is of course in a severe drought (to be sure, more rain than usual is expected
this year, but I’ll believe it when I can’t ride my bike to school), and our
household and condo. association have taken action in conjunction with the
city’s quite reasonable requirements and recommendations on this score. And
then I pick up Hollis’s book, the first chapter of which is a prologue and apologia,
while the second chapter is titled “Three men in a drought” and opens as
follows: “Water was short in the torrid summer of 1976 and there were soon
calls for restraint. Where I live, the Anglian Water Authority quickly
threatened to ban garden hoses if the calls went unheeded.” The first person
narrative is used, along with a “realist” hypothetical or thought experiment to
introduce and illustrate questions regarding collective goods and the nature of
rational action, and those, in turn, in the light of important topics in
epistemology and ethics. Much of it calls to mind the myriad and
passionate—albeit far less rational—arguments I’ve read and heard during our
drought, the principal arguments now sifted by the efforts of a creative, sensitive,
and keen philosopher.
wonderful—and this time moving—piece from this collection is prefaced by a
quote from Rainer Maria Rilke, part of which is the chapter title: “A death of
one’s own.”* The words are those of Rilke’s character Malte from his only prose
work, The Notes of Malte Laurids Brigge (1910): “The wish to have a
death of one’s own is growing ever rarer. Only a while yet and it will be just
as rare to have a death of one’s own as it is already to have a life of one’s
In the course
of this essay, Hollis treats with analytical acuity and intellectual charity if
not generosity principles and values found in Liberalism, several ethical
traditions (e.g., duty-based and consequentialist), as well as approaches
common to bioethics. As Hollis well demonstrates, “Where policy meets patient,
the doctor has moral choices to make which no code of medical ethics can reduce
to routine.” While medical ethics is often be characterized by a “top down”
approach, for example when it broadly aims to “maximize welfare subject to
constraints of justice” (a goal he neither dismisses nor derides), Hollis
suggests we complement such an orientation with a “bottom up” approach that
focuses finely on—and thus can be empathetically sensitive to—the peculiarities
of the patient as an individual person: her needs, wishes, beliefs, values,
worldview. This invariably becomes a node of friction insofar as it is where
“the system meets the patient.” I can vouch for that, albeit second hand, as my
dear wife often brings home stories from the hospital that pivot around such
points of friction (the parties in question remaining anonymous). The stories
are sad, tragic, amusing, unsettling, disconcerting, and even frightening in an
uncomfortably intimate way (perhaps because I am close in age to many of the
patients who are the protagonists of these stories).
describes the doctor-patient relationship as “more than a bricolage of
morally untidy choices but less than a systematic application of moral
philosophy” (the latter route often preferred in bioethics). In his
hypothetical sketch, based on all-too-real-life cases, the doctor, Henry, is
overseeing George’s treatment and possible discharge from the hospital. The
former’s decisions and judgments invariably involve others in subsidiary sundry
ways, largely other professionals or bureaucrats (in a non-pejorative sense) of
one kind or another. George of course is only one of the patients Henry is
temporarily responsible for, while Henry is George’s only doctor and thus the
person who decides to what degree George’s own wishes and desires will be
granted a degree of deference, in other words, how much say, such as it is,
George will have over the remainder of his life.
Hollis fill out this hypothetical a bit more with regard to who George is, at
least as it pertains to his stay at the hospital or who he has come to be
(hence we can only make the slightest gesture in the direction of who George
is as a person, with a biographical narrative, a life story, nearing its
an old man, a widower, in hospital after a stroke. Although fairly well
recovered, he still is fragile and has poor balance. But he is clear-headed,
especially about his wish to go home. He says firmly that he could manage on
his own; and so he probably could, if he had enough support. Otherwise there is
a real danger of his falling, fracturing a leg and being unable to summon help.
There is risk of hypothermia. He may easily become dirty, unkempt, emaciated
and dehydrated, since it is not plain that he can dress, toilet and feed
himself for long. He may not manage to comply with his medication. He might
perhaps become a risk to others by leaving his fire unattended or causing a gas
leak. None of this would be worrying, if there was a supporting cast. But his
house is not suited to his condition. His only relative is a daughter, living
elsewhere, with her own job and family and not willing to take George on [such a
scenario is more common than we like to imagine]. His neighbors are unfriendly.
