This essay was written while taking a fourth year Bioethics course as a medical student at McGill University.
Henry Olders 7717465
27 April 1981
It seems that a large part of the energy being expended on the subject of biomedical ethics has to do with making decisions in situations where ethics (read “morality” or “conscience” or “social good”, etc) is perceived to be a major component. A lot of worrying is being done about the physician’s moral obligations to, and the rights of, his patient, the patient’s family, society, other physicians, and himself.
A great deal of argument has gone into the attempt to prove that decisions made by physicians are often moral decisions, not value-free. Although the “right” of the physician to make such decisions sometimes comes under question, rarely does anyone wonder why the decision needs to be made, or even if it needs to be made at all.
My intuitive belief is that there must exist an all-encompassing framework of moral principles which can be invoked when needed to specify the correct, ie, ethical solution in any particular situation where such a solution is called for. Try as I might, I cannot find even the vaguest glimmering of an outline for such a framework which could apply in the situations we’ve encountered in our course. Certainly, a number of statements have been held aloft as guiding beacons; for example, “sanctity of life”, an idea enshrined in Western law. However, in the case of abortion, “life” obviously does not hold the same meaning for those in opposite camps in the current dispute. It’s not the guiding principle I’m seeking.
Other slogans such as “the right to die with dignity”, “right to informed consent”, “right to refuse psychiatric medication”, deal with the individual concerns which most people feel are inalienable, at least in our democratic society in which individual liberty is held sacred. If these rights are inalienable, then why are struggles taking place, in courtrooms, in the media, for their recovery? Obviously some individuals feel that their rights are being trampled upon. Who does the trampling, and with what authority? More importantly, why? In many of the situations where bioethics is invoked as a necessary input to obtain solutions, the situation boils down to a conflict between the individual and/or his family on the one hand, and the individual’s physician or the medical establishment, often with support of the state, on the other. The existence of this conflict gives rise to problems for which ethical solutions are sought.
My thesis is that the situational conflict giving rise to the ethical dilemma is frequently based on issues which are unrelated to the ensuing ethical problem, even though not “value-free” in themselves. Consequently, it is not enough to attempt simply to determine which of the proposed solutions is the more “ethical”; the conflict itself must be analyzed and placed in its moral and historical perspective. The process of doing so will frequently cause additional possible solutions to surface.
An example occurs in the issue of so-called rational suicide. A terminally ill patient’s refusal of further treatment can perhaps be dealt with by his caregivers, but such a patient’s request for drugs to facilitate his death raises an ethical as well as a legal dilemma. In its simplest terms, the ethical issue revolves around the perceived duty of the physician to maintain life, not to take it; furthermore, aiding and abetting suicide remains a crime (at least in Canada), even though committing suicide is no longer illegal.
What is the situational conflict which causes this ethical dilemma? By law, the patient or his family does not have access to the drugs which could be used to facilitate suicide. Historically, such laws were enacted largely because of political pressure exerted by physicians and pharmacists, acting in their own interests to strengthen their monopoly.
Another example concerns decisions to save or let die defective newborns. We can conceive of a whole range of situations, from the Down’s syndrome infant with concurrent cardiovascular and gastrointestinal abnormalities which would be fatal unless surgically corrected, to the child (or fetus!) whose “defect” happens to be that his or her sex is not to the parents’ liking.
Decisions might be relatively easy to make in such extremes, but in other cases, the physician in following his belief that his role is to preserve life, may come in conflict with the parents, a conflict which must sometimes be resolved by the courts.
In earlier times, the conflict would not have arisen. Without the recent advances in surgical techniques for correcting congenital defects, or neonatal intensive care units, many children would simply have died, whether this accorded with the parents’ wishes or not. Then as well as now, the question of to save or let die is often resolved quietly and privately in cases where parents have their babies at home. While there are many other relevant factors, it must be acknowledged that at least in some cases, today’s immediate concern over a defective newborn would never have arisen if the medical profession were able to accede more easily to wishes of those parents and doctors for home birth and delivery by midwives. Again, the self-interest posture of medicine in calling for licensing of those who wish to perform “medical acts”, such as assisting at childbirth, and also medicine’s insistence that pregnancy is an illness to be treated in hospital, can be seen to contribute to generating “ethical” problems.
By considering such historical and situational factors, one can analyze other current issues, such as abortion, involuntary psychiatric committal and treatment, informed consent, and so on, to discover what conflicts give rise to the ethical dilemma, and why conflicts exist. Such an analysis may not be immediately useful in resolving individual ethical questions, but it may suggest alternative solutions which can obviate similar problems in the longer term.
In considering alternative solutions, particularly those which provide for settings in which today’s ethical conflicts would not arise, one may again turn to the search for an all-encompassing framework of moral principles. One such principle could be that one should not interfere with the right of others to enjoy autonomy and self-determination, as long as exercise of such right does not interfere with the same rights enjoyed by others. A corollary would be that an individual should not permit someone else to interfere with his right to autonomy and self-determination.
Immediate application of such a guiding principle in daily life would imply far less government and far fewer laws than we have currently, a situation that perhaps not many people would be able to accept. Its application to the bioethics examples above might be easier to visualize. For example, a relaxation of restrictive laws regarding the distribution and use of drugs would permit those contemplating rational or facilitated suicide to do so without involving their physician in potentially criminal activity. If suicide is not illegal, surely we can do away with laws proscribing the aiding and abetting of suicide; present laws dealing with homicide are sufficient to prevent abuse.
In the case of defective newborns, an environment in which the wishes of the parents are given priority would mean fewer newborns being placed automatically into neonatal ICU’s or subjected to “heroic” life-sustaining measures, without limiting the freedom and rights of those parents who wish everything possible be done to save their child.
The physician’s wish to follow the most ethically correct course of action must include a search for solutions which can modify the conflict situation giving rise to ethical dilemmas, as well as an active promotion of those solutions with which he finds himself in moral harmony.
As doctors and human beings, can we ethically do less?
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