Question 1: The following seems true:

(GOOD) If agent S is reasonably confident that agent T’s life will be worse if S performs action A, then S has a prima facie responsibility to not perform A

For example, if I’m reasonably confident – i.e. I’ve sufficient evidence to believe, I’ve not made any logical errors evaluating that evidence, I’m not intoxicated, etc. – that Mauricio’s life will be worse if I steal his cat then I’ve a responsibility to leave his cat alone. This could be overridden given different details, e.g. if Mauricio had stolen ‘his’ cat from me. That’s what it means to say prima facie; the responsibility in (GOOD) might be overridden. With that qualification, (GOOD) seems defensible, and is perhaps what underwrites physician oaths to ‘do no harm’. Of course, (GOOD) is more general than medicine; it hold for all of us. That suggests there must be more underwriting physician responsibilities than (GOOD). Relevant here is that physicians sometimes must cause significant suffering in the interest of avoiding future suffering. That suggests:

(BETTER) If a physician is reasonably confident that agent T’s life will be better if the physician performs action A, then the physician has a prima facie responsibility to perform A

If this were general, it might generate, say, a responsibility to help people change tires, clean up parks, take out your neighbor’s garbage, etc. These might be contentious. Restricted to physicians, however, (BETTER) seems defensible…assuming they’ve the relevant training needed to help. A neurologist confident that a patient’s life will be better if they’ve surgery but who themselves is not a surgeon, does not seem to have a responsibility to conduct surgery. In fact, it’d seem wrong if they tried to conduct surgery. And that seems underwritten by our old friend (GOOD), since it’s likely they’d make things worse.

Now, consider the following arguments:

(1)   (BETTER) is true
(2)   If (1), then physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better
(3)   Hence, physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better
(4)   Physicians engaging in empathetic discussion with patients concerning recommended treatments is an effective and respectful way to convince patients to accept those treatments
(5)   If (3) and (4), then physicians have a prima facie responsibility to engage in empathetic discussion with patients concerning recommended treatments
(6)   Hence, physicians have a prima facie responsibility to engage in empathetic discussion with patients concerning recommended treatments

So far, so good. Consider next:

(1)   Physicians are not trained to engage in empathetic discussion with patients concerning recommended treatments
(2)   If (1), then physicians can reasonably expect to make the lives of patients worse by attempting empathetic discussion with patients concerning treatments
(3)   Hence, physicians can reasonably expect to make the lives of patients worse by attempting empathetic discussion with patients concerning treatments
(4)   (GOOD) is true
(5)   If (3) and (4), then physicians have a prima facie responsibility to not attempt empathetic discussion with patients concerning treatments
(6)   Hence, physicians have a prima facie responsibility to not attempt empathetic discussion with patients concerning treatments

Both arguments are valid, i.e. if the premises are true then the conclusions are true. But these arguments cannot both be sound given their conclusions are in tension.

Select one of the arguments and - in under 200 words - provide a counterexample for one of the lines of that argument. For your responses, in under 50 words, attempt to counter the counterexamples provided by at least two other students.

Solution 1: We’ll examine each argument line-by-line. Start with the first line of the first argument, which says that the following is true:

(BETTER) If a physician is reasonably confident that agent T’s life will be better if the physician performs action A, then the physician has a prima facie responsibility to perform A

Recall that a prima facie responsibility is a responsibility that can be overridden but is a plausibly a default responsibility. For example, you have a prima facie responsibility to tell the truth, but if doing so would lead to your best friend’s death, then you better not tell the truth! This is because you also have a prima facie responsibility to not let your best friend die if you can help it, and that trumps your prima facie responsibility to tell the truth. This is to say that line (1) claims if a physician can be reasonably confident that a patient’s life will be better if they do something, then the physician has a prima facie responsibility to do it. I think this is true largely due to the role physicians occupy. That said, we could nitpick and note that BETTER seems to suggest that physicians have prima facie responsibilities outside their field of expertise. For example, as stated BETTER implies a physician who is reasonably confident a patient’s marriage is harmful and that breaking up the marriage would make the patient’s life better, has a prima facie responsibility to break up the marriage. Yet, marriage counseling and advice is likely outside the scope of the physician’s expertise. That seems the wrong result.

