A Saturday Exploring the Ethics of Medicine

Ethics is about making choices using reason.

From 8 AM – 5:30 PM this Saturday, I attended the Abigail Adams Institute Medical Ethics Seminar. I heard about it from my neighbor who is a palliative care researcher after a talk I attended on physician-assisted suicide (or death). The talk was pretty horrible so he suggested this seminar. It was led by Farr Curlin, MD, a professor of medicine and humanities at Duke and Christopher Tollefsen, PhD, a professor and philosopher at University of South Carolina. I had actually met Dr. Curlin while at University of Chicago once about 3 years ago, and he remembered me! Good memory on his part.

After about 6 months in Boston, I feel less of a medical student than I did when I started. I am this wannabe researcher trying to find her place in this weird year of uncertainty, growth and discovery. Therefore, it was an interesting experience to engage the following ideas.

The Purpose of Medicine 

It seems pretty obvious doesn’t it? To make people healthy. But, what does it mean to be healthy? Is health relative? What if you cannot restore that person’s health?

Physicians have gotten rather angsty about their roles in medicine because we can do so much more than we used to do in let’s say 1935. In 1935, doctors could treat trauma wounds, remove diseased organs, do c-sections, blood transfusions and prescribe some early anti-psychotics. Health was so much about survival.

Today, health encompasses the preservation of life (ex. dialysis), beauty (cosmetic surgery), the alleviation of pain, the control of reproduction, the preservation of social functioning (from gender reassignment surgery to anti-depressants), and the end of life.

We can do so much for patients today to the point in which we may question, should we do this? Like Leon Kass, Curlin and Tollefsen posit that conflict arises when we pursue the tenants of health above first instead of HEALTH as a whole. Health defined as, the “well-working of the whole organism.”

Natural Law Foundations of Medical Ethics 

I was told natural law is meant to “uncover what is constitutive and normal for a flourishing life.” One of the big points I took away from this discussion was the fact that there is something lost whenever we make any particular choice. Some “goods” or principles discussed were:

  • health/life
  • knowledge
  • friendship
  • aesthetic experience
  • play
  • integrity
  • religion
  • marriage –> “the state of being married”

Tollefsen suggested that these goods are incommensurable. It’s not like currency where we can say that one is worth more than another by an x amount.

Another point discussed was that sometimes constraining what we WANT to do FREES us up to pursue things/achieve specific aims.

For example, I really love watching films. It’s one of my favorite ways to spend time, and I consider myself a movie buff. It’s relaxing and good fun for me. But, if I pursue this so much, it will certainly limit my ability to engage in other things I want to do. SAYING NO does not mean being LESS free. Sometimes denial is what brings about freedom. 

The Doctor-Patient Relationship 

Definitely relevant and central to medicine. This relationship was broken down into three types:

  1. STRONG PATERNALISM: doctor gives an order and the patient complies 
  2. PATIENT SOVEREIGNTY: patient requests and doctor provides 
  3. PHYSICIAN-PATIENT ACCOMMODATION: doctor proposes and patient consents

There are some benefits to the paternalistic model, the biggest of them is efficiency.  Things are just easier sometimes when people just do what you say and you do not have to think for yourself and just obey. This model also makes physicians the major bearers of responsibility regarding the patient’s well-being. However, it devalues patient autonomy and induces patient passivity.

In the model where patients are sovereign (in my opinion the worst), it is positive that patients have more control of their care, but it also reduces physician responsibility as well as increases physician demoralization. We become technicians, afraid to offer our opinions which are often sugared with experience and years of acquiring knowledge. Sometimes this really can do a patient a disservice.

The last, physician-patient accommodation, I think is the best model. In it, people fall into their appropriate roles. The doctor’s job is not to control her patient. It is to provide her best care which the patient consents. With the physician proposing ideas for the patient’s care, responsibility falls back on her to use wisdom and experience instead of having the patient do their own job. And, the patient is not controlled by his physician. He gives consent if he finds the doctors proposition appropriate. This provides what was described to be enhanced autonomy. 

If you come to a decision you feel certain about, and then can be reasoned out of it, perhaps that was not the best choice for you to make. But, if after given all of the information on what to do about a health decision, as well as your physician’s opinion, and you still hold your position or shifted it slightly, you have autonomy still but it is enhanced in that you have thought more deeply about why you have made your decision. You can make a decision not just informed by facts, but on your physician’s own experiences. If you disagree with your doc, you have still had the opportunity to consider and grapple with your own personal motivators.

