The Linacre Quarterly

Volume 43 | Number 4 Article 9

November 1976 Progress in Medical Ethics: How the Ethicist Can Help Paul F. Camenisch

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Recommended Citation Camenisch, Paul F. (1976) "Progress in Medical Ethics: How the Ethicist Can Help," The Linacre Quarterly: Vol. 43: No. 4, Article 9. Available at: http://epublications.marquette.edu/lnq/vol43/iss4/9 Progress in Medical Ethics: How the Ethicist Can Help Paul F. Comenisch, Ph.D.

In this article Dr. Camenisch (not just physicians) and the presents a plea for mutual under­ professional ethicists. standing between ethicists and Territoriality medical professionals. He is As­ The ethicist is often perceived sociate Professor of R eligious by the medlcal professional as an Studies at DePaul University and invader, a usurper who seeks to is a post-doctoral FellollJ at the bring under his own aegis terri· Texas Institute 0/ Religion. tory - problems, decisions, pre· rogatives - which has until now There would be some justice or belonged indisputably to the at least symmetry in the com­ medical profession. Thus resent· panion piece to Dr. Lisson's ar­ ment and resistance are often ticle being authored by a physi­ visited on the ethicist who seems cian. And in onc sense Charles B. bent on upsetting the status quo Moore has already done this.! or at least on further disturbing But there are also advantages to troubled waters by raising addi· critical reflections and gentle rep­ tional doubts in the minds of peo· rimands originating from within pie already uncertain about the the fraternity being addressed. quality of current medical care, We ethicists, often with the very the truly human benefits of cer· best of intentions, sometimes cre­ t a i n technologically advanced ate our own obstacles by our medical procedures, t he justice of mode of entry into medical areas having to spend so much money and by some of our unexamined in the attempt to preserve their working assumptions. We also life and health. often permit existing obstacles to The first and most obvious way stand by, fai ling to clarify the to defuse some of this resentment nature of the ethical task. Being and resistance at being "invaded" aware of these troublesome ele· is for the ethicist to state as ments and exorcizing them where clearly as possible that the ethical possible should facilitate progress issues being raised are not iden­ in medical ethics, especiaJl y at tical with questions of the per­ those points where such progress sonal ethics - honor, integrity, hinges on an adequate under· etc. - of the medical profession­ standing of the nature of ethics al. But this is not a simple issue, or on good will between the medi · and those ethicists who simply cal professionals and institutions toss off this distinction as a pan-

November, 1976 269 acea for all such unhappiness the which most often serve only to medical professional feels have obscure the real issues when they simply missed the complexity of do become the focus of aUention. this issue. A more significant response to There is not space here to ex­ the medical profession's inclina­ plore the various levels on which tion to defend its "territory," the questions being raised in however, is to suggest that so medical ethics might relate to the long as ethicists are raising the moral/ethical integrity and sen­ right issues, the territory which sitivity of the medical profession­ would appear to be in dispute be­ al. But most ethicists, being tween the medical and the ethi­ teachers, can perhaps grasp some­ cal professionals in fact belongs thing of what medical personnel to neither of them. The territory under ethical scrutiny feel if they ---ethical questions about various imagine themselves in an analo­ areas of medical practice such as gous situation. How would we re­ whether some medical procedures spond to being accused of engag­ should be used at all, whether ing in practices, of employing in­ some medical research should go structional methods, of partici­ forward, and if so, under what cir­ pating in a system wh ich, in spite cumstances ,etc. - belongs either of our own personal integrity, in­ to the patient/ subject involved jure, even brutalize and dehu­ or to the public at large. [n the manize our students? (Many of first case, for example, the ques­ us, of course, were accused of pre­ tion of whether to elect radica l cisely this by black groups several and grossly disfiguring surgery to years ago when they aUacked combat cancer or to die probably the " institutionalized racism" of sooner but "intact" is the pa­ much of formal education.) In tient's question. not the doctor's such a situat.ion it is some com­ or the ethicist's. And the question fort, but not reall y enough, to be of whether proxy consent should told that one's personal morality be invoked to permit non-thera­ is not under attack. Such assur­ peutic research on children is a ances declare us innocent of the question of social policy requiring more obvious, the grosser viola­ a decision from society at large, tions. But they still imply that we however difficult that is to obtain have been party to other wrongs or to interpret. (This last state­ which we were not perceplive ment does not mean that morality enough to detect. And that is no is a question of majority vote, but compliment. only that neither doctor nor ethi­ Here the I;!th icist can only try cist can relieve society of the re­ to make sure that medical pro­ sponsibility to shape its own poli­ fessionals do not read into his cy. its own moral character in analysis, his questions and sug­ such matters.) Thus these mat­ gestions, personal accusations ters do not constitute territory to which need not be there and be awarded as a prize for excel-

