The Scylla and Charybdis of Medical Ethics

[[{"type":"media","view_mode":"media_crop","fid":"28346","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5725017213262","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2861","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"132","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; float: right;","title":"Paul Burcher, MD, PhD","typeof":"foaf:Image"}}]]I was at a conference last week in medical ethics, and I was surprised by, or perhaps appalled at, the attitude displayed by many of the philosophers regarding the importance of medical knowledge in medical ethical decision making. Several of them proudly announced a total ignorance of the medical issue they were speaking on, and also showed no interest in what I would call “real world” implications of their conclusions.

Although I have a PhD in philosophy, I am not a philosopher in the sense that I am capable of, or interested in, spinning arguments from “thin air” with no grounding in medical facts and no implications for real medical practice. Medical ethics must begin in real-life issues and problems and end with equally real and meaningful conclusions that can be applied-and sometimes even empirically tested.

This is not to say that philosophers cannot make good, or even great, medical/clinical ethicists. But they need to begin with a healthy respect for the way in which the “facts on the ground” inform the ethical decision-making. A brief example illustrates my point. In Hilde Lindemann Nelson’s famous article explaining narrative ethics, she discusses the case of Carlos and Consuela.¹

Carlos is an HIV-positive gang member wounded in gang violence and recovering from his injuries in a hospital. He is now ready for discharge but needs dressing changes at home. He wants his sister Consuela to do the dressing changes, but he insists that she not be told about his HIV status. While Lindemann Nelson uses this case to make several excellent points about the limitations of principle-based ethics, one aspect of the question, crucial to any ethical reasoning on the case, is (obviously) the transmissibility of HIV infection through dressing changes. This “fact” is an essential aspect that underpins any ethical judgment regarding the case. The conflict between patient confidentiality and duty of nonmaleficence (toward Consuela) pivots in part on the fact that HIV is not readily contagious, and simple universal precautions should make the risk to Consuela essentially nil.

But if it is problematic when philosophers inveigh on issues of medical ethics without a proper respect for the way medicine itself has something to say to ethics, equally frustrating are physicians who think that ethics is just “opinions” or that the principle of patient autonomy is the only thing that decides all questions of medical ethics.

Physicians sometimes use a simplistic unnuanced version of principalism that places patient autonomy hierarchically over other principles of bioethics. This absolute support of patient autonomy is ethically unjustified and often disingenuous in that when physicians claim they cannot overrule a patient’s choice no matter how ill advised or potentially dangerous this choice may be, it often also serves the physician interest as well.

For example, in my specialty, this argument is sometimes invoked when a physician is justifying a hysterectomy that doesn’t meet accepted medical indications or when a physician does a cesarean delivery on patient request. In both cases, the patient and physician interests align, and the physician is justifying his or her decision by claiming to respect patient autonomy while conveniently forgetting that the principles of beneficence and nonmaleficence may also have something to say in these cases.

The questions of medical ethics are wide-ranging, and they require attention to both the medical details and the ethically relevant principles. Being a good ethicist, and being a good clinician, requires sailing between the six-headed monster and the whirlpool (Scylla and Charybdis). There is a successful path between, but it entails attention to both medical facts and ethical theories.

References:

Nelson HL. Context: backward, sideways, and forward. HEC Forum. 1999;11:16-26.