Time for another blog post.

Its late, almost 2 am. Im drinking coffee in the mug my friend Mel got me from NYC, listening to all the Bright Eyes albums on my computer, and I'm working on a paper right now that was due earlier today that I did not complete. I have been slacking a bit behind in my school and now is the time to get back on track and not fall further behind. So sorry ahead if I make myself a bit scarce.

Its sort of hard to focus when I keep getting distracted by cool articles like this:
http://www.dimaggio.org/Eye-Openers/consciousness_is_a_meaningless_accident.htm

Its fun to contrast articles like that to articles like such:
http://community.livejournal.com/philosophy/1828488.html
(FYI - The catch phrase "Fuck you, Im a dragon!"; it comes from this poster...)

Oh! Lemme take this opportunity to post my Medical Ethics essay. Its not that great but gosh darn it I like it.


Is the Customer Always Right?
For the most part, there seems to be an accepted presupposition in thinking about the relationship between a medical doctor and his or her patient. This presupposition is so ingrained in the collective conscious of contemporary people that it seems almost a given.
The story goes something like this: the patient discovers something physical about himself or herself that he or she does not desire to have: a tumor; a virus; all conditions which fall under the category of things called diseases. Upon discovery, the patient will usually go to or be taken to a place such as a clinic or hospital where the patient will meet with a physician. And then, the physician will do everything he possibly can, within reason, to remove the unwanted element from the patient’s body.
To see the process described in such a way gives the whole ordeal the feel of a business transaction; which is the unspoken presupposition: that patients are customers and physicians are providing a service, and that, as the old chestnut goes: “the customer is always right,” or in this case, the patient.
Patient autonomy is a concept, and a belief, that refers to the capacity and entitlement patients retain in making their own medical decisions and choices. It is the backbone of a subset of beliefs in medical ethics which might be called the Patient Centric Model; the belief that medical decisions ought to be based upon either what the patient wishes or upon what his or her best interests would be.
Professor John Hardwig takes issue with this stance, in his article “The Problem of Proxies with Interests of their Own: Toward a Better Theory of Proxy Decisions.” In this article, Hardwig states “An excluse patient-centered ethics must be abandoned...because it is patently unfair to the families of patients.”
In a response to Hardwig, entitled “Hardwig on Proxy Decision Making,” Professor Baruch A. Brody seems to agree with the general spirit of Hardwig’s article, but takes contention with a few key issues.
In this paper, I will attempt to explain and interpret both Hardwig’s and Brody’s articles by outlining their arguments and conclusions. Afterwards I hope to edify some of my own feelings and beliefs on the matter; specifically focusing on Hardwig’s conclusion and arguments for such.
Hardwig on Patient Autonomy and Proxy Decision Making
Hardwig opens his article with a sordid tale involving an elderly woman with Alzheimers who has become incapable of making her own decisions. Said woman is hospitalized with pneumonia, and in spite of their best efforts, the doctors begin preparing her for terminal care. Yet, her physicians insist on continuing aggressive treatment.
However, this is not something that her husband, who had been providing care for her at home, wishes. He implores the attending physicians to scale back treatment, which confused the physicians, who wished to continue aggressive treatment on the small hope that she may survive to live a while longer.
Since the patient herself was incompetent and unable to make her own reasonable choices, the charge of making her medical decisions fell to her proxy, which in this case would be her husband. Now, why would a husband wish to discontinue treatment for his wife? Because he had recently proposed to the housekeeper, who had accepted, and any more money spent paying for the Wife’s medical care would leave them destitute.
Against intuition, Hardwig wants to argue that we ought not to automatically write off the husband as some sort of selfish, philandering vaudeville-esque villain. The physicians attending the patient’s case certainly did though. They wished him to be removed as a decision maker because of his obvious conflict of interest and his inability to put aside his own interests and consider only his wife’s.
But, it is exactly that sort of reasoning that Hardwig wishes to attack, for why is it that we should expect, argues Hardwig, that proxies should put off their own interests when they have their own interests at stake as well? And when these interests are invariably tied up with the interests of the patient?
Hardwig gives several reasons for this belief, but they are all driving to the same point: human beings are not lone solitary entities who’s interests are theirs and their’s alone. Humans are communal and interconnected so much so that there will always be a psychological ripple effect when something happens to anyone in our shared public community.
As for following the patient’s wishes as closely as possible, Hardwig offers two arguments against this idea in the form of two clever reductio ad absurdums.
Firstly, assume that the patient is in fact a mean spirited, vindictive, emotionally manipulative woman who derives pleasure in seeing her poor husband go finically broke just to keep her alive. She unreasonably demands costly procedures and uses emotional blackmail when her wishes are not met. It seems counter intuitive to say that it would be a GOOD thing that such a woman’s demands would be met, without question, by virtue of the fact that the role she plays in this story is that of patient.
