In medicine, we commonly make distinctions between care that is ‘necessary’, say taking medication to prevent an infection from escalating, and care that is not necessary, say breast augmentation for aesthetic purposes. In many countries, public healthcare is limited to care that is deemed to fall in the first category. Although this is an intuitively plausible distinction, there are several unresolved issues under the surface that have implications for how we allocate scarce resources in healthcare. While the debate on medical necessity is far from new, the long way to find an operational framework may receive fresh impetus from the alleged move toward disruptive innovation in medicine. In a new article published by two members of the UGent Metamedica platform in Clinical Ethics, this topic is addressed by exploring how the current wave of allegedly disruptive innovation is invoking a resurgence of this concept and related debates on ‘the’ goal(s) of medicine. This blog post is a reduced version of their article.
The what of medicine?
The notion of ‘medical necessity’ is elliptical, in the sense that it prompts the question ‘necessary for what?’. The answer to this question gives the end for which the need is a necessary condition. Thus speaking of ‘medical necessity’ seems to minimally lead to questions about the goals of medicine.
To make it more complex, it may first be noted that the ethical controversy already starts at the more fundamental concept of ‘need’ and, by extension, ‘medical need’. These notions deceptively seem to refer to a descriptive state of affairs, while they are in fact connected with a normative – hence contestable – end. The expansion of the scope of medical needs from physical interventions to psychological interventions in recent decades can thus be explained by the increased recognition that psychological well-being is as important as physical well-being (which is a normative claim). While, as argued by the pioneering bioethicist Daniel Callahan (1991, p.32), it has proven ‘hard altogether to avoid the notion of need, in one guise or the other’, this concept has always had an inherent ambiguity, with a troubled history to find a coherent meaning for it. We contend that this ambiguity is tied up with precisely this normative question of which ends it ought to serve.
Though the goals of medicine have been regarded as foreshadowing the notion of medical necessity, the construal of this concept is controversial and we lack clarity and accepted consensus around the proper ends in the ethics literature. If we look into which attempts have been made to define the goals of medicine, we find some have identified ‘prevention of disease and promotion of health, relief of pain and suffering caused by maladies, cure of maladies, care when cure is not possible, avoidance of premature death and the pursuit of a peaceful death’ as the central goals (cf. Daniels and a task force at the Hasting Center). Other scholars define ‘restoration and improvement of health, alleviation of pain and suffering, improvement of quality of life and prevention of pain and suffering as fundamental goals of medicine’ (cf. Fleischhauer and Hermerén). The various ends that have been suggested are all too often found to be stipulative and contestable on other normative grounds.
More questions than answers
In view of this inherent normativity, one should perhaps not expect an end to this process. It may be identified as a continuous moral negotiation in which the current calls for disruption in healthcare may be regarded as defences of a particular conception of what ‘good healthcare’, along with its respective ends, encompasses.
If disruption is indeed about such changes to what medicine is directed at, then one may also expect that the related concept of ‘medical necessity’ may require recalibration, and with that, the ethical question of what it means to do good in medical and clinical practice.
It may be rightly noted that ‘medical necessity’ is and has been a peculiarly elusive notion, but it may become even less clear what that notion amounts to after the ‘creative destruction’ of traditional medicine that some hypothesize in the near future (cf. Topol). Will the concept only be reserved to that residual subset of conditions that cannot be prevented (which indeed raises ethical questions about how far prevention should reasonably go and by which means)? Or will medical necessity rather become ubiquitously synonymous with not only preventing medical conditions, but indeed with ‘empowering’ individuals to act for themselves by shifting power relations between doctors and patients, challenging expert knowledge and enhancing individuals’ access to information?
The reflections that we provide in the article are, admittedly, a discussion starter, and research is needed to further flesh out their details and boundaries. Let’s philosophize a bit more before disruption bites back in undesirable ways.
Author: Dr. Michiel De Proost (Bioethics Institute Ghent & METAMEDICA-platform, Ghent University)
Further reading
Callahan D. Medical Futility, Medical Necessity: The-Problem-without-a-Name. The Hastings Center Report 1991; 21: 30–35.
Daniels N. Justice, Fair Procedures, and the Goals of Medicine. The Hastings Center Report 1996; 26:10.
Fleischhauer K, Hermerén G. Goals of Medicine in the Course of History and Today: A Study in the History and Philosophy of Medicine. Stockholm: Almqvist & Wiksell International, 2006
Segers S, De Proost M. Disrupting medical necessity: Setting an old medical ethics theme in new light. Clinical Ethics 2023, DOI: 10.1177/14777509231156046
Segers S, Pennings G, Mertes H. Assessing the normative significance of desire satisfaction. Metaphilosophy 2022; 53: 475–85.
Topol E. The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. New York: Basic Books, 2012.