW BIOMEDICAL PRINCIPLE
It would be impossible to overemphasize the singular character of the
caregiving agreement concluded between two unique individuals: this
physician and this patient, and the prescription which opens a singular history
that of the treatment of this patient confided to this physician. I
The critique of autonomy is not simply that it fails to accurately describe the human
condition unless it is nuanced as Tauber does, to make autonomy itself to arise in
relationality. Kittay's critique is also that it is limited in its scope-few achieve
substantial autonomy and only at the expense of others. Furthermore, autonomy is
rarely useful in medical encounters where important decisions need to be made
because the gravity of the illness is itself an important limiter to autonomy.
When Paul Ricoeur discusses the just distance he is not responding to the
principalist theory, but I believe that if medicine remains committed to this ethical
theory to regulate its decision-making processes it must replace "respect for
I Paul Ricoeur, Reflections on the Just, trans. David Pellauer (Chicago: The University of Chicago
Press, 2007), 214.
30
autonomy" with a principle useful in every clinical encounter. The just distance
resonates with much of the prior philosophical work of Ricoeur. His philosophy of
narrativity, relationality, singularity and selfhood are not simply consistent with it,
they are the concepts embodied in his suggestion that this principle is central to every
clinical encounter.
Even prior to Ricoeur's writing of a just distance, his philosophy of narrativity
had found proponents in both medicine and medical ethics. Although his descriptions
of narrativity are both philosophically technical and not directed at medicine, they
have been taken up by Rita Charon and other clinicians and ethicists as useful to
reconceptualizing the clinical relation. For Ricoeur, the self is narrative, so to ignore
the narrative is to fail to see the person entirely.
Ricoeur makes his argument for the narrative unity of selfhood in both Time
and Narrative and again in Oneselfas Another. Although these works do not lend
themselves to a brief re-statement, I will try to summarize his conclusions if not all
the discussion that precedes it. Like Aristotle, Ricoeur sees humans as teleological-
we set goals, we project ourselves into futures, and these goals play an important role
in our self perception. We unify ourselves in the present and the past relative to this
plot (substituting plot for goal because with emplotment we can now include in our
story all the history or facticity that we do not control). As a narrative-making
species, we determine meaning through the interaction of these factors, and this
meaning determines our deepest sense of self:
31
It is indeed in the story recounted, with its qualities of unity, internal structure,
and completeness which are conferred by emplotment, that the character
preserves throughout the story an identity correlative to the story itself?
Mark Johnson offers further support for this narrative unity by showing the
cognitive basis for it. He shows that there is a narrative unity to our experience, so it
is only natural that this unity is carried over into our understanding of self and our
descriptions or stories that we use to communicate our lives to others. In fact, this
narrative core is an imperative to a meaningful, coherent human life:
Life stories are thus tasks we perform in composing our lives, and they are
motivated by these sorts of pressing practical and moral considerations, partial
solutions to which constitute our present identity. Consequently, living out a
narrative quest is not merely optional, if we hope to make sense of our lives at
all. Making at least some sense of our lives is something we all try to do in
varying degrees and with different amounts of success and failure. Whether
or not we ever verbalize our self-understanding, we still at least minimally
seek to construct our life narratively.3(Italics original)
The role of narrative in the clinical encounter is actually twofold, and Ricoeur
recognizes both aspects. Narrative both defines our selfhood, and in narrative, such
as the well taken history in a clinical setting, the patient is given an opportunity to
express herself as herself to the doctor. But narrative also allows the incorporation of
2 Paul Ricoeur, Oneselfas Another, trans Kathleen Blarney (Chicago: University of Chicago Press,
1992), 143.
3 Mark Johnson, Mora/Imagination: Implications ofCognitive Science for Ethics, (Chicago:
University of Chicago Press, 1993), 178.
32
the contingent into the life story-as humans we both act and suffer, and making
sense of this suffering can be facilitated by a truly narrative encounter with a care
provider.
Narrative philosophy also has two roles in medicine as a profession as well.
