FOR THE PATIENT'S GOOD - The Restoration of Beneficence in Health Care by Edmund D. Pellegrino, MD and David C Thomasma, PhD. Oxford University Press, New York - Oxford, 1988; ix & 240 pages, $41.50; ISBN 0-19-504319-7.

When Dr Pellegrino spoke at the 50th annual meeting of the AAPS in Raleigh, North Carolina, I made a note to check out some of his writings. Of the number of books he has in print, I ordered several and chose to look at probably his most academic volume even though it is dated. It also provides a perspective. On discussing this with our Editor-in-Chief, we felt he provided some hard data on behalf of our patients and why what's going on in medicine is not in our patient's interest.

Dr Pelligrino, professor of Medicine and Medical Humanities at Georgetown, is joined by Dr Thomasma, Professor of Medical Ethics at Loyola in Chicago, in reviewing the post-Hippocratic era, which has shaken and even dismantled parts of the Hippocratic ethics. Pelligrino feels there have been more changes in medical ethics in the last two decades than ever before in the entire twenty-five-hundred-year history of medical ethics. There is serious question about whether the medical profession can ever again be united under a common set of moral commitments. He feels the future is uncertain.

He details the two major ethical theories which are currently vying for dominance in medical ethics. The first stresses the liberty and autonomy of the individual. It gathered strength in the nineteenth century in response to the depreciation of personal worth that accompanied the Industrial Revolution. This theory is grounded in ethics as rights, duties, and obligations. The second theory stresses social utility: social good, rules of conduct, and social accountability. Stuart Mills laid the foundation for such theories when he proposed the principle of autonomy, on the one hand, and the principle of utility, on the other.

Applied to the physician-patient relationship, the first theory imposes on the physician the obligation of respect for the patient's self-determination. The second theory requires that the physician act to maximize benefits and goods even if this might demand acting without the patient's consent. It sanctions overriding the patient's autonomous decision if that decision is not judged by the physician to be in the patient's or society's good.

Pelligrino gives us hope for reconstruction by recounting the forces of deconstruction that have been at work in Western society at least since the Enlightenment. He feels the chief cause is the loss of moral consensus and the moral authority of religious institutions. The resulting moral diversity, he feels, has caused an undeniable moral defection of some physicians. As a result, patients and physicians cannot assume they will share any common set of moral values. They may find that at a time when the most fateful decisions must be made, that they are moral adversaries. A legalistic rather than a fiduciary climate then comes to dominate many physician-patient relationships. Litigation and the court decisions become the arena for the settlement of ethical disputes.

Every one of the prescriptions and proscriptions of the Hippocratic oath has been questioned or openly violated: Abortion is not longer forbidden; confidentiality has been challenged as outmoded; direct euthanasia is proposed and even quietly practiced; sexual relationships with patients are deemed therapeutic by some psychiatrists. The benignly paternalistic image of the physician so characteristic of the Hippocratic ethos is everywhere under attack. He states that even traditional medical ethics itself is perceived by some to be simply a mechanism for preserving professional power and privilege.

Pelligrino proposes a third theory based on beneficence, that is, on acting for the good of the patient, and on virtue which he feels is more appropriate to the special context of the medical encounter today. This theory was originally formulated by Socrates, Plato, and Aristotle, reinforced by the Roman Stoics, and modified by Saint Thomas Aquinas. It was the theory that prevailed in Western culture until Enlightenment, when it came under attack by the French philosophers and the British empiricist.

Pelligrino's chapter on gatekeeping was of special interest since I had previously written an editorial on the subject. Since 75% of the nation's expenditures for health care is our responsibility, we are the traditional or de facto gatekeepers. This is our responsibility to practice rational medicine--use only those diagnostic and therapeutic modalities that are beneficial and effective for the patient. A second form or negative gatekeeping is usually found with some form of prepayment system in which the physician tries to limit the use of health care services which conflicts with the physician's role as primary advocate and as society's guardian of resources. The third form or positive gatekeeping is a physician's encouragement in the use of health care facilities and services for personal or corporate profit. The latter two are morally indefensible.

Beneficence includes more than the negative principle primum non nocere, but entails positive enhancement of all components packed into the complex notion of the patient's good. Pelligrino argues that medicine is neither a science nor an art, but a practice that gives rise to ethical axioms. If these axioms are violated, the good of medicine is also violated.

There is much more. This volume needs to be on our consultation desk and given space and attention to balance the deluge of morally unjustifiable information coming from a large number of groups who don't have our patient's interest at heart--sometimes even our professional organizations.