Ethical Practice in Clinical Medicine

William J. Ellos S.J.

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415050708
• eBook ISBN:
  9781134942305
• Topic: Medicine
• Subtopic: Ethics & Moral Philosophy

Increasingly, medical students are required to face up to ethical issues in their training and practice. At the same time, there is growing interest in philosophy courses in the ethical issues raised by medical practice. This textbook, designed primarily for students of medicine, develops the issues to a philosophical level complex enough to be satisfying to students of philosophy as well as MA students on applied ethics courses. The author advocates an approach to medical ethics which breaks out of the straitjacket of the narrow choice between utilitarian or deontological theory, and contains a valuable discussion of practical wisdom. It maintains a balance between case studies and philosophical arguments - which are developed in a historical context, and will be of interest at all levels of the medical profession.

1

THE PLATONIC FOUNDATION

While often presented as the ultimate philosophical idealist, Plato can better be understood as a rather thorough pragmatist. This is so for two reasons. The dialog form in which he always wrote was actually a way of dealing with a single or set of problematic questions by working through them. Seldom is a conclusion clear and lasting. Rather there is always the need to develop more clarity on the subject. Also, along with this pragmatic approach in each dialog, there is a more general pattern to all of the dialogs. The earlier dialogs are shorter and more incomplete, the later longer and more finished. The central dialog is really a collection often dialogs called The Republic. In these ten dialogs is the statement of the most absolute idealism in Plato. Our knowledge is to be somehow reaching the ultimate form or idea of truth itself. Our actions should strive to attain goodness itself. But while the earlier dialogs lead upward to this idealistic presentation, the later dialogs lead on downward to the complexities and details of everyday life. The whole sweep of the Platonic enterprise is not to reach some never changing set of answers to ethical questions, but rather to provide an idealistic frame in which to deal precisely with individual questions.

One of the most famous of the early Platonic dialogs is certainly the Phaedo. Here Socrates presents arguments why death is not to be feared. There is an early noting of the role of virtue. Ordinary people have the virtue of courage in the face of death because they are motivated by fear or dread. Also people who are temperate and restrained in their actions may be so because of a balancing of pleasures and pains. However, only the philosopher practices courage or temperance because of a knowledge of the workings of these virtues. Wisdom makes possible courage, self-control and integrity. This wisdom is a kind of moral purgation from lower and more base motives.¹ This is clearly a form of moral development ethics.

This need to be reflectively aware of the reasons for the development and practice of virtue is developed almost humorously in another early dialog, the Laches. Two distinguished generals, Laches and Nicias, remark on the bravery which they have seen Socrates practice in the field. All three are strong practitioners of courage, but none of them is able to define or explain courage at all. They make an interesting advance in methodology, however, in that they recognize that while it is impossible to understand courage as such, they might be able to understand specific instances of courage. Each time a specific instance of courage is studied, there is a realization that no specific instance will explain courage in general.² Tendencies to identify the part with the whole must be fought off. But while Socrates in this early dialog still holds out the possibility of somehow reaching an ideal knowledge of the virtue of courage in itself, the failure of the project is itself extremely instructive. A careful knowing of the parts and pieces of any project may be all that can be done. We certainly do not and probably will not know all the parts and pieces of the practice of medical ethics or of the practice of medicine. But the thorough knowledge of one aspect of medicine or of ethics may be quite enough. This would be especially true of the knowledge and practice of virtue. The development of any one virtue could mean in effect the development of all of them. It would just be a matter of a point of entry having to do with personal preference or talent.

While this might be true as regards the practice of virtue, Nicias is aware that it will not be true as regards the practice of medicine. The physician will know of the workings of health and disease, but not of the values underlying the enhancement of health or the preventing of disease. Questions are raised as to whether life or health are always to be preferred to sickness and death.³ The practice of medicine, piecemeal as it is, cannot be a central unifying factor for the practice of virtue. The practice of a single virtue might, however, be a key to the practice of all the virtues, including the virtues of medical ethics. Perhaps this is why it requires so much time to extensively study medicine, but rather a little intensive time to study the virtue of medical ethics.

At this stage in his investigation of the virtues Plato is not yet ready, however, to settle on one single virtue as central. There is rather an early suggestion of what will become a classic formulation of the number of types of key central virtues. Socrates remarks that there are at least three parts to the practice of virtue: justice, temperance and courage.⁴ If we were to take the whole exploration of the topic of virtue itself as in some sense a prudential action, then there is present here already the classic formulation of the four cardinal virtues of prudence, justice, fortitude and temperance.

