Making good choices: toward a theory of well-being in medicine

Abstract

The principle of beneficence directs healthcare practitioners to promote patients' well-being, ensuring that the patients' best interests guide treatment decisions. Because there are a number of distinct theories of well-being that could lead to different conclusions about the patient's good, a careful consideration of which account is best suited for use in the medical context is needed. While there has been some discussion of the differences between subjective and objective theories of well-being within the bioethics literature, less attention has been given to the questions of what work a theory of well-being needs to do in bioethics and which standards of success ought to be used in selecting a theory of well-being for use in medicine. In this article, I argue that traditional theories of well-being developed in philosophy are not well suited to meet the needs of the medical context. For the principle of beneficence to be most useful, the underlying account of well-being should satisfy two conditions: first, it needs to lead to a concrete, action-guiding determination of the patient's good; and, second, any recommendations it offers need to be justifiable to patients. Standard accounts of well-being have difficulty satisfying both conditions. Exploring the limitations of these theories when applied to treatment dilemmas helps point the way toward the development of an account of well-being better suited to healthcare.

The theorisation of ‘best interests’ in bioethical accounts of decision-making

“…Best interests are also associated with theories of wellbeing [ 52 , 57 , 71 – 73 ], often called ‘prudential value’ theories, which identify what it is that makes things go best for individuals. While these theories potentially have links to the concept of utility (identifying prudential value may on some accounts identify the overall good to be maximised in a population), they are distinct from utilitarianism.…”

“…Some consider objective lists defensible for patients whose values are unknown, like intellectually disabled children [ 57 ]. Despite the similarity of desire theories to the English legal account in the Mental Capacity Act 2005 [ 72 ], others consider all three theories advanced by DeGrazia deficient for healthcare decision-making [ 72 , 73 ]. These authors disagree on whether a mixed approach should be taken drawing on all three theories on a case by case basis [ 72 ] or if a new theory is needed.…”

“…These authors disagree on whether a mixed approach should be taken drawing on all three theories on a case by case basis [ 72 ] or if a new theory is needed. Of the latter, Hall [ 73 ] proposes ‘Pragmatic subjectivism’, a theory that bases wellbeing on whichever of the patient’s own values are most stable and functional.…”

“…Some [ 57 ] argue pain is only against interests to the extent a person is aware of it Quality of life Frequently identified [ 49 , 50 , 52 , 54 , 55 , 57 , 60 , 62 , 85 , 88 , 98 ]. Defined as either subjective or objective value of life [ 49 , 54 , 73 , 75 ] Authors argue that quality of life is an implicit factor guiding legal [ 49 , 62 , 98 ] and clinical [ 44 , 50 ] best interests decisions or used as explicit cover for arbitrary and prejudiced decisions [ 44 , 52 – 54 ] Futility Identified by [ 49 , 53 , 61 , 76 , 88 , 98 , 99 ]. Sometimes [ 44 , 62 , 75 ] identified with a medical judgment Effective treatment possibilities and prognosis Identified by [ 44 , 86 ] Developmental potential Identified by [ 34 , 50 ] Medical progress Identified by [ 51 ] in context of research Sanctity of life Noted in the...…”

“…Frequently identified [ 49 , 50 , 52 , 54 , 55 , 57 , 60 , 62 , 85 , 88 , 98 ]. Defined as either subjective or objective value of life [ 49 , 54 , 73 , 75 ]…”