Narrative ethics uses narrative theory to resolve ethical dilemmas in clinical
situations, and opposes itself to the principalist theory.4 Here the gathering of
narrative detail-allowing all the involved parties to fully participate in the "telling of
the story" stands as a different path to resolving conflict without resort to outside
principles. Narrative medicine has also gathered force as a new way of approaching
the clinical encounter that emphasizes listening for and respecting the story of the
other as a way of increasing the physician's therapeutic potential by honoring more
fully the selfhood of the patient. 5
In Reflections on the Just, Ricoeur explains why narrativity and his concept of
a narrative selfhood are so critical to the clinical encounter. Medicine, as a profession
directed at helping others, and in particular at ending or reducing suffering, must
understand the patient's suffering well enough to address it. Suffering, for Ricoeur is,
"not defined solely by physical pain, nor even by mental pain, but by the reduction,
even the destruction of the capacity for acting... ,,6 He writes this amidst a discussion
and defense of Aristotelian ethics---each of us seek goods to achieve our individual,
4 Rita Charon and Martha Montello, eds, Stories Matter: The Role o/Narrative in Medical Ethics,
(New York: Routledge, 2002).
5 Rita Charon, Narrative Medicine: Honoring the Stories o/Illness, (Oxford: Oxford University Press,
2006).
6 Paul Ricoeur, Oneselfas Another, 190.
33
unique conception of "the good life". Our goals in turn inform our sense of self, and
are central to our story-our narrative. It is the thought of what we wish to achieve
with our lives that frames the story for us. It determines what is important, and what
is forgotten:
... between our aim of a "good life" and our particular choices a sort of
hermeneutical circle is traced by virtue of the back and forth motion between
the idea of the "good life" and the most important decisions of our existence
(career, loves, leisure, etc.) This can be likened to a text in which the whole
and the part are to be understood in terms of each other.7
The hermeneutic of understanding the part through the whole, and the whole in the
part is a crucial skill in medicine that requires narrative competence. In medicine the
part is represented by the presenting complaint, and the whole is the person's story or
narrative project. They must be "read" together for the full meaning at that moment to
be appreciated.
Because the story of self is completely intermeshed in our sense of "the good
life," a physician, whose goal is to end or reduce suffering, must know the story to
know how to proceed. The example ofthe young woman in a Jehovah Witness
family makes this point quite well. There were many possible wrong turns that would
have healed her body, yet increased her suffering-particularly when suffering can be
understood as loss of relation. A decision to straightforwardly value beneficence,
defined in a narrow sense of doing what is good for the body, and deny her
7 Ricoeur, Oneselfas Another, 179.
34
"autonomous" choice to refuse blood voiced in front of her family, may well have led
to her losing her family's love and support even though she did not choose the blood
products. Similarly, respecting her autonomy in a straightforward sense would
probably have led to her death. Without what Charon refers to as "narrative
competence" either loss of relation or loss of life could have been the result.8 Both
ends fail to relieve suffering, and thus fail in the simplest test of what constitutes a
successful therapeutic encounter.
Suffering, defined in the large sense that Ricoeur has given as loss of capacity
to act, is the circumstance that initiates a relationship between the physician and the
patient with the common goal of relieving the suffering:
Let me recall what constitutes the heart of medical ethics, the establishment of
a caregiving agreement. This is an act between two people, one of whom is
suffering, who presents his compliant and requests help from an expert in
matters of health and the other of whom knows, knows how, and offers his
assistance. Between these two people an agreement is concluded based on
9trust ...
It seems odd to place the physician-patient relationship at the center of medical ethics,
but remembering that Ricoeur is working with an Aristotelian sense of ethics makes
this clearer. Medicine, whose goal is to relieve suffering, begins in a relationship of
trust where the patient's need becomes the physician's objective. They pursue the
8 Charon, Narrative Medicine: Honoring the Stories ofIllness, 110.
9 Ricoeur, Reflections on the Just, 213.
35
goal together, but this can only be achieved if the physician correctly ascertains the
goal of the patient-suffering is more than pain and physical infirmity, so without a
sense ofthe patient's story the physician has little chance of addressing completely
the causes of suffering.
