Abstract

The means by which medical patients are persuaded to participate in treatment have received little attention in the bioethics literature. Recent detailed accounts of the Tuskegee Syphilis Study provide a rich source of material concerning this as well as raising relevant questions. Two models commonly proposed as governing ethical clinical practice, Beneficence and Autonomy, are considered. Several interpretations of these principle-based models are evaluated. I argue that once general social expectations are fixed, the most plausible interpretations of the models tend to coalesce in their prescriptions for clinical conduct. Three cases are examined, one involving a thoroughly competent patient desiring to discontinue life-sustaining treatment, one a patient whose emotional susceptibilities threaten the outcome of his rehabilitation, and one an incompetent patient who resists needed daily care. It develops that the Autonomy and Beneficence models prescribe similarly except in the means and aims of expected and permitted persuasion. Since successful legitimate persuasion is the key to gaining proper consent from someone who has previously withheld it, persuasion itself becomes the focus. Austin's theory of speech acts is applied to straightforward persuasion as well as to education, diplomacy, manipulation, and related activities. Persuasion is shown to influence choice by addressing belief or desire. I argue that it is implausible to suppose that beliefs or desires may be induced without connection to those already existing in the subject. Further, because of the logic of emotion and desire, neat separation of belief and desire is not possible though they may be distinguishable by differing "directions of fit". Thus, common uses of such concepts as education and manipulation require correction. Applying the results to the clinical practice models yields some unexpected conclusions. Both models may require manipulation of patients' deliberations and decisions. Beneficence may require a higher standard of precision in informing and gaining consent than does Autonomy. Neither model requires that patients' irrational trust be actively dispelled by clinicians except to prevent harm. Both models require that the nature and general goals of the clinical relationship be understood and agreed to before clinical activity begins. Many questions raised by the Tuskegee study are answered