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Key Points
- In many cases of wish-fulfilling medicine, no concept of illness or disease is involved, and the interventions do not constitute medical treatments, but instead so-called lifestyle enhancements aimed at wishes outside the medical sphere.
- Modern medicine seems rather ill-equipped to provide normative guidance or clear-cut rules on how to deal with the growing potential for medical wish fulfillment.
In my second year as a medical student, I was sitting with a group of friends after a long pathology class, when the conversation turned to an exciting topic: What exactly is it that medicine does, and what should it do? I remember that, after a lot of back and forth, we agreed that the proper goals of medicine — and hence of us, future physicians — were healing and preventing illnesses, and, whenever that was not possible, alleviating pain and suffering. Rather straightforward, we thought at the time.
Ever since that day, I've come back to this question. I thought about it when observing the growth hormone consultation in the Paediatrics department; when I heard exhausted mothers ask, some with tears in their eyes, for Ritalin for their unruly child; when a violinist asked my attending in Neurology for ß-blockers to treat his stage fright; when a friend discussed taking Prozac to overcome his shyness with women; when there was controversy on the ward over some specific wish a patient laid down in her advanced directive; and, of course, when I was assisting, for the first time, in a breast augmentation surgery.
PATTERNS OF DREAMS
These cases stood out from all the other clinical situations and treatments I encountered during my medical education. There was a pattern: they were performed in order to fulfill a prima facie non-medical wish of a patient. No symptoms of illness or disease were present; there was no diagnosis, and the decision-making process lay almost exclusively in the hands of the patient. At the same time, I was learning the nuts and bolts of correct diagnoses, figuring out the right treatment to help my patients, and assuming responsibility for my clinical decision making, I found out that quite a lot of medical practice today is actually not like that. Rather, it takes place within the category of "wish-fulfilling medicine."
TREATING THE SOUL
In many cases of wish-fulfilling medicine, no concept of illness or disease is involved, and the interventions do not constitute medical treatments, but instead so-called lifestyle enhancements aimed at wishes outside the medical sphere. However, there are several cases in which wish-fulfilling interventions come very close to treating an illness, for example in cases when the desire to look differently — to have a different nose, or larger breasts — causes significant psychological distress. How then, is the line between treating an illness and treating a non-medical wish to be drawn? How do we distinguish between medical and non-medical wishes? Are patients the ones to determine when there is a "clinical problem"? Should we invoke (bio-) statistical guidelines? What, in essence, are the criteria of illness we can invoke?
THE ETHICS OF 'NO'
These might seem to be theoretical questions for philosophers of medicine far removed from everyday practice. However, in healthcare systems battling scarcity of resources, the lines drawn between pure wish-fulfilment and treating an illness gain importance, because they can be — and are — used to justify which treatments to fund. Drawn too loosely, budgets will continue to swell; drawn too tightly, the divide between those able to pay out-of-pocket for the care they need — or wish — and those who cannot, will expand even further.There are ethical aspects of wish-fulfilling medicine which will ring familiar to cosmetic surgeons: Are there some wishes physicians should refuse to fulfill, even if they could fulfill them? There is one sense in which this question is rather easy to answer: a conscientious physician will consider refusing to fulfill the wish of a patient whose autonomy is clearly compromised. When the conditions of informed consent are not satisfied, and the patient either is not competent, lacks information or is under external pressure, ethical as well as legal rules urge physicians to help the patient improve her decision-making abilities instead of simply fulfilling her wish.
HOW FREE?
However, in many cases, it will be unclear whether patient autonomy really is compromised or not — think of the 19-year-old asking for Lindsey Lohan's face, or the pilot requesting Modafinil to enhance focus while flying transatlantic flights, afraid of losing his job. There may even be some instances in which patients are, by all accounts, fully autonomous, yet one still might be reluctant to provide them with the desired treatment, for example because it is very risky or very extravagant.
Between the two alternatives of simply "doing everything" and running the risk of paternalistically refusing the express wishes of autonomous patients, modern medicine appears to be rather ill-equipped to provide normative guidance or clear-cut rules on how to deal with the growing potential for medical wish fulfillment. Cosmetic surgeons have been walking this fine line for a long time. The rest of medicine, it seems, is increasingly required to do the same.
Dr. med. Alena M. Buyx, M.A. phil.,
earned her medical doctorate in neurology, and wrote her philosophical masters thesis on justice in healthcare. She works as an ethicist for the Max Planck Institute for Molecular Biomedicine in Münster, Germany, also affiliated with The Institute of Ethics, History and Philosophy of Medicine at the University Hospital Münster. She is currently a visiting scholar in The Harvard University Program in Ethics and Health. She may be reached at
Alena_Buyx@hms.harvard.edu
.