The story of the patient is important in the sense just described of clarifying
the source of suffering, the perceived lack ofthe patient, but is also important in a
second sense-a relationship of solicitude requires that the self of the patient be
revealed to the doctor if the doctor is to be able to correctly diagnose and treat the
patient:
Every case is particular in relation to medical knowledge and general medical
know-how. Here too it is necessary to interpret in an appropriate manner the
available medical knowledge, through an intelligent use of the ability to
classify the disease in question... this also requires, describing, in an
appropriate fashion, on the narrative plane... the symptoms of the case, which
come from the personal history of the patient. IO
This is a remarkable insight for a philosopher who has not practiced medicine. The
symptoms given by an individual patient are far more meaningful, and are much more
likely to lead to a correct diagnosis when they are understood within a narrative
context. The same set of symptoms-abdominal pain, vomiting, anorexia can signify
appendicitis in one person, and an acute exacerbation of chronic pelvic pain following
a history of physical abuse in another. The life story separates, or individuates, the
10 Ricoeur, Reflections on the Just, 219.
36
two similar sets of symptoms, because the context of the symptoms is not similar.
This is one reason emergency physicians order more tests to make a diagnosis than a
primary care physician: not knowing the patient's story, they rely more heavily on
technology to separate the life threatening from the less urgent or acute.
Ricoeur's discussion ofnarrativity is closely related to the singularly of the
encounter quoted at the beginning of the chapter, but singularity needs additional
description to round out the meaning of "the just distance". Obviously, the move
from narrativity to singularity is not a quantum step-the singularity of narrative is
crucial to narrative selfhood. We each have a story that is only our story, and
although we do not control many aspects of it, our goals are individually chosen. But
if illness is not unique, suffering is always singular because suffering represents the
intersection of illness and selfhood. The same illness affects different individuals
with different life stories, values, and goals very differently.
It is the importance Ricoeur places on the singularity of the patient's history,
and the singularity of each encounter that makes the new principle be best articulated
as "the just distance" rather than "respect for narrativity" or "respect for autonomy".
Finding the just distance is more than giving narrativity it's due-it also requires
acknowledging that the correct "distance" for this encounter will be different than the
last, and that the story of the patient is part of what determines this distance. The
degree of suffering and illness is also part of the dialectic:
A third precept adds to the ideas of nonsubstitutability and indivisibility that
of self-esteem...This precept speaks of more than the respect due another
37
person. Esteem has to do with oneself. Yet in the situation of caregiving,
particularly when one is hospitalized, there is a tendency to encourage the sick
person to regress to dependent forms of behavior...The caregiving agreement
ideally implies a correspondence between the two partners in the agreement.
But the regression to a situation of dependence, once one enters the phase of
serious treatments and situations that may be lethal, tends insidiously to
reestablish the situation of inequality that was supposed to be set aside by the
caregiving agreement ...The only way to fight against such offensive kinds of
behavior is to return to the exigency at the base of the caregiving, that is, to
the associating of the patient with the carrying out of his treatment or, in other
words, to the agreement that makes the physician and patient allies in a
common struggle against disease and suffering.. .In self esteem a human being
approves his existence and expresses a need to know that his existence is
approved by others. I I
This long quotation makes several important statements regarding singularity and the
just distance. Its central theme is that the caregiver needs to remember to not lose
sight of the human dignity of the patient that is at the core of the relation established
for healing. Dependency occurs as a necessary result of disease and treatment, but
the dignity of the person must be preserved and held by remaining "allies in a
common struggle". The just distance is a moving frame of reference particularly in
an extended illness with varying degrees of debility and dependence, but the right
11 Ricoeur, Reflections on the Just, 203.
38
relation is the one that best preserves the patient's self-esteem, and it is the doctor's
responsibility to keep this central in her assessment of the relation.
