September, 1979 I/1
Ethical Issues in Health Care
1. DO ETHICS AND MEDICINE MIX?
If medicine is the "science of applied biology" and ethics is the "science of applied values," what is the relationship between the two disciplines? At first glance, it might seem that each is autonomous because each is concerned with a different phase of human activity. Indeed, many practitioners of ethics or medicine seem to function with this mind set. If we consider the human person who is the "patient" of both medicine and ethics more closely, however, we see that there is an intimate relationship between the two sciences. The human person is not merely a biological being; rather, each person is a composite of interactive needs and drives. Along with biological needs and activities, we can discern psychological, ethical, and spiritual needs and activities. If a person is to be healthy, therefore (to function in an optimal manner), the professional who helps improve and foster human function at one level of human activity should at least be aware of the influence of other forms of human activity. It does not follow that the health care professional must be expert in ethics or vice versa insofar as the ethician is concerned. Ordinarily, it would not be the role of the health care professional to influence a person's value system, just as it would not be the role of the ethician to write prescriptions. But it does follow that the health care professional should acknowledge that some biological or psychological ills will be connected with ethical or spiritual difficulties and that ethicians must realize that the difficulty people have in discerning and applying values may be due to a physiological or a psychological dysfunction. Professionals from both sciences, then, should acknowledge the role that the other science plays in bringing about complete human health and have some knowledge of its purpose, method and goals.
Another reason for positing a relationship between ethics and medicine arises from the fact that there is a right way and a wrong way of performing any human activity. This is especially true if the activity in question may cause serious harm to other people, if it affects society, or if it involves personal integrity of the practitioner. In health care, some of the ethical norms for "right practice" are intrinsic to the science of medicine itself. That is, they do not depend upon the determination of the individual physician or nurse. "Do no harm" and "receive consent" would be examples of some principles intrinsic to the practice of health care. Principles of this nature arise from the fact that human beings have certain rights and needs that must be respected, especially when they are in need of help. Recently, some physicians are calling for a more explicit statement of these intrinsic principles (C. Chapman, NEJM, 9/20/79; T. Ballantine, ibid.) While this might be a step forward, it would not take away from the individual physician or nurse the responsibility of applying these principles with care and concern. In order to do that, some attention must be given to the meaning of the principles of ethics, how the application may vary from one person to another, and what to do when there is a conflict of principles. In other words, memorizing a list of rules, even if they are rules drawn from the intrinsic nature of a physician-patient relationship, will not ensure that the rules are applied with wisdom and tact.
2. "SEX CHANGE OPERATIONS ARE STOPPED AT HOSPITAL" (Globe-Democrat, 8/18/79).Baltimore, AP, "Johns Hopkins Hospital has stopped performing sex-change operations because its research failed to show the surgery improved the lives of transsexuals, hospital officials said. Dr. Jon Meyer stated that time apparently works as well as surgery in resolving personal feelings of conflicts brought on by transsexualism" (cf. Science, 9/21/79).
The Gender Identity Clinic (1966) at Johns Hopkins was the pioneer center for this type of surgery. In transsexual surgery, the patient's sexual organs are restructured to resemble the sexual organs of the other gender. However, a true change in sexual gender is not achieved. Because they had the courage to stop an unproductive practice, we must admire the personal integrity and sincere adherence to scientific protocol of the people at Johns Hopkins. But given the growing potential of medicine to change and manipulate the human body, an announcement of this nature prompts many ethical questions: What justification does medicine need in order to alter or modify the human body? Does the telelogy of the human body, the research project of the physician, or the desires of a particular patient determine what type of surgical or medical care is ethical? Before assuming that a particular form of surgery or therapy is beneficial, what prior testing should be demanded? What happens to the person who had sex change surgery and now realizes that he or she would be better off without it? Could their plight have been avoided? Would the requirements of HEW concerning protection of human subjects, which were not in effect when this type of surgery was introduced, prohibit the same type of procedure from being introduced today? Is the risk of harm that was suffered by patients (loss of sexual integrity) comparable to the good that might possibly be attained (greater ease with one's physical appearance)? Should this type of surgery be continued at other centers? If experimentation upon humans is not curative but only palliative, as Meyer describes this type of procedure (Meyer, Clinics in Plas. Surg., 1, 1974), does it give the right to modify human organs? Is the physiological good to be considered at the disposal of psychological need?
Admittedly, these are very serious and difficult questions and they penetrate to the very core of the science of medicine -- "what justifies intervention in the human person?". But they are questions that will not go away and they must be pondered by serious professionals in the field of health care as they contemplate their increased power to affect human nature.
Kevin O'Rourke OP
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