270 Linacre Quarterly lence in disputation to either probings, their suggested resolu­ medical or philosophical doctor. tions should be no more, and no Both may and should make their less, than a responsible attempt own contribution to the discus­ to help the medical profession sion to aid the patient or the pub­ bear this heavy load. For exam­ lic in arriving at an informed and ple, the ethicist discussing in­ critical conclusion. But the ques­ formed consent with research tions, the territory itself, are not physicians should not be defend­ theirs to dispose of between them. ing some vested interest of his At most the professions deal own which must be mapped out with such matters as with a trust. and protected against medical The medical profession does not personnel. He should rather be own the human goods it is de­ offering the analyses, the insights signed to provide. These goods - of ethics to the researchers as health, long life, and the sci­ possible aids in their struggle to entific-technological a d van c e s discover precisely what society which are meant to contribute to has entrusted them with in this them-are not possessions which area and how it can be most re­ the profession is free to dispense sponsibly dealt with. or withhold at its own discretion.2 Clearly the ethicist ca n not These goods are public trusts stand in the physician's place which are most extensively dealt and decide when to operate, when with by the medical profession to resuscitate, or how to weigh simply because it has been en ­ the cost/ benefits of a particular trusted by society with what are therapy. But serious ethical re­ currently seen as the best means flection does aim at reducing the for securing and maintaining need at such points for medical them. personnel to draw only on their When me d i c a J professionals own past experience and their and institutions realize that these own hurried reflections. If the goods are public trusts, then the ethicist can lighten that burden, entrance of qualified and sensi­ it is not because of his own tive ethicists into the ethical dis­ moral/ethical superiori ty but be­ cussions which those goods gen­ cause of the traditions of sub­ erate should be met not with re­ stantive values and commitments, sistance and resentment, but with of critical analysis, and on rare relief. To those aware of their occasion the societal consensus own fallibility (humanity?) it he can make available to help in­ should be an awesome thing to form the decisions of the medical hold life and death, health/ professional. On this construction wholeness and their opposites in of the situation in medical ethics one's hands. And if ethicists can the ethicist is seen not as an in­ achieve the impartiality, the per­ vader of medical territory but po­ sonal disinterestedness they as­ tentially as one embodiment of pire to, then their analysis, their society's willingness to help the

November, 1976 271 medical professional bear the swers which are also in appropri­ ethical, decisional burdens at­ ate. Such religious insights are taching to the goods he has been thought inappropriate because entrusted with. The mystery here they are perceived as deriving is why anyone bearing such bur­ from the values and commitments dens would shun any responsible of a limited group - a particular attempt to share and thereby to religious community - and as lighten that load. resting on some esoteric base The Nature of Ethics such as revelation or church au­ Part of the physician's feeling thority rather than on "reason." of being invaded by "aliens" de­ There are several important rives no doubt from his correct misconceptions in this response perception that ethicists are rais­ to the ethicist. First. ethicists do ing questions quite different in not bring the ethical issues into kind from those the scientifically medicine - they are already trained physician ordinarily deals there. Wherever situations re­ with. There are several ways of quire a decision between compet­ characterizing this difference but ing human goods, there are ethi­ here it need only be said that the cal choices being made. We might doctor's questions are usually sci ­ refuse to recognize them as such entific on some significant level and pretend that they can be an· - that is, they deal with empi ri ­ swered on some "purely scien­ cal data. are usually thought to tific" basis. But that is a dan­ have objective answers that can gerous illusion because it permits be arrived at by agreed upon us to keep submerged and unex· procedures, answers which can be amined the ethical grounds we verified, which are the same for are operating on. The ethicist all competent investigators, etc. simply makes the ethical issues The ethicist's questions, on the already present in medicine ex­ other hand, are "soHer" in sev­ plicit as ethical issues and chal­ eral respects. They seem to be lenges the profession to confront answerable only on the basis of them directly and critically rath· personal or group preference and er than pretending that they are taste, commitments and values, not there. all of which are beyond proof. Secondly. the ethicist should And since many practitioners still make clear that while it is true see their fie ld on a strictly sci­ that ethical questions are quite entifi c model, they sometimes re­ "unscientific," this is no grounds sent even having this sort of issue for eschewin g ethics and trying in troduced into it. In some circles to practice some sort of "value· such resentment is at its height free" medicine. ("Value-free" against theological or religious medicine would at best be medi· ethicists who are seen not only cine in which the values were per­ as raising inappropriate questions mitted to remain implicit.) Rath­ but as offering insights and an- er, this realization that ethical