Ricoeur is also correct that with serious illness there can be a tendency for the
physician to stop treating the patient as an ally against a disease and instead push the
dependent person to the side and fight the disease single-handedly, leaving the patient
behind. This tends to happen at times of great dependency when the patient is already
feeling a loss of selfhood and the doctor's loss of interest in the patient as a person
only reinforces this. It is, as Ricoeur reminds us, at these times especially when the
doctor needs to reaffirm the person, the story, the self-esteem of the other. It can be
as simple as continuing to consult the patient as much as possible about each new
treatment or intervention being proposed rather than moving ahead with what the
physician believes to be in the patient's best interest. The respectful dialoging even
when the patient is too ill or overwhelmed to truly make each decision in the fullest
sense of "informed consent" reminds the patient of her personhood and that the
treatment is for her, not simply against the disease. She remains a part of the team,
rather than a bystander.
The quotation also illustrates the many unique factors in each relation that
must be brought to bear on a determination of the just distance: the patient, the
illness, the level of dependence, the course ofthe illness (the temporal variability),
and the physician as the other side ofthe relation. Narrativity is crucial to seeing the
patient and the disease (the whole and the part) and how together this combines to
create a unique instance of suffering. Narrativity implies this singularity, but Ricouer
39
brings the concept of singularity to the forefront in order to remind us that the just
distance can never be "pre-set" or assumed based upon any circumstance except the
present.
Ricoeur also sees the caregiving relation as a struggle against a particular form
of singularly-the singularity of suffering:
Suffering ... is the ultimate refuge of singularity.. .It is true that suffering is not
just the concern of the practice of medicine. It affects and upsets one's
relation to oneself as the bearer of a variety of abilities and also many of our
relations with others, in our family, at work... but medicine is one of those
practices based on a social relation for which suffering is the basic motivation
and whose telas is the hope of finding help and perhaps healing. 12
This dual alienation from self secondary to the patient's loss of ability and from
others is one reason suffering is greater than the physical pain itself. The caregiving
relation is ideally a reduction of suffering simply by reestablishing relation with the
suffering individual. The treatment if successful then directly heals the schism
between the patient and herself as her abilities return. These abilities in tum are what
allow her to fulfill her commitments to others-and this "promise keeping" is at the
heart of Ricoeur' s understanding of selfhood. 13
The quotation at the beginning of this chapter also speaks to the "unique"
alliance between physician and patient, and both quotations contain the implicit
12 Ricoeur, Reflections on the Just, 199.
13 Ricoeur, Oneselfas Another, 268.
40
reminder that the physician is the other side of the relation, and the uniqueness of the
agreement includes the physician component as well. The same doctor does not
respond similarly to each patient or each situation-Balint analysis has shown that
doctors react differently to patients depending upon a host of memories or feelings
that may be elicited by an individual patient. 14 This also is part of the unique
interchange and may play an important role in what distance will work best for this
relation, or even if the relation is workable. The unsaid aspect of the just distance is
that sometimes the unique mix does not work at any level, and the best relation is a
non-relation with the patient finding a doctor that is capable of hearing and respecting
her story.
The other important aspect of the just distance as a principle is the centrality it
places on the relation itself. Tauber is correct in criticizing respect for autonomy as a
principle that is not relational in its focus, and tends to create too much distance
between doctor and patient. His observation is that it has lead to a market economy
between physician and patient because the patient essentially becomes a consumer of
goods offered by the health care provider after reviewing the options. Like shopping,
a choice is made and "let the buyer beware"-the responsibility has shifted to the
consumer of the health care product. Ricoeur is clear that this is the wrong direction
for medicine to take, and that to do so is to forget its origin as a social relation-a
caregiving agreement within a larger context of society, between two people:
14 Michael Balint, The Doctor, His Patient, and the Illness,(New York: International Universities
Press, 1957).
41
...medicine is not a form of commerce. Why? Because the patient, as a
person, is not a form of merchandise, even though further along something has
to be said concerning the financial costs of providing care, something that
stems from the contractual relation and brings into play the social dimension
of medicine. IS
It is a social relation also in the sense that historical rules have developed that govern
the behavior of the physician, and as Ricoeur acknowledges, there are financial
implications to medicine that go beyond the two people immediately involved in the
relation.
