The New Medical Ethics of
Medicine's New Economics
Probably the most important implication of medicine's economic revolution is that it forces us to reconsider not just financial arrangements, but also some long and widely held tenets of medical ethics. Initially, physicians' obligations of fidelity stemmed from patients' substantial vulnerability. Illness, impairment, ignorance, and an imbalance of power in the physician-patient relationship gave rise to strong duties of personal and professional fidelity. Since the advent of modern bioethics over the past three decades, this traditional view has been powerfully augmented by another concept, patient autonomy. Coincident with early legal cases establishing the doctrine of informed consent,1 early bioethics literature argued vigorously against longstanding physician paternalism in favor of the view that competent patients are entitled to make their own medical decisions.2 Whereas the older, vulnerability-based ethic of fidelity required the physician to promote the patient's benefit in whatever ways the physician thought best, autonomy-based fidelity requires the physician to promote the patient's benefit as the patient himself defines it.
Largely because of this initial concern to defeat paternalism, early bioethics literature tended to define autonomy quite exclusively in terms of freedom—both the internal freedom of the competent person to make his own choices, and his external freedom to carry those choices out. As noted by Beauchamp and Childress, autonomy is the "personal rule of the self while remaining free from both the controlling interferences by others and personal limitations, such as inadequate understanding, that prevent meaningful choice."3 To honor this capacity for reflective choice is, after all, not only to benefit individuals and promote their happiness; it is integral to our respect for them as having unconditional moral worth.4