Reason in Action

Another book I recently read in conjunction with the bibliography on “philosophy, psychology and methodology for the social sciences” was the late Martin Hollis’s Reason in Action: Essays in the philosophy of social science (Cambridge University Press, 1996). While the directed reading regimen was intentional, it turned out to be serendipitous:

California 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.

Another 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 own.”

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). 

Hollis 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.

We’ll let 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 end):

“George is 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.”

Questions of 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: 

“I imagine 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:

O Herr, gib jedem seinen eignen Tod,
Das Sterben, das aus jedem Leben geht,
Darin er Liebe hatte, Sinn und Not.
[O Lord, 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. 
• Montgomery, 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.