The caregiving agreement is a relation of solicitude-but not of friendship.
Friendship is a relation between equals, and the doctor-patient relation does not start
as a relation between equals:
In the beginning, a moat and even a noteworthy dissymmetry separate the two
protagonists. On the one side is someone who knows what to do; on the other,
someone who is suffering. This moat gets filled, and the initial conditions
become more equal, through a series of steps beginning from each side of the
relationship. 16
Here Ricoeur's analysis of the caregiving relation breaks sharply with Sherwin's. He
acknowledges the initial asymmetry of power, but argues that this asymmetry must
not persist in a successful doctor-patient relation. It is a joint commitment to
15 Ricoeur, Reflections on the Just, 205.
16 Ricoeur, Reflections on the Just, 200.
,---------- --------- ---
42
narrativity that begins the process of equalization-the patient must "bring to
language" her suffering, and the physician must "follow" her. 17 Once the story is
shared, the next step of equalization involves mutual promise-keeping: the patient
promises to follow the doctor's advice and the doctor promises to remain true to the
needs of the patient. On the doctor's part this is a promise to place the needs of the
patient first, and also to seek the healing of the individual over the needs of medical
science itself.
It would seem that this equalization of the relation through mutual promises,
Ricoeur refers to it as a "covenant", stands against the variability of relation that I am
seeking in the just distance. In fact, the promise-keeping is the pre-condition of the
relation, and the variability of the just distance still presupposes this foundation. That
is to say without relation, there is no measure of distance, and there must be a mutual
commitment to relation for a caregiving agreement to proceed.
Ricoeur's discussion of the relationality involved in the patient encounter is
situated in the larger context of his philosophy of relationality. In Oneselfas Another,
Ricoeur argues for both a narrative and relational unification of self. These two
concepts are closely related, so there is not only a lack of contradiction in this
position, it would be better to see the two terms as different perspectives on the same
question. The most obvious connection between narrativity and relationality is the
way in which significant events in our life's story interweave with the story of others.
The relation between patient and doctor is significant for both-the suffering for the
17 Ricoeur, Reflections on the Just, 200.
43
patient, the felos of ending suffering and giving solace for the doctor. The relation is
part of both narratives-it in fact furthers both narratives, and this is only one aspect
of why there can truly be no narrative without relation. Suffering, for Ricoeur, has
been defined as a loss of ability. This includes the act of telling one's story:
But we must go further and take into account more deeply concealed forms of
suffering: the incapacity to tell one's story, the insistence of the untellable-
phenomena that go far beyond mishaps and adventures, which can always be
made meaningful through the strategy of emplotment. 18
In this statement Ricoeur brings out how suffering and narrativity are connected; that
is, that the failure of narrative may enhance or even be central to one's suffering.
Relation may then be therapeutic by "giving words" to the untold story-helping the
patient find meaning, and thus relief from her suffering. As Charon explains in her
description of narrative competence in a medical encounter, the reader (physician)
interacts with the narrative to both draw it out, and in the relation, actually change it:
The skilled reader or clinician learns to select an interpreter who "fits" the
particular text or patient-for example some texts need a forgiving reader
instead of a skeptical one, and some patients need an authoritarian doctor
instead of a collegial one. Developing skill as a reader or a clinician entails
knowing which of one's countless registers to bring to bear on each
interpretative situation. The reader adopts his or her readerly stance toward
the work-based in part on the makeup and behavior of the narrator but also
18 Ricoeur, Oneselfas Another, 320.
44
based on the reader's own makeup and behavior-which will alter the work.
(Italics original) 19
The narrative is both drawn out by the relation, and in a doctor-patient relation this
drawing out is part of the process of healing, and the narrative is changed, or even
shaped together in the relation.
The story of OUT lives is completely dependent upon others--{)UT significant
actions of promise keeping, responsibility, and caring all have no meaning except in
the context ofrelationality. There can be no story without relation; the story, and thus
our selthood, is created in our encounters with others. To see the medical encounter
as both relational and narrative is itself derivative of the narrative, relational selthood
that Ricoeur posits.