272 Linacre Quarterly analyses and claims rest not on as such. some sort of factual or logical Thus the question is not proof, but ultimately on human whether ethical decisions will be choice, commitment, on values made in medicine, but whether aflinned and goods pursued, they will be faced as ethical and should be noted and highlighted confronted openly and critically. not as the death of ethics but as And if the latter question is an­ a crucial insight into the nature swered affirmatively, the next of ethics - and in fact in to much question is not whether we will of human li fe. The fact which respond to them on the basis of must be faced by medical profes­ some specific group's convictions sionals and all scientifically and values, but rather which trained experts who might be groups and/ or individuals will be tempted to take retuge behind permitted to offer their commit­ their expertise is that they have ments and values as possible been and will be making this kind starting points for ethical delib­ of choice on this kind of ground, eration. Open acknowledgment and that such choices - at least and careful elaboration of these where they impinge on the well­ points about the nature of all being of others - must now be ethical reflection will aid progress made the subject of public dis­ in medical ethics by making clear cussion. the sort of task we are engaged in. Finally, if the above assertions Constituency about the nature of ethics and the All too often ethicists seem to grounds of ethical decision mak­ cast themselves in the role of de­ ing are correct, then theological fender of the public interest ethicists must boldly respond to against the harm done by self­ those who accuse us of speaking seeking and/ or morally insensi­ from a limited base of commit­ tive and/ or et hicall y inept ments and convictions while other medical professionals. While this ethicists presumably speak from assigning of roles is often only some broader, even universal tacit, the medical partners in the base. We must insist that all nor­ discussion are alert to it and are mative ethics finally rest on con­ rightfully resentful of the various viction, that every et hic is a " be­ ways in which it shapes the dis­ lievers' ethic." That is, that ul ti­ cussion. Such an assigning of roles mately it speaks only for and to is unfair and inaccurate on sev­ those who share its convictional eral counts. First, the ethicist base. Religious ethics is unique rarely succeeds in being a per­ here only in that it publicly pro­ sonally disinterested, entirely claims its base. Other ethicists, in "objective" champion of the pub­ making no such public declara­ lic good. We too have our vested tions, create the illusion of having interests. Ours are perhaps less nothing to declare. But that is obvious and are surely less re­ an illusion and should be exposed warding financially than those

