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ss nucleus - Easter 2010,  medical ethics for beginners

medical ethics for beginners

Giles Cattermole explains the basis of medical ethics
Ethics is far more than the life and death issues currently popular in the media. It's about every decision we make; 'I should do this' or 'I shouldn't do that'. This article introduces the sorts of questions that ethics is concerned with, the answers that humanist frameworks offer, and a critique of these from a Christian perspective.

what is ethics about?

On a ward-round, it's easy to think that prescribing antibiotics is a 'scientific' decision, without the need for ethics or 'value judgments'. But If the patient is foreign, unconscious, terminallyill, with life-threatening pneumonia, and if the antibiotics are very expensive with nasty side-effects, all sorts of ethical considerations become apparent: how we treat patients who can't consent; which people are entitled to NHS treatment; how good and bad outcomes ought to be balanced. Even for everyday cases, value judgments are intrinsic to medicine. 'Patient' implies a particular relationship of duty and care. 'Infection' suggests something that is bad. Medicine presupposes that disease is 'bad' and health is 'good', and that clinicians 'ought' to help people from disease to health. These are value judgments, this is ethics.

Ethics is about deciding what is morally right and wrong, about what we should or shouldn't do. Medical ethics therefore is concerned with the obvious issues like abortion, cloning, and euthanasia. But also with what life is and what a person is. What disease and health are. Our attitudes to disability and mental illness. Justice and rationing. Confidentiality, dignity, consent, truth-telling, paternalism, professionalism, research and much more.

how can we know what is right?

Is morality revealed, discovered or chosen?

In the West, morality was once generally accepted to be 'revealed'; God tells us, in the Bible, or in nature, what is right and wrong. Our task is to discern his will. Enlightenment deism saw morality as 'discovered'; there is moral truth 'out there', but God won't tell us what it is; we have to work it out for ourselves according to a moral framework. Post-modernity says that there is no absolute moral truth; morality is 'chosen'. Ethics becomes no different from aesthetics.

what is truth?

Some philosophers use the categories of 'factual' and 'value' judgments. Factual judgments concern scientific truth and logical truth. The former is determined empirically, the latter is self-evident based on first principles. Value judgments concern aesthetics and ethics.

For example:

  • Wales is west of England - scientific truth, observed on a map or on a visit
  • 2 + 2 = 4 - logical truth, assuming the rules of mathematics
  • Coffee is nicer than tea - aesthetic judgment, 'true' for some but not all
  • Murder is wrong - ethical or moral judgment

For some people, value judgments, whether aesthetic or ethical, are merely matters of personal preference. But even though they sometimes behave as though all that matters is their personal pursuit of happiness, in practice few people consistently live as though there is no moral truth at all. Just ask them whether Hitler was wrong. Or whether rape or racism are acceptable. Instead, most people still think that some actions really are 'right' or 'wrong', even if they disagree about which are which. They operate according to some sort of moral framework, even if they don't know it.

humanist ethics

    Three classic theories:
  • Virtues (1)
    BE the right person
  • Duties (Deontology) (2)
    DO the right action
  • Consequences (Utilitarianism) (3)
    WILL the right outcome

virtue

Virtue ethics are concerned with the character of the moral agent. By becoming the right sort of person, what Aristotle called 'the great man', one will naturally behave correctly.

Many people think this sort of theory too vague and incomplete for practical use, but there is still an assumption that doctors and nurses should be competent, compassionate, altruistic people.

duty

Duty based ethics are concerned only with the rightness or wrongness of an action itself, not with its outcomes. Some things are universally right, some universally wrong. Kant's 'categorical imperative' was to 'act only according to that maxim whereby you can at the same time will that it should become a universal law'. Not to lie, for example. The Hippocratic Oath4 was a list of duties. But many people object to the idea of absolute, exceptionless duties:

Imagine you are sheltering a family of Jewish refugees in your home in 1940s Holland, and a Nazi patrol asks if there are any Jews there. Would you tell the truth?

utility

Consequence-based ethics look to the outcome of any action to determine whether it is right or wrong. The end justifies the means. 'Utilitarianism' is a form of consequentialism in which the desired outcome is the greatest net happiness of all concerned.

However, one can never be sure that an action will achieve its desired end. Even if it did, it's difficult to sum 'happiness' and 'sadness' for different people who might appreciate happiness differently from each other. It's also obvious that this sort of thinking is very dangerous for individuals and minorities:

Imagine a very unpopular colleague. If you kill that person, there is a very negative outcome for that individual. But you might create a small degree of happiness for many other people. If the many small happinesses outweigh the one big unhappiness, then for a utilitarian, this would be the right thing to do.

rights

For many, virtue ethics were too vague and duty-based ethics were too absolute. As governments took over the role of providing heath care, the driving ethic became more utilitarian: an ethic of efficiency, maximising the good of the whole population. But the atrocities carried out for the 'greater good' in the Second World War led to the adoption in 1948 by the United Nations of the Universal Declaration of Human Rights, (5) rights to protect individuals and minorities from unfettered utilitarianism. Duties can be perceived as the corollary of rights: if I have a right to healthcare, then someone has a duty to provide it. Confidentiality is not seen as an absolute duty as Kant would have defined it, nor as the nucleus easter 2010 29 medical ethics for beginners characteristic of a virtuous clinician, but as respect for the patient's right to confidentiality. These duties are now often described in professional codes of conduct, such as the UK General Medical Council's 'Duties of a doctor'. (6)

principles

Virtue, duty and utility-based ethics are ethical theories, from which principles and rules can be derived for practical decision-making. In the 1970s, Beauchamp and Childress 7 famously promoted the idea of 'principles' of medical ethics: most people, of whatever religious or cultural background, tend to agree on certain basic ethical principles. The standard four principles they described were: autonomy (respect for a person's choices); beneficence (doing good); nonmaleficence (not doing harm); justice (fair distribution of resources).

