GESTIÓN EN SALUD PÚBLICA: BioEdge: ‘Medical ethics’ is ethics by, for and about medics, not common morality, says bioethicist

domingo, 15 de septiembre de 2019

BioEdge: ‘Medical ethics’ is ethics by, for and about medics, not common morality, says bioethicist

BioEdge: ‘Medical ethics’ is ethics by, for and about medics, not common morality, says bioethicist

Bioedge

‘Medical ethics’ is ethics by, for and about medics, not common morality, says bioethicist

by Michael Cook | 15 Sep 2019 |

The presence of the word “ethics” in “medical ethics” (and “bioethics”) suggests to the hoi polloi that the principles of the latter are derived from the former. Thus, ethical behaviour for doctors is the same as ethical behaviour for financiers or soldiers or social workers. Doctors do not work in isolation on their own ethical island.

This “common morality” is more or less the dominant paradigm in medical education today. As articulated by Beauchamp and Childress's Principles of Biomedical Ethics in 1979 and in subsequent editions, it assumes that there is a primitive, pre-theoretical insight which is shared by all morally serious persons. Applications of this to medicine are to be clarified with their famous four principles.

However, the fate of paradigms is to be broken. In an online article in the Journal of Medical Ethics and in a book to be published next year, Rosamond Rhodes, of the Icahn School of Medicine at Mount Sinai, New York, argues that medical ethics is its own domain, with its own laws. “A new theory of medical ethics is needed to replace common morality as the standard for understanding how medical professionals should behave and what medical professionalism entails,” she writes.

What makes this plausible is her observation that society grants doctors rights to do things that are uncivil or even criminal for normal people. They can ask probing questions; they can scold, lecture and hector; sometimes they can even kill people. They are also held to a more demanding standards of conduct in areas like confidentiality, making rational decisions, in being non-judgemental. Doctors are different.

She argues that the “the first and fundamental duty of medical ethics must be to seek trust and be deserving of it. The second duty of medical ethics constitutes medicine’s fiduciary responsibility, that medical professionals must use their medical knowledge, skills, powers and privileges for the benefit of patients and society.”

With these principles no one is likely to quarrel. But the conclusion she draws from these is bound to raise hackles in some quarters. “The ethics of medicine is internal to the profession: it is constructed by the profession and for the profession, and needs to be continually critiqued, revised and reaffirmed by the profession.”

It sounds as though medical ethics would eventually become a power game in which standards are determined by the spokespersons for professional bodies. But she admits that another project is needed “to articulate, explain and justify the specific duties and virtues that constitute medical ethics”.

Michael Cook is editor of BioEdge

Conscientious objection to procedures like abortion and euthanasia often features in BioEdge. There is a growing consensus that CO has no place in modern medicine. It’s often argued nowadays that a doctor’s duty is to carry out the wishes of patients, regardless of whether they agree with them or not.

I stumbled across an interesting hypothetical on the American Medical Association Journal of Ethics which makes me question this consensus. In it, three bioethicists analyse a situation involving a difficult patient with deep Christian convictions. He is refusing post-operative pain medication because he believes that he needs to suffer in order to atone for his life as an alcoholic. What should the physician do?

The bioethicists conclude that he should neither acquiesce nor refer the patient to another doctor who will acquiesce. Instead, the physician should “refuse to offer this course of action, regardless of the religious rationale for such a request”.

They go on to assert that “Indeed, as part of their professional commitment to the patient’s health, physicians have some obligation to respectfully challenge patients' refusals of medical care that the physician believes is needed. A sincere discussion—even a respectful debate—in no way denigrates [his] religious beliefs.”

Indeed, this makes good sense. But, viewed from another angle, the bioethicists are advising the physician to conscientiously object to a course of action determined by a lucid patient after serious consideration. They even counsel him to argue (respectfully) with the patient to convince him that he is wrong.

If this is so obviously the case, why is it wrong for a doctor to refuse to perform an abortion? I’m having trouble reconciling the ethical reasoning of the two situations. Can anyone help?