Commentary

Bad Ethics Is Not For the Patient's Good

Jerome C. Arnett, Jr., MD


"When I use a word," Humpty Dumpty said in rather a scornful tone,
"it means just what I choose it to mean --- neither more nor less."
"The question is," said Alice, "whether you can make words mean so many different things."

Lewis Carroll
Through The Looking Glass

 

I read the excellent review by Delbert Meyer, M.D. of Drs. Edmund Pellegrino and David Thomasma's book, For The Patient's Good, in the May/June 1999 Medical Sentinel. I would like to offer some additional observations that perhaps he did not consider.

Ethics is not a series of theories, but a systematic study of values which will allow our actions to conform to reality. Through ethics, we identify a code of values to guide our choices in order to live morally as happily as possible under the existing circumstances.(1) Ethics never change over time in spite of advances in technology (or even recently, the presence of third party payment). Our ethics are chosen, not forced, and voluntarily followed, not coercively obeyed.(2) Although aspired to by many, not every part of an ethical code will be preferred by all physicians.

There is no question that Drs. Pellegrino and Thomasma are nationally recognized in the field of medical ethics with numerous publications to their credit. However, it seems they have been caught up in the tide of political correctness sweeping the demoralized medical profession. Apparently, they fail to understand three important aspects of the problem:

1. The Oath of Hippocrates must be interpreted and understood in light of the historical setting in which it was written;

2. The authors erroneously presume the inadequacy of the Oath because it is not popular or politically correct, or is not pertinent to the "modern" setting; and

3. The use of force in social relationships (socialism) has been discredited years ago.(3,4)

The authors propose a new ethics theory more appropriate to today's medical encounter and they list three requirements:

1. It must replace a monolithic with a modular structure;

2. Specify what constitutes the good of the patients; and

3. Refurbish the ideal of a profession as a true "consecration."(5)

They state: "A fiduciary model such as the one we will propose is based on a rediscovery of the ethics of virtue rather than an ethic of rules. A number of insights lead to this rediscovery. The first is that an ethic of rules alone cannot provide guarantees that the responsible individual, the person with duties, will carry out those rules. That person must have the kind of character that disposes him to act in accordance with the right rules of actions. He must be the kind of person who can be trusted."(6)

Many of the authors' ideas and statements are conflicting, confusing and/or irrational. The following are typical:

° "Ultimate good is the highest sense of the patient's good...The second highest sense of patient good for a competent patient is that which preserves his or her capacity to act in a fully human way, that is, to express and act on her own perception of her own good...The patient's conception of her own good ranks right behind her good as a human person. It takes precedence over biomedical good or medical indications."(7)

° "Thus, the stewardship of patient values is blocked on one hand by the prohibition against paternalism. On the other hand, it is blocked by the limits on patient autonomy a hierarchy of good may impose on a case."(8)

° "An ethics of the process of clinical moral choices, therefore, obligates the physician to respect the several dimensions of the good of the patient and to keep them distinct and in proper order when they are in conflict."(9)

The following statements underscore the authors approval of the use of force in social relationships (socialism):

° "...the criteria for rationing and the principle of justice to be followed should rest with society, not with the physician. There is no assurance that the physician is any more fair or just than others in deciding who shall receive so crucially important a resource as health care. Do we as a society really want to give this kind of power to physicians?"(10)

° "If we cannot afford all the health care people want or need, we can find other ways of rationing or allocating resources that are more morally valid than those now in use. While tragic choices must always be made, they can be made on the basis of a more thoroughly thought-out national plan."(11)

° The authors insist that physicians (should) treat all patients regardless of their ability to pay and that this duty be expanded to society as a whole."(12)

Even many of the terms used are obfuscating or irrational. The following are examples: "therapeutic parsimony"; "the primary ordering principle of medical ethics"; the "right rules of actions"; an "ethic of rules"; "moral adversaries"; and the "unrestrained monetary instinct."

The authors treat physicians as though they work in a trade union rather than in a profession. What are the "right rules?" Who decides? How does one force physicians to follow them? They list possible conflicting priorities for the physician as follows: "Physicians cannot interpose other priorities, such as research goals, their personal self-interests, or institutional goals, if these conflict with the good of the patient."(13) They ignore an important priority which should have been listed here - the "good of society" often conflicts with the good of the patient.

As one author recently has observed, medical ethicists seem to be "more concerned with creating government regulations on the medical industry than they are with upholding the Oath of Hippocrates."(14) The Oath places the patient first. When the patient makes his own choices, then "right rules of actions," "beneficence-in-trust," and "complex notion of the patient's good," aren't a problem. One does not need to force physicians to act properly, or find "the kind of person who can be trusted," who will act "in accordance with the right rules of actions." In addition to this, in the free market, without the distortions created by government regulations, any physician who ignores the patients' choices faces economic hardship or even legal action.

In summary, For The Patient's Good appears to be a cleverly-camouflaged attempt to transform the individual-based ethics of the Oath of Hippocrates into the population-based ethics of socialism. In the authors' search for "social justice," the good of the individual has been replaced by the good of society.(15) Their book is a typical example of the medical ethics textbooks available today, and it reveals why American medicine is self-destructing. The book should be exposed for what it is --- obfuscating, irrational, and a moral failure in its attempt to "reconstitute" existing ethics codes to fit the needs of contemporary society.

References

1. Rand A. The Virtue of Selfishness. New York, NY, New American Library, 1961, pp. 13-35.
2. Binswanger H. (ed.) The Ayn Rand Lexicon. New York, NY, Penguin Books, 1986, p. 314.
3. von Mises L. Socialism. Indianapolis, IN, Liberty Fund, Inc., 1969 (orig. pub. 1936).
4. Hayek FA. The Road to Serfdom. Chicago, IL, University of Chicago Press, 1944.
5. Pellegrino ED, Thomasma DC. For The Patient's Good. New York, NY, Oxford University Press, 1988, p. 134.
6. Ibid., p. 53.
7. Ibid., p. 132.
8. Ibid., p. 202.
9. Ibid., p. 133.
10. Ibid., p. 181.
11. Ibid., p. 182.
12. Ibid., p. 32.
13. Ibid., p. 71.
14. Goldsmith PG. You copy that? Medical Sentinel 1999;4(4):141.
15. Vazsonyi B. America's 30 Years War. Washington, DC, Regnery Publishing, 1998.

Dr. Arnett is a pulmonologist in Elkins, West Virginia and a member of the Editorial Board of the Medical Sentinel.

Originally published in the Medical Sentinel 1999;4(5):182-183. Copyright©1999 Association of American Physicians and Surgeons (AAPS).