Whether this is forceful depends, however, on how “reasonably confident” is understood. I’ve left it underspecified on purpose. Suffice it to say that the stronger this constraint, the more plausible it begins to sound that a physician does have a prima facie responsibility to perhaps break up the marriage, i.e. knowledge is power and power brings responsibility. On the other hand, if “reasonably confident” is understood as a weaker constraint, then it seems less likely the physician has a prima facie responsibility to break up the marriage. To avoid the counterexample, it seems the weaker reading should be adopted, and this informs discussion of the remaining next argument. But before we get there…

Consider next lines (2) and (3). If we assume line (1) is true, then note that line (2) is simply a specification of the part between the “if” and the “then” of line (1), to a given action. The logic from (1), (2), and (3) is:

i. If a physician is reasonably confident that agent T’s life will be better if the physician performs action A, then the physician has a prima facie responsibility to perform A
ii. If [if a physician is reasonably confident that agent T’s life will be better if the physician performs action A, then the physician has a prima facie responsibility to perform A] then physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better
iii. Hence, physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better

We can spell it out further though:

i.  If a physician is reasonably confident that agent T’s life will be better if the physician performs action A, then the physician has a prima facie responsibility to perform A
ii. If a physician is reasonably confident that agent T’s life will be better if the physician tries to convince T to accept treatments they believe will make the T’s life better, then the physician has a prima facie responsibility to try to convince T to accept treatments they believe will make the T’s life better
iii.  Suppose a physician is reasonably confident that agent T’s life will be better if the physician tries to convince T to accept treatments they believe will make the T’s life better
iv.  Hence, the physician has a prima facie responsibility to try to convince T to accept treatments they believe will make the T’s life better

The move from (i) to (ii) in this second expansion of the argument reveals the specification of line (1) to a given action. Line (iii) of this second expansion supposes – as is plausible – that a physician is reasonably confident such an action will be helpful for T. This is all to say that we should grant (2) and (3) since they’re points of logic, though they needed unpacking to see that.

Next is line (4), which I repeat here:

Physicians engaging in empathetic discussion with patients concerning recommended treatments is an effective and respectful way to convince patients to accept those treatments

This seems true, and borne out by briefly expanding on what it means to have an empathetic discussion. I think Gawande provides an excellent example of this sort of discussion, for reference. But you can see intuitively – I’m sure – how this works. Patients often receive bad news from physicians or treatments that alter their lives. Physicians who are able to help patient’s feel heard, validated in their concerns, and encouraged through the perhaps difficult near future the patient can expect, create an environment of dialogue so that patients are themselves more likely to listen, validate, and encourage physicians in their recommendations. As my mother used to say: “You catch more flies with honey.” (Ignore that I used to say back: “Why do I want flies? My honey is ruined.”)

Lastly, consider line (5), repeated here and unpacked:

If physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better and physicians engaging in empathetic discussion with patients concerning recommended treatments is an effective and respectful way to convince patients to accept those treatments, then physicians have a prima facie responsibility to engage in empathetic discussion with patients concerning recommended treatments

This also seems true, given that the assumed prima facie responsibility from (3) plausibly transfers through the effective and respectful means of convincing patients mentioned in (4). One might attempt to object here that (5) implies the only way for physicians to make patient lives better is by empathetic discussion, and they believe that. That, however, is incorrect. All this argument says is that empathetic discussion is a way to achieve that end; there are surely others.

Let’s consider the second argument next, starting with line (1):

Physicians are not trained to engage in empathetic discussion with patients concerning recommended treatments

As stated, this seems true. Physicians are trained to treat patients as – simply put – presenting problems to be solved with certain diagnostic tools. But physicians are not often trained to supplement those tools with empathetic discussion of the sort described here. This is, of course, something that could be added to physician training, and – as Rebecca suggests – seems in the current era something medical students are sensitive to, which fills me with optimism about the future.

Consider next line (2):

If (1), then physicians can reasonably expect to make the lives of patients worse by attempting empathetic discussion with patients concerning treatments

Here is where our earlier discussion of “reasonably confident” enters again. Recall, to avoid obvious counterexamples to line (1) in the first argument, we must read this as restricted in some manner. Earlier we didn’t want physicians to become impromptu marriage counselors simply because they’re reasonably confident someone’s life would be better if they weren’t married. We could avoid this counterexample by restricting the scope of “reasonably confident” to physician area of expertise. Restricted thus, and since (1) is true, then it seems plausible empathetic discussion is outside the scope of physician expertise.