November, 1976 273 the medical professionals are of­ "We have come to speak fo r those ten accused of; but they are you serve but whom you do not equally capable of distorting our hear - they have sent us - we analysis and our arguments. Who speak with their voice!" When among us would not like to be either ethical or medical profes­ acclaimed as a giant-killer, or at sionals assume this role, they least as a fu ll professor on the engage in an unbecoming pater­ basis of having tweaked the nalism which is a discredit to giant's beard? And what more themselves and a disservice to lik ely candidate is there for the the public. role of Goliath today than the medical network? Strategically it is unwise of ethicists even to raise this ques­ Secondly, this assigning of roles tion of the constituency we speak is unfair since the medical pro­ for since the medical professional fessional is seldom as devoid of can easily put us to shame on this the worthier motivations - com­ count. The public at least knows passion, a sense of public service, who the medical professionals are etc. - as the critic often suggests and what they do. And in the he or she is. This is so obvious continuing insistent demand for that it needs no elaboration here. their services the public continues to give them something very like But perhaps the most signifi­ a vote of confidence. It may be a cant misrepresentation in this grudging vote qualified by con­ view of the ethicist's role is the cern over the cos t and quality of assumption that he speaks for the care, and even by the ill -defined public. On the basis of the pre­ wish that some alternative were sumed pu ri ty of our motives and available. But so long as the over­ the intensity of our dedication to whelming majority of the people defending the public good, we of­ turn to medical professio nals in ten declaim and exhort as though their search for health, long life we were the officially appointed and deliverance from suffering, spokesmen for the voiceless the medical network has an im­ masses - as though they them­ pressive constituency for which it selves had sent us in to the fray can in some limi ted ca pacity as their last, best hope. But clear­ speak. Thus ethicists must not ly we have no such constituency. draw battlelines which put them­ We have received no such man­ selves and the public on one side date, no such vote of confidence. and the medical professionals and We do not speak for the masses institutions on the other. except in the limited sense of urg­ ing courses of action which we The temptation which lies in see as serving their best interests. wait here fo r the ethicist is a sub­ Thus it is presumptuous of us to tle but dangerous one. I recently conduct ourselves in ways which attempted to survey the physi­ seem to say to the medical fie ld, cian examining and licensing

274 Linacre Quarterly boards in the country's fifty-one Expectations jurisdictions concerning the ethi­ I have already suggested that cal dimensions and implications the ethicist ca n be too much re­ of physician licensing. At my last sisted and resented. But it is also coun t only sixteen of them had possible on the basis of exagger­ responded. I was originally in­ ated expectations for him to be dignant at the arrogance of these too much welcomed. Some moral­ boards to which the public has ly concerned physicians apparent­ entrusted such great res ponsi­ ly feel they have been deserted bility and granted such great by the public to bear their bur­ privilege in denyin g to the public dens alone. In conversations with insight into how they perceive such persons I have sometimes and carry out their public trust. had the disq uieting feeling that The fallacy here, of course, is they expected more than I could that in requesting such informa­ in good conscience deliver, that tion I was in no real sense acting they hoped for answers which as a representa tive of the public. would once nnd for all set their Denyin g the reques ted informa­ minds at ease. Of course some tion and in terpreta tions to me ethical traditions do provide just could not simply be equated with such clear and unambiguous an­ denying it to the public. And in swers. One of the most familiar pretending that it could I wa .. examples here is the official Ro­ assuming an office to which I had man Cathol ic teaching on ma tters no legitimate claim. I am still in­ such as direct abortion and mercy clined to be indignant over the killing. Ethicists working out of mat.ter. And on the basis of some such traditions should offer such of the boards' past records I sus­ anwers with conviction and with­ pect that some arrogance was at out apology. And those of us who work along with other morc legi­ do not stand in such tradition" ti mate and practical reasons for should know them well enough to not responding to the question­ insure them a fair and informed naire. Bu t any such indignation 1 hearing from l-Iy mpathizer and feel cannot be predica ted on an critic alike. But the fact is that affron t to the public which did not for reasons too numerous and too in fact. occur. If there is arrogance complex to explore here most in the boards' denial of the in­ ethicists do not feel that they can provide "answers" in this formation, nothing is t. o be ga ined sense. They rather approach the by matching it wi th my own ar­ questions 'of medical ethics as rogance. The boards have no right fellow-seekers with the medical to withhold such informa tion professional, offering tools which from the public when it has been they hope will help in their com­ duly requested. But I have not. mon pursuit of resolutions to in­ been commissioned by the publ k f;o luble human dilemmas. But ~o to request it. they do not come wi th catalogues