In describing the just distance in terms of narrativity, singularity, and relation
I hope to have shown that Ricoeur's principle is not subject to the same critique as the
principle of autonomy. It is consistent with a feminist (and Ricoeurian)
understanding of selthood in relation with others, rather than as an atomistic ego. Its
unique contribution is the recognition of singularity-that each relation must
encompass the stories of the people involved and therefore there can be no single
answer that will describe the correct relation-it must be found in the encounter itself.
19 Charon, Narrative Medicine: Honoring the Stories ofIllness, 110.
45
CHAPTER IV
THE JUST DISTANCE: A RESPONSE TO POSSIBLE CRITIQUES
AND ITS APPLICATION IN THE MEDICAL ENCOUNTER
One of the strengths of the principle of autonomy is its simplicity in
application. Physicians who have never read Kant nor have any familiarity with the
history of autonomy as a philosophical concept have had little trouble adjusting their
practice to increase the autonomy of their patients, once this was an accepted goal in
medical practice. This simplicity led to certain benefits already described-it ended
the acceptability ofpaternalism, and increased the discussion of risks and benefits
buttressing truly informed consent before significant procedures. Perhaps the
ascendant time of the principle of autonomy was a developmental phase of medicine,
but now it is time for a more inclusive, relational principle: just distance.
The last chapter explained what is philosophically "behind" Ricoeur's
conception ofthe just distance. The work still to be done is to apply the new
principle in clinical encounters and show how it would function differently than a
principle of autonomy, and to respond to the two most obvious critiques of the just
distance. The first critique that I believe needs to be answered by Ricoeur's principle
is that it presents too great a challenge in application to the clinical encounter. The
46
other concern that I see as a possible response to the just distance is that it does not
actually articulate any difference in comportment for the good physician in a typical
patient interaction.
Objection Ie The Just Distance sets too high a standard for clinical
relationships
The principle of autonomy is understood outside a philosophical setting, and
this understanding differs from the philosophical history more in its depth than by any
significant substantive distinction. The just distance has no similar history, so
adoption of it as a principle will require a genuine education and re-education of
physicians. This is obviously both a challenge to be overcome, and an opportunity to
improve physician understanding of narrativity and relationality. As Rita Charon
amply demonstrates in her book Narrative Medicine, there is a great need to re-teach
the basics of a successful clinical encounter to many doctors, and the effect of this
would be to improve the lives of patients and doctors alike.! But since the adoption
of the principalist theory was not preceded by an effort to re-educate existing
physicians in its nuances, why should its modification? Doesn't this suggest an
untenable closeness to philosophical theory that will not translate well into a clinical
setting by doctors neither trained nor comfortable in philosophy?
1 Dr. Charon writes that even the classical formula of history taking, beginning with the history of
present illness, and then moving to past illness, and only later taking up a "social history" where a
patient's opportunity to tell a story outside very narrow confines begins to open a little closes off a
narrative telling for the patient, and even the listening is circumscribed to direct answers to questions.
Rita Charon, Narrative Medicine.
47
The counter to this is that to not do this work is to ignore problems in
medicine that will not improve without attention. Tauber, echoing Charon, sees the
autonomy model of care at the heart of the problems plaguing medicine, so if this
represents a difficult course correction then that only further signifies how far we
have veered from a relationship that truly serves the needs of our patients.
There are also many precedents for retraining the clinical skills of physicians.
This year, for example, all physicians in Oregon must spend an additional eight hours
of continuing medical education time specifically focused on chronic pain
management because it was decided that as a group we lacked an essential skill. To
decide at a national level that narrative, relational skills have been undervalued and
appreciated and that physicians must acquire this expertise who wish to continue
clinical practice is no insurmountable feat. If Tauber is correct that physicians also
sense the inadequacy of the current relational model (or non-relational model as I
have suggested), then there may be less resistance to this proposal for change.