DIALOGUE is HEALTHY.

Reproductive Ethics (in this case, “Abortion”)

To start, Professor Tollefsen disclosed that he believed that abortion is wrong/unethical. He then took us through the “personhood argument” as to why.  It’s interesting to me in these kind of settings for a leader to disclose their opinion from the start as well as for a person with a differing opinion to not also share the floor. But, perhaps this was transparent and an honest way to proceed.

His questions/answers:

  1. What are we essentially? Human Beings 
  2. When do human beings begin (developmentally)? Fertilization
  3. Which beings deserve fundamental forms of respect? All 

He described that persons begin from fertilization and that the right of every person is that of fundamental respect (ie not to be intentionally killed). Although, this perspective is certainly not held true in the world (many people are thought to be underserving of this right to life after they are born/many fundamental respects).

It is very clear to me, that the organism of human potential, the fertilized egg, is alive. It is life.

What if this issue is not about whether or not developing embryos/fetuses etc are human beings? 

If we cannot bring ethics into the real world, it is useless. When a woman decides to have an abortion, I think she is entirely aware of a person developing in her uterus. She knows it’s alive. Trying to convince her it is a person and because it is a person has a right to survive may get her to change her mind in some cases, but perhaps not. People have abortions, I think, because in that moment, her right to not have that life supersedes the right we may impose on the fetus to survive. What we are dealing with is an issue of rights of the woman v the right of the fetus and a battle for control.

Is it ethical for the government to block a woman’s choice to choose life or death for her fetus?

How can we discuss this without examining why a person may make this choice? Can we have an absolute, unwavering perspective on the ethics of abortion or is this fluid (is it wrong in every case)? Whether it is a matter of “inconvenience,” unwillingness to have a “sick child” or inability to raise that child in a financially comfortable way, there are real reasons why women make this choice. Unless we grapple with these reasons, it will be difficult to have a practical conversation about it. Abortions are at their lowest in the US since Row v Wade was enacted. Less abortion, is probably linked to increased access to contraception or increased difficulty in accessing abortions. If we live in a world where a woman has a choice to choose yes or no to life for her fetus, and we want her to say yes more, we cannot just say that abortion is unethical. We have to work towards a world where it is easier for her to do this.

The healthiest world, in my opinion, is when a woman becomes pregnant when she wants to be, and when having a child is not a burden she alone must bear.

Clinical Challenges to the End of Life 

This was the original reason for me attending this seminar. What are the arguments for and against physician-assisted death or suicide?

Two cases were presented with young patients with inoperable brain cancer (glioblastoma multiforme).  They both are/were in the twenties and had a prognosis less than 6 months. You do not want this cancer.

Brittany Maynard chose when she wanted to die. She died with her idea of dignity intact.

JJ chose to stay alive for as long as he could. He is still living.

Both of their stories are very much worth listening considering. And, I honestly respect both of their choices. Is PAS absolutely and unwaveringly, unethical? I am currently leaning to the position that like most things in life, it is circumstantial.

Professor Curlin offered, “There is a difference between with holding treatment and making someone dead.”

Palliative care, which entails making someone’s dying process, as comfortable as possible is perceived as an alternative to “making someone dead.” Nonetheless, this is difference is not black and white. Increasing a patients morphine dosage may “hasten death” a very little bit.

This session more than anything, challenges developing physicians to consider their own opinions and what they think to be right. Dr. Curlin calls for solidarity between doctors and ailing patients. The solidarity being the physician attending to her patient’s needs and the patient allowing her to practice medicine that does not violate her commitments as a physician.

I think this looks different for each doctor-patient relationship. In the end, I think we should always return back to the idea of enhanced autonomy. NO physician should make a decision that they believe is unethical. If that situation is presented, it is on them to remove the patient from their care and place them in the care of someone else that can fulfill the role of that patient’s physician. If a patient consents to hearing our opinion on the matter, we should be entitled to share it, but the patient must consent.

At the end of such a day, seldom does anyone leave with more answers than questions. Ethics is about making choices using reason. Often our reason is determined by things that may defy reason like faith, circumstance and experience. These contributors can ebb and flow.

Our conscience judges the moral quality of our own decisions.

 

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