November, 19 76 275 of ready answers. For those of us sense in the world the doctor operating from this perspective sees. Any opposition to it must we must first see that we do not therefore reflect the respect we ourselves cultivate any such un· should always feel in the presence realistic expectations. Secondly of a conscientiously choosing we must take note of them where moral agent. Of course, we might they do exist and firmly disclaim in this case feel that t his choice them. Being publicly referred to favors the most immediate, the as an "expert in ethics" is so most empiricnl and possibly the unnerving precisely because it most superficial of the competing bespeaks such an "answer man" goods. But it is nevertheless a understanding of what we are good chosen and not an evil em· about. braced, and the choice and the Competing Goods chooser should not be morally In the heat of moral debate it disqualified or excoriated because is salutary to keep in mind that it is a choice we happen nol to in virtually all ethical dilemmas agree with. there are competing goods all of It is particularly distressing which we cannot sim ultaneously when ethicists let a single and maximize. (That, in one import· often rather limited moral issue ant sense, is what makes it an disproportionately s h a p e their ethical dilemma.) Consequently response to medical professionals we must choose which among and ignore the fact that many these competing goods or values such proressionals appropriately will be given priority. In addition perceive their entire professional _ and here is the crux of the identity and involvement as a matter - we must remember moral undertaking. To ignore this that this choice is one about latter much larger moral reality which persons of good will may because the medical professional in conscience disagree. For ex­ is not alert to the latest "hot" is­ ample, the research physician sue in medical ethics is a serious who chooses the future benefits injustice. For example, it is dis­ wh ich may result from non·thera· tressing on one level to see medi· peutic research on a child over cal professionals SO vcry disturbed the absolute inviolability of his over malpractice insurance costs her privacy, bodily integrity, etc., (especially when it is not accom· is not thereby revealed to be a panied by equal concern over ghoul choosing the darkest of sky·rocl{eting patien ts' medical evils over a self-evidently over· costs), and in some instances to whelming good. The physician see their practice of medicine so has chosen one good from among significantly guided by their de· the various goods available. Not sire to avoid malpractice suits. all of us will agree with that This is disturbing primarily be· choice. But we should at least be cause such facts suggest that the able to see how that choice makes medical professional has traded

276 Linacre Quarterly in the traditional professional immediately following Watergate dedication to serving the public would conform to this pattern. for the less edifying selF-serving But such an assumption would quest for economic gain. But we not be fair in the case of medical must also recognize that such ethics. The amount of attention concern might reflect the profes­ being given medicaJ ethics cur­ sionals' awareness that the mal­ rently is disproportionate on sev­ practice issue is threatening seri­ eral counts. It does not reflect an ously to disrupt the only system alarming disintegration of ethics we currently have by which they and morals in medicine either in can deliver to the public essential some absolute sense or in com­ services they feel morally com­ parison to other professional! IDitted t.o making available. The occupational groups. Nor is it malpractice situation is therefore proportional to the amoun t of seen as a threat to their ability to harm the public suffers at the make good their entire profes­ hands of medical personnel and sional-moral commitment. Ad­ institutions which the ethicist mittedly this interpretation of wants to reduce through his in­ the profession's response to the volvement there. Surely other malpractice situation is too ideal­ sectors of society such as the eco­ istic to fit with the public's cur­ nomic, the legal and the poli tical rent assessment of the medical inflict as much harm on the pub­ network as a whole. But this fact lic as does t.he medical. alone gives us no real grounds for Medical ethics has attained the dismissing it, and therefore no prominence it has not primarily grounds for ignoring it and simi­ for any such negative reasons lar more inclusive moral commit­ which would reflect discredit on ments in any fai r response to the the medical profession , but rath­ medical profession. er because of the coincidence of Origins of the Present Situation a variety of positive influences. It is not always flattering to be Most. obvious among these are the in the spotlight. The maintenance impressive scientific-technological of good will with medical person­ advances made in medicine in t.he nel and institutions requires that last two decades which presented we keep clearly in mind the vari­ vast new possibilities for doing ous influences which have put both good and harm. These pos­ medicine in the ethical spotlight. sibilities frequently arose in ethi­ Tn most cases it is reasonable to cally uncharted waters and there­ assume that a Cocus on the ethics fore pressed the medical profes­ of a group or field follows a gen­ sionals themselves, as well as the eral agreement that those ethics public and the ethicists, to sub­ have fallen to a conspicuously low ject them to careful moral ex­ level. The widespread but appar­ amination. ently short-lived concern with the A second major influence was ethics of politicians and attorneys the willingness of various sources,

