Preface Introduction 1. The Way of Medicine 2. The Requirements of Practical Reason 3. The Doctor-Patient Relationship 4. Autonomy and Authority 5. The Rule of Double Effect 6. Sexuality and Reproduction 7. Abortion and Unborn Human Life 8. Medicine at the End of Life 9. Last-Resort Options 10. Conscientious Medicine

Every culture gets the medical practice it deserves, and in our culture medical practice is dominated by a consumerist understanding, where well-being is understood in terms of the patient’s desires being satisfied. Efforts to identify an ethical framework capable of guiding practitioners and patients in our time have resulted in consequentialism, contractarianism, and, most prominently, principlism—the framework that gives us the familiar “four principles” of medical ethics. In the context of an individualist and consumerist environment, however, these efforts all tend to default to three norms: what the law permits, what is technologically possible, and what the patient wants. Thus, for the provider of services model, if an intervention is permitted by law, technologically possible, and autonomously desired by the patient, then medical practitioners should provide the intervention. Indeed, they may be professionally obligated to do so. After all, these norms fit our expectations for other providers of services. The good folks who provide us with Wi-Fi or who make our double soy lattes do not bring further considerations to bear on whether to give us what we want. They do not consider the appropriateness of our desire for a double soy latte; they do not ask what websites we’ll be visiting. We expect them to obey ordinary norms of law and not defraud or deceive, but beyond that we expect them to do as we wish (provided that they can perform the service, and we can pay). There is no distinctive professional ethic for these practices, because there is no profession, no deep orientation to a good or set of goods that gives meaning and purpose to what they do. Thus, in the provider of services model, the work of physicians becomes demoralized, and its ethic becomes what the philosopher H. Tristram Engelhardt has identified as a “morality of strangers.” One does not knowingly do violence to the unconsenting innocent, to be sure. But within the boundaries of law and consent, what is technically possible is ethically permissible. That which is permissible and also desired may even be ethically obligatory. Medical ethics reduces to a set of procedures for negotiating noninterference with patients’ wishes to the greatest possible extent. Medicine itself devolves into a powerful set of means to be used to satisfy the preferences and desires of those who are authorized, legally and procedurally, to choose. Among the many consequences of the provider of services model, the following three loom. First, professional authority has steadily eroded. If there is no objective standard or end for medicine, then physician expertise is merely technical. Thus, instead of exercising the authority of expertise within a sphere constituted by their professional commitments, physicians become increasingly subject to the exercise of power by lobbyists and political advocacy groups. Medical professionals come to work in a highly regulated domain in which the exercise of clinical judgment and prudence is neither possible nor desirable. No surprise, then, that declining professional authority is followed by a second consequence: a crisis of medical morale. Insofar as medicine merely provides desired services, then its pretense to moral seriousness is a charade, and its attempts at professionalism a façade. The practice of medicine is characteristically grueling, with long hours spent under taxing circumstances. Is it surprising that physicians who experience themselves largely as mere functionaries—asked to set aside traditional medical norms, religious convictions, and their best judgment—suffer high rates of burnout? Finally, when medicine is understood as the provision of health-care services, the physician’s judgment—and particularly the physician’s claims of conscience—come to be seen in competition with the fundamental, but minimal, norms of the profession. The exercise of physician conscience is treated as the intrusion of “private” or “personal” concerns into transactions that should be governed by physicians’ professional commitment to provide legally permitted services to patients who request those services. Michael and Tracy Balboni note that this artificial separation of the personal and professional leads patients and clinicians to suppress and ignore their moral and spiritual concerns, to the detriments of both. As a result, the medical profession and society at large appear increasingly ready to abandon the idea of the conscientious physician, and to use the coercive powers of the profession and the state to compel physicians to participate in practices that violate norms that have guided medical practitioners for millennia.