A more important dialog, the Protagoras, underscores the importance of wisdom as the most important and central virtue.⁵ While holiness is added to the list of virtues, the discussion is really concerned with the problem of there being a more central or unifying virtue. Protagoras claims courage as the central virtue.⁶ But, since this is only learned by practice, it seems that it cannot be taught. Protagoras is, however, very much the champion of the teachability of virtue. Socrates has taken the other point of view. Now at the end of the dialog they seem to have reversed positions.⁷ The question will dominate the next dialog. It also remains a most practical question for the teaching and development of medical ethics today. Presuming that medical ethics really can be taught, what possible methodology would be employed in the learning of this most practically elusive power?

Meno in the great dialog which bears his name asks Socrates whether virtue can be taught. In reply Socrates says that he does not even know what virtue is.⁸ Responding to Socrates’ plea for help, Meno provides a list of virtues. Socrates makes Meno aware that all of these virtues deal with temperance or justice.⁹ He goes on to demonstrate that acting according to any part of virtue, such as justice, will be to act in general virtuously. Yet there still remains the question as to actually just what virtue itself is.¹⁰ There follows one of the most famous sections of the Meno. Socrates questions a slave boy about his knowledge of geometry. This shows that all knowledge is recollection. This does not maintain that we recall something of a former life or state. It just means that we have knowledge as part of our basic make-up. The wise person will pursue ever more knowledge. Wisdom is the guide to right action. Wisdom may well then be the central virtue.¹¹ We must constantly wisely work at virtue. Virtue, then, is not an aspect of us which automatically works. Socrates explains this by saying that virtue is not a part of human nature.¹² He is also concerned to point out that virtue cannot be taught. The reason is that we cannot clearly identify the teachers of virtue.¹³ But virtue might come to us as a sort of divine dispensation.¹⁴ This is certainly rather vague. Failing to reach precise clarity on the question as to what virtue really is, the dialog ends inconclusively.

Consider the Socratic mode of posing these questions in relation to the practice of virtue in medical ethics. Might we take it that all people are by nature good? Does this not underpin the physician-patient relationship? There is the deep presumption that doctor and patient are working toward the same good goal of increased health. The wise patient and physician will work together for what is best. But indications are much to the contrary. It is difficult to know what is best. We tend not to see the whole picture. There may be reasonable care for one or another aspect of the patient's physical situation. There is seldom good care for the larger holistic psychological situation. What is of benefit to one or another of the physiological or psychological aspects may actually be a detriment to other aspects. Administration of drugs or therapies is often (and often rightly) resisted by patients. This resistance may be taken to be a bad thing in the patient. The patient may see the physician's action as bad. The basic presupposition of a nature somehow tending towards the good meets severe strains and stress. The practice of virtuous medicine is more of a struggle than a simple cooperative venture. And this is so in the best of scenarios.

Aristotle will remain more optimistic about the place of nature in all of this. Difficulties notwithstanding there will be a certain place for the ordering of matters toward good outcomes. Should physicians share in this optimism? Do you know physicians who indeed do? Or should we follow the lead of many physicians known to us who take such a cautious view of the workings of nature and the confidence and trust to be built on those workings as to be not only pessimistic but regularly downright hostile. Some diseases are hereditary, progressive and terminal. These can be very difficult for a physician who is trained to cure disease. But nature doesn't always work the way we would like it to, and there may be very little we can do except offer patients sensitive care and understanding. In the following situation, a physician forgets that we can't always control natural biological processes, and lets his insecurities interfere with his relationship to the patient.

Bob Jeffries has been hospitalized with Huntington's chorea for over a month. Symptoms of Huntington's begin with personality changes, moodiness, diminished memory and judgment, leading to involuntary and uncoordinated movements, dementia, and finally complete loss of control ending in death within 10–15 years. There is no cure.

Mr. Jeffries’ attending physician, Dr. Walters, has always had trouble with patients whom he believes will inevitably die a painful death. He has had an excellent scientific training and has never come to grips with diseases like Huntington's because they leave him feeling powerless, despite his years of training and experience.

