By What Standard?

Medical ethics are those principles which govern conduct in medical decisions. It is unfortunate that most attention is paid to the "big," knotted, snarled, questions, such as: “Should this 13 year old child on Medicaid, with liver failure, the son of a Christian Scientist mother and a Jehovah's Witness father, receive a baboon liver transplant over the objections of animal rights activists and his parents, and should the state of Oregon pay for it, though it is not on their Medicaid list?” That kind of issue is a headline maker along with all those ethical decisions which cluster around the plugs of ventilators in intensive care units.

I am more concerned with the mundane decisions.

• Is mother competent to decide that she does not want surgery for her cancer, or is she too senile?
• What do you tell a 15 year old girl who tags a request for birth control pills onto the end of her visit for an ankle sprain?
• Is it right to "chemically restrain" an elderly demented person who is disrupting the home with spitting, shouting, cursing, and refusal to eat?
• How do you deal with a 75 year old man with no urinary symptoms who heard a radio ad encouraging retired men to have themselves checked for prostate cancer and wants you to do the testing?
• What about the nasty patient who has fallen out with every doctor in town, and is now furious with you, threatening lawsuit, but bound to you financially by his managed care plan?

Although it is less interesting than plunging into these questions, there are some necessary preliminaries. Before we decide the “right” pathway, we have to consider the means by which we determine what is right. It won't do to assume that we will agree, because we almost certainly will not. The first principle of an ethical decision, one that is normally overlooked because it poses difficulties, is that a standard is required by which the decision is to be made.

• Not everybody shares the same standard.
• Individual freedom of decision is a highly valued principle in the U.S.

Different standards can lead to very different conclusions. By no means do all standards share some essential elements which lead to the same outcome. One common way these problems are “solved” is to avoid explicit confrontation of the matter and slip in a standard by implication. That is cheating.

An article favoring, say, euthanasia may describe the suffering of terminal disease and conclude that, therefore, mercy killing is right. By implication, the proponent of mercy killing has decided that the suffering is the determinative factor when the situation looks hopeless. Now, if one just came out and said that baldly, it would be evident that the decision is based on a corollary to hedonism – that life is about maximizing pleasure and minimizing pain. The principle governing this proponent of euthanasia – I don't claim, by the way, that all proponents of euthanasia would own this as their principle – relates to the standard of hedonism. It should be so recognized, so stated, and defended if possible. Or, a proponent of say, socialized medicine, may support the position by saying that most of the people of the world are in such systems, and/or that most people in the U.S. favor it in some poll. Bootlegged into this statement is the assumption that right and wrong is decided by majority action. That standard deserves to be stated outright.

The difficulty of achieving a standard seems to some people so insurmountable that they bail out by asserting that the problem is impossible and we must, somehow, just go on without solving it. “You'll never get everyone to agree,” they say. Well, never is a long time, but even to say that is to imply that a right standard requires group agreement. Are right decisions invariably held hostage to group agreement? Acting on a decision may indeed be blocked by a powerful group, but making a decision, advising a course of action, are not subject to group consensus unless you presuppose that they are. I do value group consensus in medical ethics. However, I do not believe it to be ultimate. When I am having difficulty in advising an ethical course of action, I find that my desire for consensus is sometimes merely a lack of the courage of my convictions. I don't like to be different.

Another way Americans deal with the different standards dilemma is to confuse data with wisdom. We heap up information. Computers help. Estimates are that there are six million articles annually published in English alone which relate to medicine. We do computer searches. We find out how much it costs. What the risks are. What the various treatments are. These are statements of what is. We will return to them, for they are important in making ethical decisions. However, ethics is about what ought to be, or what ought not to be. Data is about what is, or what is not. Even stacked exceedingly high and heated, a pile of “is” statements will not convert to an “ought” statement. Empirical statements do not transform under pressure and heat to normative statements.

Lest I now fall under my own condemnation of making ethical pronouncements without making clear the standard, I wish to state my own. My ultimate ethical standard is the Bible. I recognize that many will not agree with that, and, of course, some who would disagree with the interpretation and application. I do not pretend to have solved all problems with that assertion. Nonetheless, to pretend to be able to go very far at all without having a standard is foolishness, and to withhold the standard or apply it implicitly is deceptive. Neither is it essential that patients agree with me on the standard. Ordinarily, we are able to work out an agreed-upon course of action though we do not share the underlying reasons for the action. If we are unable to agree upon a right course of action, we may be able to see that the failure comes from different standards. The foundation for counseling persons with questions on medical ethics, then, is to see that ethics requires a normative standard, that the counselor needs to know his/her standard and be explicit about it if difficulties arise. "Oughts" come from "oughts" not from knowledge of what is.


Excerpt from "Counseling Persons with Questions on Medical Ethics"