Different River

”You can never step in the same river twice.” –Heraclitus

March 22, 2005

Medical “Ethics”

Filed under: — Different River @ 8:34 pm

I’ve always been puzzled by the notion that medical doctors have some special expertise when it comes to making ethical decisions. Doctors are trained, licensed, and chosen for their knowledge of a body technical information and various related skills — how the human body works under various conditions, how diseases can impact it, what types of information are needed to diagnose diseases, and what procedures, devices and drugs can be used to treat diseases and improve body functions. The human body is extremely complex; this is indeed an impressive body of information and skills that must be acquired. To acquire these skills requires lots of hard work and considerable intelligence, not to mention physical endurance (given the hours of medical residencies).

However, it does not require any particular level of ethical wisdom or insight. Being an ethically good person will not guarantee an easy path through medical school, residency, and board exams — nor will being an evil person make it any harder. In short, there is no reason to believe that the average physician is any more or less ethical than the average electrician. You would not dream of asking your average electrician what you should watch on TV just because he knows all about the voltage and amperage required to operate your TV — yet some people think we should defer doctors, or committees of doctors, on questions of who should live and who should die, just because they (sometimes) know how to make either one happen.

Over their four years in medical school, medical students take a course or two in something called “medical ethics” or sometimes “bioethics.” The term seems to imply, “ethical issues that arise in medical situations,” which would imply that it’s a subset of ethics, not medicine. Viewed this way — i.e., correctly — it involves taking some agreed-upon ethical system and applying that system’s principles to questions that arise in a medical context. The agreed-upon ethical system could be a religion, or perhaps some secular substitute for religion, say, a list of agreed principles of right and wrong. But most medical schools take students from a variety of backgrounds, with a variety of religious and non-religious outlooks, without regard to their ethical values (as long as they don’t get caught cheating on their MCATs or undergraduate exams). Medical students may be religious or secular, Catholic, Protestant, Jewish, Muslim, Hindu, atheist or indifferent; they may have highly developed notions of right and wrong, or they may thing “right” is whatever you can get away with.

In short, there is basically no way to teach a medical ethics class in medical school that is actually about medical ethics, since you can’t count on the students agreeing on the ethics.
But they have to teach the class anyway, since “everyone knows” doctors are supposed to be ethical. And they have the course taught by doctors, which implies that it’s a subset of medicine independent of anyone’s religious or secular ethical systems, or by “bioethicists,” which implies it’s a subject unto itself, based on neither morality nor medicine.

They do of course have a list of basic principles, but the list is implicit, since if they listed them the vast majority of the public — and probably the medical students — would not accept them. They basically agree that it’s OK to allow the very young (newborns or fetus) or the very old to die if treatment will be difficult, expensive, or have a probability of success below some unstated threshold. They agree that life with physical or mental handicaps is not as worth living as life without them — and thus, an otherwise healthy person takes precedence over a person who is physically or (especially) mentally handicapped in some way. And, above all, they agree that it is the doctor’s job to convince the patient and/or family members to go along with the recommended decision, notwithstanding any moral, religious, or personal beliefs that patient or family might have. And they agree that the general public ought to defer to doctors on these issues.

Obviously, not every doctor believes all those things — in fact, I suspect most don’t. But most of the ones who teach or write about medical ethics do.

Yesterday, the California Medical Association passed an “emergency resolution” condemning Congress for intervening in the Schiavo case. The Association’s 1,000-member “House of Delegates” happened to be having its annual convention March 19-21, and passed it on a voice vote, with only one member objecting. (Was that one immediately deprived of his lunch ticket? Just kidding…)

And today, the New England Journal of Medicine put two articles on “early release” on its web site (they will appear in the April 21 issue). They purport to take a balanced view on the issue. The represent “two opinions” — the opinion that Terri’s feeding should be removed, and the opinion that Terri’s feeding should not be continued. In short, they’re almost as unbiased as Dan Rather.

It’s only a matter of time until “DNR” (“Do Not Resucitate”) becomes required for everybody. In fact, it might not even be a matter of time — it may already be the case.

About a year ago, I went to a hospital for a simple outpatient surgical procedure (removal of a ganglion cyst from my wrist. When I checked in, I was asked to sign a DNR order. Correction: I was not exactly asked. I was given a stack of papers and told to sign all of them. One of them was a DNR order. I am the pedantic type, who doesn’t like to sign anything without reading it. So, much to the admitting clerk’s annoyance, I kept her waiting while I flipped through all the documents and read the ones I didn’t recognize. When I got to the DNR order, I said I didn’t want to sign it. She said I had to sign everything. I asked if I had to have a DNR order to get the surgery. She said no — but that I had to sign the form anyway. So, I crossed out all the paragraphs authorizing them the withhold treatment and so on, wrote “SAVE ME AT ALL COSTS” in capital letters, and signed under that sentence rather than on the signature line.

Two questions:

  1. How many patients sign those forms without bothering to read them, thus authorizing DNR and withholding of medical treatment without even knowing it? I’ll bet it’s almost all of them, since most people don’t read what they sign, and the annoyance of the clerk at the delay clearly indicated she wasn’t used to people reading them.
  2. Given that they get “everybody” to sign these things, what are the chances that, if a situation had come up, they would bother to check the file for my form to make sure I’d signed it, discover I didn’t want a DNR, and decide to abide by my wishes — all in the four minutes it takes for brain damage to set in? I doubt it — everyone in a hospital is busy, and they don’t have time to even check to see if you have a special request. So, they treat you like you have a DNR, even if you explicitly asked for the opposite.

One Response to “Medical “Ethics””

  1. Lauren Day Says:

    This is a great blog and this was one of your best posts. The Terri Schiavo case is such an indictment of the insanity of our judicial system. And, where are the feminists in defense of Terri’s life? The fact the death row inmates and animals have more rights than a disabled woman just appalls me.

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