Tuesday, February 08, 2005

Cosmic Justice as a medical ethical imperative

Thomas Sowell speaks of "Cosmic Justice". Is the" justice" appended to the ethical precepts of medicine this type of justice.Sowell in his book " The Quest for Cosmic Justice" argues that the traditional American justice is basically applying the same rules and standards to everyone. This is in contrast to "Social Justice" which involves redressing those inequalities that proponents characterize as the fault of society.Sowell argues further that social justice proponents seek not to just correct the sins of man (or society) but "the oversights of God or the accidents of history" as they bring about inequalities.So social justice is really cosmic justice.
The "big four" medical moral principles are respect for autonomy,beneficence,non-malficence and justice. ( Beauchamp, T;& Childress, J. (2001) Principles of Biomedical Ethics. 5 th ed. Oxford Univeristy Press, Oxford) Justice is the most recent on the ethics scene and the one , I believe, most difficult for physicians to wrap their minds around. Some would argue for a big three leaving out justice as it may conflict with the beneficence clause. But the establishment's party line includes it and is increasing being emphasized. And the justice that is proposed is "social justice". (Medical Professionalism in the New Millenium. A Physician charter. Annl Int Med 5 Feb 2002. VOl 136, pg 243-246)
Executing the first three may be difficult in a individual case but conceptually seem easier.Do no harm, respect the autonomy of the patient and act to benefit the patient. These resonate with what happens most of the time in a doctor patient encounter. But Justice is less clear. In the world of social justice it has to do with "allocation of [scarce] medical resources"How does one make that operational? It can only be made operational through population based assessments and recommendations .The individual practioner and his patient -concerned as they are-with their localized points of view cannot see the big picture and have to be told what to do by the guideline writers and the cost benefits analysis experts. To value the good of the group-as impossible as that is to delineate-above the good of the individual patient is not to start on a slippery slope , it is to go off the cliff.

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