September 1984 VI/1
MEDICAL ETHICS: WHERE DOES IT COME FROM?
Many individuals and professional organizations maintain that ethics committees must be formed in hospitals in order to help answer the questions arising from advanced technology and increased recognition of patients' rights. Even if the committees are confined to a role of educational activities and not given the power to make ethical decisions for others, as I proposed in a recent essay (May 1983), a practical question arises. What principles will the committee use when deliberating about ethical issues or when trying to formulate policy to be presented to the administration for approval? Drawing together ten people with ten different ethical perspectives might bring chaos rather than consensus. Is there a common understanding of medical ethics which will enable people on ethics committees to function cooperatively and intelligently in spite of different professions, backgrounds and religious persuasions?
Medical ethics arises from the relationship between a patient and a physician. The patient goes to a physician seeking health. Health in this sense is well-being of physiological and psychological functions. Health is of a great value for the patient, but not the only value. The patient has values which are associated with social or spiritual functions as well.
The physician enters the relationship promising to help the patient achieve health. This promise implies two presuppositions: (1) the physician will strive for competency in the field of medicine; and (2) the physician promises to respect, in addition to the value of health, the other values (social and spiritual) the patient might have. This latter presupposition arises from the fact that the physician respects the patient as a co-equal human being. Though the patient is subordinate or unequal to the physician in regard to medical skill and knowledge, the patient deserves respect as a person of equal worth insofar as the other values of life are concerned.
Often there will be no conflict between the health values and the social and spiritual values of the patient. In most circumstances patients look upon healing (a physiological or psychological value) as a necessary means for achieving other values in life (social and spiritual). Thus, in most cases, difficult ethical decisions will not be in question because there will be no need to choose between conflicting values. Rather, these routine cases call only for protection of the patient's basic rights as a human person, e.g., the right to be informed, the right to maintain one's reputation.
But in some cases there will be a conflict between maintaining and/or restoring health (achieving psychological or physiological values), and achieving social or spiritual values. For example, an aging patient suffering from terminal illness may decide that he or she would be better off spiritually if life-prolonging therapy were withdrawn and he or she would be allowed to die. Or a person might believe that divine law prohibits the use of blood transfusions even if life would be prolonged through their use. In cases of this nature the conflict must be settled by affording treatment which respects the values of the patient. The ethical basis for the patient's right to choose the type of treatment is the fact that as a human person the patient is equal to the physician. When entering the healing relationship the patient does not surrender personal responsibility for determining which values are more important in a given situation.
In like manner the physician does not surrender his or her value system when entering the healing relationship. Thus there may be difficult ethical decisions for physicians to make as well; e.g., Is it contrary to my value system to allow a patient to die when I know life could be prolonged? Should I operate on the person who refuses blood transfusion knowing there is increased danger of death? Hence the medical relationship seeks to achieve health, but does not posit health as the ultimate human value for patient or physician.
The goal of healing the patient in accord with his or her value system serves as the touchstone of ethical medical practice in particular and of health care in general. Of course, there are other factors that should be considered in medical and health care; for example, there are economic and societal factors which enter into the offering of medical and health care. These economic and social factors are especially prominent today as we hear about the importance of cost effectiveness, competition and reducing utilization of health care facilities. While these economic and social factors must be considered by the ethical physician or hospital administrator, they must never be allowed to dominate the practice of medical care or health care. If they do then a perversion of values occurs and physicians and other health care professionals betray the trust of patients and their own integrity, Resisting the pressure to make economic or societal factors the basis for decision making will be difficult for ethics committees as well as for physicians and other health care professionals (cf. Ethical Issues essay, March '84).
From the nature of the healing relationship and the presuppositions mentioned above, the general principle of medical ethics can be deduced. For example, in order to enable the patient to express his value system and to ensure he is treated as an equal, informed consent is required; informed consent gives rise to the principle of telling the truth on the part of health care professionals; because the reputation of the patient is a great value, the principle of confidentiality is posited; and forth.
While these and other principles of medical ethics are deduced from the nature of the relationship between physician and patient, they are not to be applied as though they were straitjackets determining every particular decision. In practice two patients may be treated differently because each might have a different value system. Thus medical ethics is not relativistic or circumstantial because it does have valid general principles. But it is flexible because these general principles must be applied to individual patients who have different needs and value systems. Facing death, one person might choose life prolonging therapy and another person might choose only pain relieving therapy.
Ethics committees can he helpful if the people serving on them have a common grasp of the nature of medical ethics. But judging from the literature on the subject, one gets the impression that ethics committees are often promoted as a means of defusing moral responsibility, or of avoiding malpractice litigation or of removing the anguish from difficult ethical decisions. There is no way to make difficult ethical decisions "easy." People serving on ethics committees would do well to ponder constantly the question: Medical Ethics, where does it come from?
Kevin O'Rourke, OP
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