principle-based ethics

  • Autonomy
  • Beneficence
  • Non-maleficence
  • Justice

Beneficence is what clinicians have always wanted: to bring healing. Non-maleficence was Hippocrates' first aphorism: 'primum non nocere', (4) first do no harm. This is the attitude that safety comes first. These two principles can be put together as 'balancing risks and benefits'. People want fairness, even if they don't agree how it's best defined. But autonomy is sometimes criticised as being too Western and individualistic. Another problem with this approach is that sometimes the principles conflict. Autonomy is often assumed to trump the others.

A shocked trauma patient needs a splenectomy, but blood transfusion is refused on religious grounds. She requests an expensive artificial oxygencarrying compound as a substitute for haemoglobin. A balance of risks and benefits would suggest that the operation should only go ahead if blood or its substitute is available; operation alone would make things worse. Autonomy says she should be allowed to refuse blood. Justice might suggest it is unfair for this patient to have an expensive blood-free option that other patients are not offered. Duty, utility, rights and principles can all be criticised as being 'mechanical'; applied without emotional or personal involvement.

In practice, decision-making involves 'blended ethics', using different theories and principles to support an argument, or to suit different circumstances. What seems to be an attempt to discover what is really the right thing to do (as the Enlightenment philosophers intended), becomes instead an exercise in justifying one's own preferences. Ethics becomes relative, a matter of personal choice.

what should Christians do?

There is a tension between utilitarianism (balancing risk-benefit outcomes in order to maximise the greater good for society as a whole) and rights (autonomy):

Individual autonomy <<<--------------------------------------------->>> Greater good of society

Our starting point in Christian ethics must be God, and what he has told us is good. But we also need to recognise that human nature is sinful, in rebellion against God. We'll get nowhere without repenting of our sin, trusting only in God.

The problem with all the secular ethical approaches is that they take no account of sin. Utilitarianism denies any need for virtue or duty, and ignores God's concern for the weak and helpless, his love for individuals. Ends don't justify means. Dutyethics fail to take account of our inherent disobedience, and we cannot rely on our character as a 'virtuous' clinician, because we are sinful and our consciences have been corrupted. We cannot 'discover' universal duties independently from God's revelation, and similarly the idea of autonomy is to assume that we determine what is right and wrong ourselves. Whether creating duties, or insisting on our autonomy, we are merely repeating the sin of Adam and Eve: usurping authority from God and taking the law into our own hands. Rights and autonomy are also essentially selfish; we prioritise the fulfilment of our own needs over those of our friends, family, society, and most importantly, over the will of God and his Kingdom. Autonomy is not the solution to ethical dilemmas; it's the cause of the problem!

But there is at least a glimmer of truth in these approaches too. We are concerned with end results, but the end result we're concerned with is God's glory. Consequences do inform our decisions: we should act in ways that maximise his glory. But we know that this shouldn't result in atrocities, because God is glorified not just in results, but in the actions performed and the character of the person performing them, and because God is concerned with each individual. God has given us duties: but the primary purpose of the law is to show us how sinful we are, so that we trust in Christ and his work on the cross, for our forgiveness and restoration to relationship with God. God enables us to obey him by the power of the Spirit. The Bible makes clear our duties to one another and to God, but they are not a mechanical check list of do's and don'ts. They can't be performed outside of loving relationship: 'Love the Lord your God with all your heart... love your neighbour as yourself'. (8) Finally, Christian ethics are virtue ethics: we seek to be like Jesus. To the extent that we become more and more like him, we will act in the way that is most pleasing and glorifying to God.

Christian ethics are therefore revealed in God's Word, the Bible. They are not discovered or chosen by us. God defines what is good. So let's listen to him. Christian ethics are concerned with all aspects of our behaviour: our character, our deeds, the outcomes. We have 'relational responsibilities': our responsibilities to each other and God, revealed to us in his Word, are lived out in personal, loving relationship. We seek to live like Christ; we seek to glorify his name. So let's pray that we do this, because without him, we can't.

Giles Cattermole is CMF Head of Student Ministries

References
  1. Aristotle. The Nicomachean Ethics. London: Penguin; 2004. MacIntyre A. After Virtue. 2nd ed. London: Duckworth; 1985.
  2. Kant I. The Moral Law. 2nd ed. London: Routledge; 2005.
  3. Mill JS, Bentham J. Utilitarianism and other essays. London: Penguin 2000.
  4. Hippocrates. Hippocratic Writings. London: Penguin, 2005.
  5. General Assembly of the United Nations. Universal Declaration of Human Rights.
  6. General Medical Council. Good Medical Practice: Duties of a Doctor.
  7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 6th ed. Oxford: OUP; 2008.
  8. Luke 10:27
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