Utilitarian vs. Kantian Ethics in Medical Decision-Making

Withholding a Diagnosis: Utilitarian and Kantian Perspectives

From a utilitarian perspective, any action must be measured against the positive impact it provides for the individuals involved. Unfortunately, it is sometimes difficult to judge and evaluate the level of happiness among individuals. In this particular case, the final objective would obviously be for the patient to be cured or to live a longer life. However, in cases of cancer the odds are most often against this outcome, so happiness can also be evaluated in terms of the quality of the patient's life during the time that remains.

Following the utilitarian perspective, the doctor should not tell Gina about her condition and should allow this to be a family decision. From a utilitarian standpoint, the quality of a patient's life increases when she is not subjected to the full weight of a terminal diagnosis. At the same time, the family can provide the positive framework and care needed for the patient to live well in her remaining time. It has often been noted that patients with a positive attitude are more likely to improve their condition simply because of an optimistic outlook.

From a Kantian perspective, the rightness of an action is always measured against the duty of the individual rather than considerations such as happiness or personal feelings. From this point of view, the doctor's duty is to keep his patient informed about her condition, to explain the planned treatment, and to continuously discuss with her the evolution of the disease and the treatment. From this perspective, it is up to the patient to decide whether she also wishes to inform her family about her condition — reversing, to some degree, the roles seen in the utilitarian analysis.

One significant complication in this case is that the patient speaks no English — only Japanese — making direct communication with the doctor nearly impossible. Beyond their role as family members, the relatives are also present to translate and explain everything to the patient, which gives them considerably more leverage than a family whose member could communicate directly with the physician. Even if the doctor were inclined to go beyond the family's request and speak with the patient directly, he would find it almost impossible to do so without a shared language.

The Role of Language and Family in Medical Communication

As this analysis makes clear, the central assumption shaping the entire discussion is that the patient cannot understand English and cannot communicate independently with the doctor. This leaves the decision, in practice, in the hands of the family — whether the doctor wishes it to be so or not.

Emanuel and Emanuel propose four models that classify the physician–patient relationship: the paternalistic model, the informative model, the interpretive model, and the deliberative model. The deliberative model is defined as the model in which "the physician, acting as a teacher or friend, engages the patient in a dialogue to empower the patient to consider values and select a course of action which best fits his or her values" (Mary Elizabeth, O'Brien, & Edwards, 1995).

Emanuel and Emanuel's Four Models of the Physician–Patient Relationship

Emanuel and Emanuel argue that the deliberative model is the best of the four. Their main reasons include the fact that it is the only model that successfully combines professional medical care with the capacity to actively engage the patient in the medical process itself, resulting in a genuine partnership between patient and physician.

The deliberative model is also the only one that truly takes into consideration the cultural background and individual traditions of the patient, and it best provides for the patient's active involvement in treatment decisions. Furthermore, the deliberative model incorporates many of the positive characteristics of other models — most notably the informative model. Active patient participation implies that the patient is also fully informed about the course of treatment, about her condition, and even about the ways in which scientific research may affect her illness.