That said, there is still a leap from physicians not having such training to being reasonably confident that patient lives will be worse if they try. At this point, it’s worth thinking about context in more depth. Consider first, a physician might convince an individual to receive a life-saving blood transfusion though doing so violates deeply held religious convictions by the patient. If done empathetically, this is more likely to result in the patient feeling heard, and accepting that the decision is largely theirs to make. If done poorly, however, say, by offering a battery of arguments and reasons to the patient until they relent, without attempting empathy, that's likely to result in later feelings by the patient that the decision was somewhat forced on them, as if it wasn't really theirs to make. That in turn may lead to psychological harm, distrust in physicians, etc., all of which would plausibly make the patient's life worse. These are salient possibilities a physician might be reasonably confident in arising if the situation is not approached carefully. Of course, untrained physicians might approach such scenarios carefully, but this would be at best accidental virtue. But accidental virtue is like a toy soldier, it’s a toy, but not a soldier. Better to have intentional virtue, and that requires training.

That said, one might object that simply offering options doesn't make a patient's life worse off, and that’s all that physicians need here to undermine (2). But this is not obviously true. Physicians don't simply ever offer treatment options; the options come with a presumption that the physician thinks they're worth considering. That has force. Why else would we be listening going to the physician. In contrast, if I said to you "Hey, here's a treatment option" you'd be more likely to interpret me as offering merely an option. But if there's presumptive force behind physicians providing options, then the empathy worry arises again. Specifically, if done without empathy, this may come off as physicians simply telling patients what to do, which runs the risk of patients not feeling listened to, and so not feeling they have much of a say in the decision making process. These consequences are less likely if physicians provide options empathetically.

There is of course much more to say about line (2). It is underspecified on purpose, but hopefully thinking through scenarios helps illustrate that plausible specifications of it tend to be true. And if it is, then (3) follows.

So let’s consider (4):  

If agent S is reasonably confident that agent T’s life will be worse if S performs action A, then S has a prima facie responsibility to not perform A

I think this hardly requires defending. If you’d like a defense though, please see my Ties that Undermine and Judgments of Moral Responsibility (with James Beebe) in the journal Bioethics.

That brings us to (5), unpacked, pruned, and with “A” replaced with the relevant action:

If a physician is reasonably confident that a patient’s life will be worse if the physician attempts empathetic discussion with the patient concerning treatments, then the physician has a prima facie responsibility to not attempt empathetic discussion with the patient concerning treatments

A move which again strikes me as true. This is motivated by reflecting on the occupational role physicians have, requiring beneficence and non-malfeasance. Simply put, physicians shouldn’t try to do what they don’t know how to do so well, especially if the consequences of trying are so dire. This sort of justification is already common in the medical field. Physicians who aren’t surgeons don’t often attempt surgery, since others can help and the consequences are dire.

But here we reach the dilemma. It can’t be that both arguments are sound, since they generate conflicting conclusions. I think this dilemma can be resolved by observing that the conclusion of the first argument, though it seems the more plausible of the two arguments given, is actually misguided for the reasons given by the second argument. That said, there’s a nearby conclusion that emerges from an argument similar to the first, namely, that physicians should either learn empathic discussion skills or consult empathetic discussion specialists, i.e. therapists. This resolves the conflict. That argument is (changes in bold):

(1)    (BETTER) is true
(2)   If (1), then physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better
(3)   Hence, physicians have a prima facie responsibility to try to convince patients to accept treatments they believe will make the patient’s life better
(4)   Physicians trained to engage or who seek relevant consults in empathetic discussion with patients concerning recommended treatments provide an effective and respectful way to convince patients to accept those treatments
(5)   If (3) and (4), then physicians have a prima facie responsibility to train to engage in or consult with experts about empathetic discussion with patients concerning recommended treatments
(6)   Hence, physicians have a prima facie responsibility to train to engage in or consult with experts about empathetic discussion with patients concerning recommended treatments

And that seems true.