On the other hand, imagine if the woman was the kindest, gentlest woman imaginable, who, when diagnosed with pneumonia, would refuse even the most modest healthcare options because she did not want to be a burden upon her husband, and would sooner parish than live with the thought of her husband’s quality of life being downgraded even in the slightest bit. Again, intuitively, it seems that obeying this woman’s wishes is somehow wrong.
The woman in the first scenario ought to be punished and the woman in the second scenario ought to be somehow rewarded. But under the conventional understanding and acceptance of patient centric ethics, this does not happen.
Hardwig requests to see that this view of patient centric ethics be thrown out and replaced with a New Theory of Proxy Decisions, one that, as he puts it, “in which the interests of the incompetent are constrained by what is morally appropriate.” He goes on, “Proxy deciders have been given the wrong directions...we must tell them that the incompetent patient’s wishes are the best way to define her interests, but what she would have wanted for herself must be balanced against considerations of fairness to all members of the family.”
Brody on Hardwig on Patient Autonomy and Proxy Decision Making
Brody’s response to Hardwig is relatively short but still manages to raise some interesting points. The first half of the paper contains Brody arguing that Hardwig was not utilitarian enough in his belief that the decision making process should not be patient centric (ALL conceivable parties should be considered, says Brody, not simply those who know the patient.) This, I think, is a rather uninteresting and pedantic point.
His second criticism is much more substantive. To understand the second criticism, it is important to see what Brody takes to be Hardwig’s argument. Brody’s outline of Hardwig is as follows:
“1. The job of the proxy decision maker is to make the right decision.
2. The right decision is not necessarily what the patient would have decided, because the patient might not have properly considered the interests of others.
3. Therefore, the proxy decision maker should not necessarily make the decision the patient would have made. Thus, the substituted-judgment standard is wrong.”
What Brody sees as the problem with this chain of reasoning is the first premise. Brody believes that the proper way to read the job of a proxy decision maker is that of an advocate; one who represents the interests of his “client” as best as possible, like an attorney.
“Given this understanding of the role of proxy decision makers,” Brody says, “premise 1 is false and Hardwig’s conclusion...does not follow from his already established premise 2.”
This objection, while interesting and certainly relevant, I believe it is wrong for two reasons.
First, it fails to recognize the real problem of proxy decision makers with their own interests, and that is that proxy decision makers have their own interests.
The reason we believe that the closest kin should be proxy decision makers is because they are the most likely candidates to know what the patient would have most likely wanted. But, as Hardwig mentions in his article, there is a Catch-22 involved here because it is the those who are closest who will be the most emotionally invested.
To ask the people who are the most attached to detach themselves and act as level headed surrogates is not only unrealistic but also a bit cruel. Its an impossible task and it is such because of the way human communities are set up.
Second, it is a mischaracterization of Hardwig’s argument. I do not believe that Hardwig believes it is the “job” of the proxy decision maker to make the right decision, but rather it is his “obligation.” Brody puts it in descriptive terms and forgets that we are talking about subject matter that is inherently value-laden. Certainly it is the “job” of the doctor to make the patient whole again, but that tells us nothing about the merits of how he goes about doing it. In the same vein, while it might be the assigned task of the proxy decision maker to make decisions for the patient, that also tells us nothing about the evaluative quality of those decisions.
My Thoughts on the Matter
I agree with Hardwig on a many things. In general, the item I most concur with Hardwig about is this driving idea behind his article, that human beings are not isolated individuals whose actions and desires exist in a vacuum. Whether or not we like it, we are all connected in an infinitely complex and intricate system of emotional, psychological, and sociological ritual that invariably one person’s decision will effect more than himself or herself, and giving any patient a blank check just because they are, in fact, a patient, is reckless and immoral.
However, both Hardwig and Brody seem to speak of this concept of interests, and they speak of interests in a vague and broad sense. This is the heart of the matter, I think, and what we should be focusing our collective effort on. Questions like “What are these interests? How do we evaluate these interests? Or are these interests good simply because the person is interested in them?” are questions that are underplayed, if not ignored, in Hardwig’s article.
Of course, Hardwig also says nothing about why small amounts of mass are attracted to larger amounts of mass, and the reason for that is obvious: He never intended to. Just as this is not an article about the mechanics of gravity, this is also not an article about evaluating interests. Still, I feel as though this should be his next step, because if he keeps his utilitarian considerations, he will have to explain what he is a utilitarian about. Happiness? Pleasure? Eudemonia? Or is it a more Kantian notion; are interests good because a rational agent is interested in them?
One thing should be clear though, healthcare is not a business transaction and proxy decision makers are not lawyers.

For funsies.

I miss my friends in Austin. Sometimes you guys post about all the fun things you guys are doing together and I get really sad because you guys are over there and I'm over here. And its hard to find people in this city who "get" the sort of things we find funny.

Like that little boy in the cowboy hat.

Holy moley that was funny.

Kay. No more weird stream of conciousness stuff. Later.