Now Bob Jeffries is demanding more of his time and energy than he believes he can give. Dr. Walters has ordered tests, a series of treatments with L-Dopa (which can have disturbing side effects), and muscle relaxants, but he has been erecting a barrier between himself and Mr. Jeffries. Dr. Walters has been spending less and less time with him, and has developed the habit of holding only short, terse conversations with him. This behavior has intensified Mr Jeffries’ moodiness and incites his already unpredictable anger. He asks one of his nurses if Dr. Walters has given up on him. In the end, Mr. Jeffries starts to withdraw as well, and his condition appears to the nursing staff to be a good deal worse than they had expected of a man in the middle stage of Huntington's.

Dr. Walters’ anxiety in the face of a progressive, currently incurable disease is understandable. But his unwillingness to attend to Mr. Jeffries’ psychological and social needs may have contributed to the worsening of Mr. Jeffries’ condition, although there was nothing technically wrong with the treatment.

If virtue is some sort of wisdom, how is it to be taught? How do we know who are the very good teachers? Do some physicians just naturally teach good medical ethics to their students? Do we not often take it for granted that this is going on? Do a number of us simply assume that by doing good medicine we are teaching good ethics? How do you do and teach the practical arts of medical ethics?

Thomas Aquinas will maintain that virtue is preeminently wisdom or prudence. He will also say that prudence is in some sense a gift of God. Does this over-intellectualize virtue? Pragmatists such as James and Dewey will try to forge a new kind of knowing with practicality as its cardinal feature. Is the pragmatically skilled individual the highest knower? Physicians are among the most intelligent members of our society. They could not have got into medical school if this were not the case. Are they also possessed of innate practical knowledge? Are they therefore the best teachers of medical ethics? Should they be the only teachers of medical ethics?

An important debate in many hospitals today is whether or not to inform terminal patients that Do Not Resuscitate orders have been written. It is very difficult to resolve the ethical issues raised by DNR orders, and even very experienced physicians can differ with one another. In the following case study, the moral position of the experienced physician may be no better than that of the resident. Is his attitude pedagogically appropriate?

Martha Williams, 77 years old, had suffered two cardiac arrests. Dr. Halker, her attending physician, believed she could not survive a third attack. He intended to write a Do Not Resuscitate (DNR) order for her, and was strongly opposed to discussing such an order with his patients. Since the hospital was currently in the middle of a controversial debate over their policy on getting informed consent for DNR orders, decisions were being made on a case by case basis. That Wednesday, during morning report, Dr. Halker and the resident assigned to Mrs. Williams’ case had the following exchange:

R : Doesn't the patient have a right to know that she will not be revived if she has another arrest?

Dr. H : Mrs. Williams is very weak and very frightened at this point. We must empathize with her and try to understand how she would feel if we told her. Don't you think she would be even more frightened than she is already? And would that be a kind thing for us to do?

R : But I know how things work around here. A DNR would, in effect, be like declaring her dead. She would be put at a distance from the sources of care, so her care would diminish.

Dr. H : That would be wrong, of course, and we have to make sure she continues to get the best treatment possible. But don't you see that the damage we can do by telling her outweighs any moral rules about paternalism? And it's beyond anyone's control at this point. There would be no point in resuscitating Mrs. Williams, and that is all we could tell her.

R : You talk about empathy, but are you really trying to put yourself in her shoes? This isn't just a matter of “following moral rules” or respecting Mrs. Williams’ rights in an abstract sense. We can try to feel her pain and fear, but we have to see her as a mature woman who may want to know about the DNR. Empathy is important, but sometimes distance can help us see what our patients need.

Dr. H : What this patient needs is a kind of parental care.

R : Perhaps she needs to know.

Do you think Dr. Halker's practical knowledge and experience gives him a special grasp of what his patients ought to know? Or can a resident, nurse, or even a bioethicist takes a perspective not available to some physicians on a patient's right to know that a DNR order has been written?

The central Platonic dialog, the Republic, is a pivotal point for almost all of the basic philosophical questions discussed throughout the entire Platonic corpus. It also presents t...

Table of contents

• Front Cover
• ETHICAL PRACTICE IN CLINICAL MEDICINE
• Title Page
• Copyright
• Dedication
• CONTENTS
• INTRODUCTION: ETHICAL PRACTICE IN CLINICAL MEDICINE
• 1 THE PLATONIC FOUNDATION
• 2 THE ARISTOTELIAN FRAME
• 3 THOMISTIC PRUDENCE
• 4 SCOTTISH MORAL SENSE
• 5 AMERICAN PRAGMATISM
• 6 CONTEMPORARY DEVELOPMENTS IN VIRTUE ETHICS
• Notes
• Index