However, even if the problem is clear to many, and the possibility of teaching
a new approach to the clinical encounter is also feasible, the real impediment to
improvement is economic. Physicians have been driven by demands for greater
productivity, and rising overhead costs, especially malpractice insurance, to see ever
greater numbers of patients with less time allotted to each patient. This obviously
works strongly counter to developing an ethic of the clinical encounter that relies
upon attentive listening and establishing a rapport unique to the situation presented by
that encounter. I am not suggesting that this can be done well, or even at all, in a ten
48
minute visit. Rather the solution to this may be from physicians ourselves if we are
willing to trade-off income for job satisfaction-that is treating fewer patients well
rather than deriving more income from seeing more patients, but with the physician
cost of being left always with the sense of what was not done. This hope is similarly
stymied by the increasing number of physicians who work for corporate entities that
dictate physician schedules rather than letting them find a pace that works for them.
If this discussion has journeyed far from the philosophical question of whether the
just distance is a better principle than respect for autonomy it is only because just as
this project arose for me in real world concerns, I cannot wholly leave them behind as
I try to envision how it could work "in the trenches."
Objection II. The Just Distance is a new name for a good doctor
If the just distance is an obtainable clinical goal, is it actually a new one? Is
this not the manner of approach offered by any good doctor given the clinical setting
that allows it? One aspect of this argument comes from the justification I have
offered for it: if we are narrative, relational beings, it would not seem necessary to
put forth a principle instructing doctors to be simply who they are-narrative and
relational in their approach to patients. There are both truths and flaws to this
response that I would like to elucidate.
Although the just distance is founded upon narrativity, relationality, and
singularity, Ricoeur is still suggesting something new rather than a repackaging of his
philosophy when he first suggests it. As discussed in the last chapter, the patient-
doctor relation is a specialized relation-it is neither friendship, nor commerce. Both
49
the need of the patient to be rid of suffering, and the implicit promise of the physician
to ease that suffering to the extent that she is able, are foundational to the encounter.
As a special type of interaction, medical students are trained in its rules. But there is
a substantial difference between the training they currently receive and the training
that would occur if the principle of the relation was changed from respect for
autonomy to finding the right relation-the just distance. Two examples may serve to
illustrate this.
I remember an elderly patient (this is a composite without identifying detail
and this type of interaction has occurred many times in my clinical practice) with a
pelvic mass that could possibly represent cancer, although the radiographic
characteristics were not terribly suspicious. A significant surgery was the only option
that would give a definitive diagnosis, and constitute treatment, or at least its
beginning. However, she also had numerous pre-existing health issues that
substantially increased the risks of surgery. She asked me what I would do if I were
in her place. Like most physicians, I was taught that to answer this question
potentially violates her autonomy because my opinion would carry too much weight,
and she would tend to follow it perhaps even over her own judgment. But I could also
see that she was having real trouble with the decision, and her husband was equally at
a loss, so I gave an answer something like this: "Well, I don't think this mass is a
cancer, although I cannot be sure, and the risks of the surgery itself worry me more
than the risk of it being cancer, so I think I would forgo the surgery."
50
Her response shows how, I believe, I had correctly judged this situation and
that my answer that some would judge as being too close, too assertive of my values,
actually helped her. After hearing my answer she decided to go ahead with the
surgery because she said it had clarified the issues for her, and that she was more
afraid of cancer than of surgical complications. Ironically, she was able to make a
decision that was truly more her own because in closing the distance-that is, by
showing her how I thought about it, she was then able to differentiate her thinking
from mine, and make a decision that she now trusted. I think the narrative and
relational aspects of this example illustrate what is meant by the just distance. It was
after listening to her and hearing her struggle with the decision that I decided to speak
as I did. Some of her story was known to me, but my response gave her an
opportunity to make a decision based upon her fears and values. The closeness of the
relation was only possible, or advisable, because I sensed the strength in her to not
simply follow my words, or adopt them as her own. The just distance here was quite
close, too close by traditional standards, but that was the correct distance once the
relation and the situation now allowed it----or perhaps even demanded it.