Social services can offer something—perhaps home help, meals on wheels, a
laundry service, day care, an alarm service. But this does not truly cover
nights and weekends and, anyway, George is liable not to eat the meals and not
to accept the day care. Meanwhile the advice from Social Services is that he
should stay in hospital. It is good advice for the further reason that there
will be no second chance. Often one can allow a patient a try at looking after
himself, known that he can be scooped up and returned to hospital, if
necessary. But George is too fragile and too alone for this to be a promising
option. Yet he is in no doubt that he wants to go home and denies that he needs
any of the missing support.”
self-determination (or ‘autonomy’ in the literature) and professional
responsibility can be addressed, as Hollis suggests, in the context of George’s
point of view, from the “bottom up,” which at some point confront questions of
medical ethics posed from the “top down.” I will not attempt to catalogue or
even summarize all of the lessons learned (or those one might learn) and the
insights gleaned from this exquisite philosophical examination of topics within
the scope of both bioethics and medical humanities, an examination at once
incisive, humane, sophisticated but accessible, an artful combination of wisdom
and compassion. Hollis endeavors to show “that patient centredness is not a
clear guide to action and then that, even when it is, it may not be a good
guide.” And he asks all the right questions, including some unexpected ones:
“How much responsibility does Henry shoulder if he colludes with George’s
wishes? The question is incomplete: how much responsibility to whom?”
Hollis reminds us that “Henry is answerable for more people than George and to
more people than George.” In brief, “Henry’s best efforts for George have a
price paid elsewhere. ‘Patient-centred’ starts with George but cannot mean
simply ‘George-centred’ and gives no guidance on where to stop.” An “intricate
set of questions” that address Henry’s ethical and professional duties make
vivid the fact that questions surrounding the possible scenarios that will
likely determine the nature and cause of George’s death (at home or in the
hospital) are not sufficiently faced if viewed solely and simply in the terms
of the proper exercise of personal sovereignty or wholesale deference to
George’s capacity for psychological and moral (or ‘rational’) “autonomy.”
In the end,
Henry must decide, as a doctor and a person (his integrity hinging on
the extent to which these indissolubly fuse together), whether or not George
goes home, a decision that “varies with George’s insight” (which may not be
constant) into his condition, situation, prospects—his life. In due course,
Hollis explains why this insight cannot, or at any rate should not, be trumped
by decisions and proclamations made by George’s earlier…and healthier “self.”
Hollis concludes as follows:
that most doctors will think it best to let George go, and will find this
responsibility easier to shoulder. Indeed, I think they must, as more people
live longer into a fragile and confused old age. But responsibility is not here
lessened on the ground that letting die is not killing. Having learnt to
postpone death, we have set ourselves problems of when to cut short the losses
of an extended life. We have a collective responsibility for what Henry decides
but Henry is responsible for his decision. Although he can cover his back by
recording a clinical judgment that George’s insight and prospects were
adequate, he knows that there is more to the moral question than clinical judgment.
At any rate,
George goes home. He remains on his doctor’s conscience as he is carried out a
month later to a forgotten grave. But so he would have done also, languishing
on in a hospital bed. Without hoping to make it easier to see in the twilight,
let me end with a patient-centered prayer, also from Rilke:
gib jedem seinen eignen Tod,
Das Sterben, das aus jedem Leben geht,
Darin er Liebe hatte, Sinn und Not.
grant everyone a proper end,
a passing that arises from a life
that full of love and sense and need was spent.]
Even when a death
of one’s own is a poor consumer choice, it is a proper exercise of human dignity.”
* This essay
originally appeared in an edited volume by M. Bell and S. Mendus, Philosophy
and Medical Welfare (Cambridge University Press, 1988).
Further Reading (for the second Hollis essay discussed above):
- Berg, Jessica W., et
al. Informed Consent: Legal Theory and Clinical Practice.
Oxford, UK: Oxford University Press, 2nd ed., 2001.
- Brody, Howard. Stories
of Sickness. New York: Oxford University Press, 2nd ed., 2003.
- Cassell, Eric J. The
Nature of Suffering and the Goals of Medicine. New York: Oxford University
Press, 2nd ed., 2004.
- Fulford, K.W.M. Moral
Theory and Medical Practice.
Cambridge, UK: Cambridge University Press, 1989.
- Gillett, Grant R. Bioethics
in the Clinic: Hippocratic Reflections. Baltimore, MD: Johns Hopkins
University Press, 2004.
- Manson, Neil C. and
Onora O’Neill. Rethinking Informed Consent in Bioethics. Cambridge, UK:
Cambridge University Press, 2007.
Kathryn. How Doctors Think: Clinical Judgment and the Practice of
Medicine. New York: Oxford University Press, 2006.
- O’Neill, Onora. Autonomy
and Trust in Bioethics. Cambridge, UK: Cambridge University Press, 2002.
- Quill, Timothy S.
and Franklin G. Miller, eds. Palliative Care and Ethics. New York:
Oxford University Press, 2014.
- Randall, Fiona and
R.S. Downie. Palliative Care Ethics: A Companion for All Specialties.
New York: Oxford University Press, 2nd ed., 1999.
- Schneider, Carl E. The
Practice of Autonomy: Patients, Doctors, and Medical Decisions. New
York: Oxford University Press, 1998.
- Tauber, Alfred I. Patient
Autonomy and the Ethics of Responsibility. Cambridge, MA: MIT Press, 2005.