The Limitations of Secular Medical Ethics
by Gary S. Fischer, MD
General Internal Medicine Fellow, University of Pittsburgh
As I approach the end of fellowship training in medical ethics, I am sadly coming to the conclusion that conventional, secular medical ethics is incapable of providing us answers to some crucial moral problems in health care. Contemporary "medical ethics," as it is taught in the university and written about in journals, emphasizes patients' rights and provides important rules of conduct for health care providers -- but necessarily fails to help patients determine what course of action they are morally bound to pursue.
The courts, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, and major textbooks on medical ethics agree that patients have a right to determine what is done for and to them. We are told that ethical decision making regarding the medical treatment of patients must reflect patients' interests, desires, and wishes. As a result, we have established a number of formal procedures to aid in ethical decision making: informed consent, written advance directives, and substituted judgment. This framework makes very clear the answer to the question concerning who should be making the decisions. Its limitation is that it is necessarily silent about what the decision ought to be.
This approach may be adequate to provide direction for health care providers who are ethically bound to respect patients' wishes regarding their medical care, but it gives no guidance to the primary decision maker, the patient. If anything, we trivialize that task of the patient. We speak of patient "preferences," as if the decision whether to suffer through another intubation to fight for a few months of life or to forgo that treatment is merely a matter of taste. We forget that to many patients and their families, these questions have profound moral and religious significance. The patient may reflect on questions such as what is one's responsibility to oneself as a steward of his or her body, what is one's obligation to intimates who may bear the emotional and financial burden of caring for the patient during a prolonged illness, and what are the reciprocal responsibilities of the individual and society regarding the appropriate use of societal resources?
The answers to questions like these depend upon beliefs regarding what gives life value, and what are the mutual obligations of people to each other either to preserve life or to forgo a slim chance at continued life to preserve resources for others. Attempts to answer questions like these have been made by secular moral philosophers, such as utilitarians, but for many patients, the answers are sought from religion. Patients for whom religion is important will have to turn to their religious counselors and to their own understanding of their religion. An ethical philosophy which is intended to prescribe behavior for all members of a liberal, pluralistic society is incapable of answering these questions, because in so doing, it would force upon all a particular vision of what is "good" in life. As an orthodox Jew, I am aware of the content that religion can bring to moral life and the importance of answering such questions; as a member of a religious minority, I understand the dangers of the majority trying to enforce a particular view of the answers to these questions upon all.
We must recognize the limitation that this places on clinical and ethical consultation based upon the principles of a secular medical ethic. Ethics consultants perform many important services. They can aid in patient or surrogate decision making by facilitating communication and clearing up misunderstandings. They can educate health care providers regarding the need to respect the patient's wishes and values. They can inform patients and surrogates about the options which they are at liberty to choose regarding end-of-life care. What they cannot do is tell patients which of these options is the moral choice.
This is the crucial point. The ethical and legal principles that govern the practice of medicine in a liberal democratic society can only describe the liberties which patients have regarding their medical care. They give patients "the right to be wrong," as philosopher Tris Englehardt puts it. Unfortunately, when patients themselves need to decide what is actually right, they need to look elsewhere for their answers.