Sylvia (name changed) came to me a few months ago after visiting other
doctors with whom she had been dissatisfied. She made it clear from the outset that
she needed to discuss exhaustively all her options and that she was suspicious that
doctors just, "wanted to do the hysterectomy and move on." She was both interesting
and thoughtful so it was easy to spend the extra time discussing and sometimes re-
discussing the risks and benefits of the various treatment options. But as time went
51
on, particularly after she chose surgery and then continued to come to discuss
hormonal side effects, we were spending less time talking about treatment and more
time just discussing her life, politics, and life in general. She had set an initial
distance that was greater than most encounters-she admitted suspicion and a history
of relations with physicians that had not been healing or caring. But in this example
the temporality of the just distance is also made evident-the distance changed
(closed) over time as suspicion was replaced by trust and mutual respect. The
obvious fact that relationships develop over time and that as the needs, concerns, and
even sense of autonomy of the patient changes the correct comportment of the
physician to the patient must also change is simply not accounted for in the current
formulation of the principalist theory.
III. Remaining Issues
I have until now discussed the just distance as a principle in isolation but the
proposal is not to replace four principles with one, but rather to replace one of four
principles. This is not merely a tactic-it is I believe how Ricoeur would have argued
as well. Although there are some proponents of narrative ethics that believe
narrativity replaces norms or principles, many others, including Ricoeur himself,
believed that principles were still useful when adequately situated in a narrative
context, and aided by moral imagination.2 So although the remaining principles of
beneficence, non-maleficence, and social justice may come into play less often, they
2 Julian Savulescu, "Autonomy, the Good Life, and Controversial Choices", The Blackwell Guide to
Medical Ethics, eds Rosamond Rhodes, Leslie Francis, and Anita Silvers,(Malden: Blackwell
Publishing, 2007), 18.
52
are still relevant in many situations. To listen attentively to each patient's story and
to seek to work as a partner toward furthering her goals will not always be possible.
Sometimes these goals may themselves violate other principles, such as when
physically healthy people who seek amputation of normal limbs-a desire arising
from perceptions that the patient may not be willing to address.3 Classical medical
ethics cases have also sometimes centered more on the principle of social justice. The
allocation of kidney dialysis machines when they were originally far fewer machines
than patients is one such example. So although the just distance will do much ofthe
work in the more commonplace clinical encounter, the other principles remain
relevant and necessary.
The last concern I wish to return to is whether the just distance can be derived
from the "common morality" that Beauchamp and Childress defend as the basis for
the four principles. Remembering that the common morality is a set of norms that
could be agreed upon by "morally serious people," I believe the just distance
similarly meets this standard. The concept of narrativity is itself derived from
understanding humans as teleological, and we transmute these goals coupled with the
events of our lives both chosen and accidental into a story of ourselves that allows us
to make sense of ourselves and the world. While narrative unity of self is not a
universally held philosophic belief, the ground of narrativity-the teleological nature
of humans does approach this standard. Relationality is an emerging concept, so
3 Paul Ricoeur, Reflections on the Just, trans. David Pellauer (Chicago: The University of Chicago
Press, 2007), 213.
53
much so that adherents of autonomy including Beauchamp, Childress, and even
Tauber have tried to reconcile autonomy and relationality. In short, given the tenuous
nature of their own linkage to common morality, I do not think that this offers a
significant challenge to the addition ofjust distance to the Principalist theory.
It seems strange to suggest that the time for respect for patient autonomy
needs to come to an end. It is not that patients deserve less respect; it is in fact that
respect needs to be construed as more inclusive than only autonomy. We must teach
instead respect for personhood-in all its narrativity, relationality, and singularity.
Unlike the principle of autonomy which can be abrogated by loss of competence or
by a cultural desire to not converse about illness in the way in which autonomy as a
principle requires, the just distance acknowledges difference-in fact as a recognition
of the singularity of each person's story and of each moment in that person's life it is
centered in gauging the differences before it, and negotiating the best path through
them. This is real respect and care in a doctor -patient relation and this should be the
next principle guiding medicine.
54
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