Much of our culture has been shaped by, or at least greatly influenced by, centuries of religious belief. Our Western culture has largely been shaped by Christian belief. However, the present-day multicultural matrix has resulted in the secularization of contemporary culture and the marginalization of religious influence. Indeed, efforts at encouraging political correctness have resulted in the silencing, ignoring, and even ridiculing of theological voices. This is clearly demonstrated in medical ethics. I propose that clinical ethics, one segment of medical ethics, is an avenue where this trend can be reversed.
Medical ethics is the systematic application of moral principles and values to medicine and the health sciences, addressing issues and public policy, including such matters as abortion, euthanasia, cloning, and a host of others. Clinical ethics, on the other hand, involves the identification, analysis and resolution of moral problems that arise in the care of individual patients. As such, it involves many individuals: the patient, the patient’s family, and many healthcare professionals. Each of these individuals brings to the table his or her own world view, most often encompassing religious beliefs. Such beliefs and values are significant, and often paramount, in the resolution of the dilemmas and conflicts that arise in clinical ethics.
History of Medical Ethics
The history of classical medical ethics is rife with theological voices, including Hippocrates (Greek polytheism, ~450 BC), Ishaq bin Ali Rahawi (Muslim, 9th C), Maimonides (Jewish, 12th C), Thomas Aquinas (Roman Catholic, 13th C), Thomas Percival (Anglican, 19th C) to name a few individuals from different religious perspectives. Western medicine in particular has a great religious heritage. Albert Jonsen, medical historian, concludes that the current Western medical ethos is a rope weaved from two strands — the competence taught by Hippocrates and the compassion taught by Jesus[i].
Contemporary medical ethics is considered to have started in the 1960’s and was initiated by theologians asking questions of practicing clinicians[ii]. Sadly, over the past 50 years, the discipline of medical ethics has been taken over by philosophers, judges, attorneys, legislators and health policy experts[iii]. Healthcare is, for the most part, a secular endeavor, and its practitioners often point out that faith is a private matter, outside the boundaries of health policy.
However, at the bedside, when individual patient dilemmas are encountered, issues of spirituality are increasingly recognized as pertinent[iv]. This is not new. It was recognized in antiquity and even in the 1960’s. At about the same time that contemporary medical ethics emerged 50 years ago, the maxim “Medicine is inherently a moral enterprise” was articulated, i.e., the practice of medicine involves making decisions between right and wrong, good and bad. As multicultural diversity has been increasingly recognized in recent decades, the importance of individual religious beliefs has been emphasized among healthcare educators and practitioners.
The Scope of Medical Ethics
There are two parallel, but different, questions in medicine — the “Can we…?” questions and the “Should we…” questions. Can we dialyze this elderly man with advanced dementia who has developed kidney failure? Yes, we can. This is a medical question. But should we dialyze him? That is a different question. That is an ethics question.
For many reasons, contemporary medical ethics is more complicated than it was for Hippocrates or even Percival, the author of the first book entitled Medical Ethics (1803). Technology has introduced so many new options that the “Should we…?” questions are today much more common than they were a generation or two ago. In addition, the doctor-patient relationship is much different than it has been in the past. Now instead of one doctor caring for one patient, we often have multiple specialists involved, along with nurses, therapists and others. The very high cost of many medical treatments also leads to such questions. And finally, the diversity of beliefs in our society frequently causes people to look at these questions from differing perspectives.
The Principles of Secular Medical Ethics
There are four well-recognized principles in secular medical ethics[v]:
Non-maleficence – “First of all, do no harm” has survived from Hippocratic writings[vi].
Beneficence – This similarly ancient precept of seeking the patient’s best interests has endured over the centuries and is now a vital part of the physician’s fiduciary responsibility.
Autonomy – The understanding and acceptance that a patient has the right to make his or her own treatment decisions is a rather recent development in medical ethics. In earlier times, the physician was accorded primacy in making treatment decisions, based on the principle of beneficence. However, in the social upheaval of the 1960’s and ‘70’s, individual rights came to the fore — minority rights, women’s rights, consumer rights and even patient rights. Currently in Western medicine, the physician makes recommendations, and may even try to persuade a reluctant patient, but ultimately it is the patient (or patient surrogate) who makes the final decision about treatment or non-treatment in most cases. This precept is not as widely accepted in non-western or developing societies where family and community wishes may be allowed to trump patient wishes.
Justice – Along with the development of patient autonomy has emerged the concept of non-discrimination — like patients should be treated alike without favoring one over another because of race, nationality, economic status, religion, etc. However, in our current generation, this concept of justice in healthcare has taken on a new shade. Whereas in the past, healthcare professionals were expected to focus solely on their individual patients, now we are expected to also consider the good of society as well as the individual patient. This not infrequently creates seemingly irresolvable dilemmas. For example, if my patient develops kidney failure and wants to live as long as possible, as his physician I should try to arrange for him to have dialysis. However, if he also is demented and has a relatively short life expectancy, the modern concept of justice would encourage me to discourage him or his family from pursuing this expensive treatment, making it available for someone else with kidney failure who has a better overall prognosis. Should I seek the best interests of my patient or of society?