November, 1976 277 mostly private, to fund investiga­ money-and-status-pursuing vice­ tion into medical ethical issues. president of General Motors is no This willingness arose in part cause for public scandal. A doc­ from the developments just men­ tor operating on similar criteria is tioned, but also in part from a more disconcerting, but is ground continuing concern about medical neither for condemning the pro­ issues of longer standing. And fi­ fession as a whole nor for reading naliy, medical ethics has pros­ the individual involved out of the pered because of the willingness human race. of many within the medical pro­ Remembering Who We Are fessions and institutions to enter One last suggestion aims as into discussions, to host confer­ much at benefitting the ethicist ences, and in other ways to foster himself as at cultivating good will and participate in such inquiry. between him and the medical pro­ Thus it behooves all of us to re­ fessional. It might, however, con­ member tha t while being in the tribute to this latter goal as well spotlight is not always a flatter­ by making clear what kinds of ing or pleasant experience, the credentials can rightly be reo simple fact that medical ethics is quired of the medical ethicist. As currently there is in itself no neg­ I understand ethics and there­ ative comment on the moralf after medical ethics, an ethicist ethical state of the medical field . working in medical issues - We should also be aware of the whatever title he carries - must almost universal tendency to blow be an ethicist before he can he a out of proportion those instances medical ethicist. And the former of moral failing - greed, decep­ remains his prior, his more basic tion, self-seeking - we some­ identity even after he has be­ times find among medical profes­ come a "medical" ethicist. sionals and institutions. This is Whether we "do" our ethics out an understandable reaction to of theological, philosophical, be­ such shortcomings in a profes­ havioral scientific or some other sional group when the aspirations starting points, our identity as and claims of that group and the ethicists is a necessary prerequi. public's expectations of it are so site to doing medical ethics. high. Such wide disparity be­ This conviction has several tween the ideal sought and the grounds and several implications. actual perfonnance observed does The implications are of more in­ perhaps warrant some indigna­ terest here. Fi rst, it means that tion. But such a response should however deeply we get involved in not blind us to the fact that such medical ethics we cannot afford failings seldom fall below what is to let our roots in critical ethics, publicly admitted to by, and even wherever they are sunk, wither expected of, most other gainfully and die. If that happens we have employed persons in the econo­ nothing to offer in the medical my. An ambitious power-seeking, or any other area but intuitive

278 Linacre Quarterly ad hoc suggestions. Secondly, it virtue which every agent must ex­ means that we need not be medi­ ercise for himself. We ca nnot as­ cal experts in order to do medical sume that when we as professional ethics. We need not "read all the ethicists are not on the "cutting literature." The medical people edge" of medical advances, there with whom we converse must is no one there to deal with the keep up with their lield. And we ethical implications. need to be " up" enough to be able The above items, kept firmly in to join in their conversation with­ mind and said aloud when others out bringing it to a dead halt by overlook them, can contribute to continual requests for elementary progress in medical ethics. Where information. But unless we have the above seems too harsh on paraded ourselves as medical ex­ ethicists it should be taken as a perts we have no need to be such personal confession of this ethi­ in order to do medical ethics. The feeling that we must be informed cist and not as a rebuke aimed on every breaking medical story at medical ethicists in general. rests on the assumptions that ev­ Where it seems too gentle on the ery medical advance raises new medical professionals and institu­ ethical problems, and that only tions it should be taken no t as a we ca n solve those problems. rejection of needed critical and Both assumptions are false. Most sometimes divisive moral analysis medical advances offer new oc­ of the difficult problems in medi­ casions for bringing to bea r long cal practice, but as a plea for established values. commitments mutual understanding between or principles, but seldom do they ethicists and medical profession­ raise totally new issues. Heart als as well-intentioned fellow transplants, while radically new seekers of the good. I t is hoped technically, were humanly and that such an understanding will morally s UII about the value of make it possible for ethical de­ life, respect for life, respect for bate to center on the crucial the dying, etc., values which have substantive issues facing us in helped shape moral reflection for medicine rather than on the per­ millenia. The second assumption sonal failings of which we all have is also fal se. We need not, in fact our share. we cannot without preempting the moral agency of the medical REFERENCES personnel and the patient/ suh­ I. Moore. Charles B" "This is Medi­ cal Ethics?" The Hustings Center Re­ jects involved, make the applica­ port 4 (Nov.. 1974) . 1-3. tions of the principles or values 2. See B. 8. Page, "Who Owns the in every case. Such applications Professions?" The Hasting. Center lie in the realm of prudence, a Report 5 (DeL, t975). 7-8.

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