"The fixed person for fixed duties, who in older societies was such a godsend, in the future ill be a public danger." Twenty years ago, a single legal metaphor accurately captured the role that American society accorded to physicians. The physician was "c- tain of the ship." Physicians were in charge of the clinic, the Operating room, and the health care team, responsible - and held accountabl- for all that happened within the scope of their supervision. This grant of responsibility (...) carried with it a corresponding grant of authority; like the ship's captain, the physician was answerable to no one regarding the practice of his art. However compelling the metaphor, few would disagree that the mandate accorded to the medical profession by society is changing. As a result of pressures from a number of diverse directions - including technological advances, the development of new health professionals, changes in health care financing and delivery, the recent emphasis on consumer choice and patients' rights - what our society expects phy- cians to do and to be is different now. The purpose of this volume is to examine and evaluate the conceptual foundations and the moral imp- cations of that difference. Each of the twelve essays of this volume assesses the current and future validity of the "captain of the ship" metaphor from a different perspective. The essays are grouped into four sections. In Section I, Russell Maulitz explores the physician's role historically. (shrink)

We offer a critique of one prominent understanding of the principle of respect for autonomy and of analyses of medical paternalism based on that understanding. Our main critique is that understanding respect for autonomy as respect for freedom from interference is mistaken because it is overly influenced by four-alarm cases, because it fails to appreciate the full dimensions of legal self-determination (one of its main sources), because it conflates the research and therapeutic settings, and because it fails to appreciate themes (...) of authority and power that have historically shaped the principle of respect for freedom from interference. We argue that respect for autonomy involves more than just freedom from interference and, on this basis, offer a critique of prevailing accounts of medical paternalism. (shrink)

The ethicist's role in the clinical context is not presently well defined. Ethicists can be thought of as moralists, technicians, Sophists, or as teachers and learners. Each of these roles is examined in turn. An argument is made for the ethicist as a teacher who must also learn a great deal about the clinical setting in order to encourage an effective critical examination of basic values. Four specific tasks of this teaching role are discussed: describing moral experience, eliciting assumptions, considering (...) multiple alternatives and justifying choices. (shrink)