Patrick D. Guinan, MD, MPH
This article was first published in the May 1998 issue of Linacre Quarterly
Modern medicine began with the Greeks and has developed over the past 2,500 years. Medical ethics, which was also initiated by the Greeks, and summarized in the Hippocratic Oath, has guided the moral actions of the physician in his medical practice for the past two and one half millennia. Recently, however, there have been profound changes in bioethics, not only in how the basic Hippocratic cannon is understood, but also in who interprets the code.
The purpose of this essay is to explain why the clinical decision-making role of the physician has been overshadowed by ethical theories and ethical specialists. To this end we shall briefly review the history of medical ethics (Table 1) with an emphasis on the recent past (1960 - present). The Hippocratic tradition of the art of medicine refers not just to diagnosis and treatment modalities, but to the moral dimension of life and death decisions affecting the patient. It is this latter dimension of the medical profession which has been usurped by non-physicians in the ethics debate, as we shall explain.
It is the thesis of this review that the operative relationship in medical ethics, the doctor-patient relationship, and the physician’s judgment, are being displaced by the intrusion of third parties who do not have the experiential prudence of the practicing physician. Perhaps at the root of this problem is the loss of awareness of the distinction between the theoretical sciences and the practical arts. The medical profession, while relying heavily upon sciences, is nonetheless a practical art. While specialists in bioethics and other related disciplines may have theoretical knowledge relevant to medicine, that information should not displace the physician’s expertise in his own field. When we do not appreciate the crucial role of the experiential skill acquired by each professional as his practical source of particular judgment calls, there is a subsequent loss of respect for the role of the three learned professions - law, medicine, and religion. These lost distinctions combine to weaken the conditions necessary for a working covenant of the physician and his patient. Without this moral bond, medicine and physicians will lose the ethics battle.
Table 1 - MEDICAL ETHICS
|I-Hippocratic||800 BC-1750||Aristotle, St. Thomas/Virtue|
|IV- Ethical Autonomy||1960-Present||Derrida/Legalism|
Medicine is, by definition, the treatment of human illness. One person, the physician, is treating a disease in another person, the patient. The term "the doctor-patient relationship" has become trite by overuse. But nonetheless it is a profound human covenant involving the patient’s trust and the physician’s skill and trustworthiness. As persons we are corporeal spirits. That is, we exist in bodies that are prone to disease and will inevitably age with resultant deterioration and death. The physician occasionally can cure illness but should usually be able to ameliorate the physical and emotional effects of disease. The doctor-patient bond is a sacred one in the sense of spiritual, or beyond the corporeal, relationship1. It has been compared to Martin Buber’s “I-Thou" divine relationship.
As human societies developed, even the most primitive ones had "medicine men" or physicians. Even though, or perhaps because, there was a religious aspect to his role, his purpose was to alleviate physical or mental disease. This fundamental relationship between the physician and the sick person, the doctor-patient relationship, has from the beginning been governed by guidelines for the behavior of both persons, but particularly the physicians. These guidelines delineate right and wrong, or ethical behavior particularly for the physician.
Obviously, there has been a close relationship between medical ethics and philosophy in general for two reasons. First, because Greek physicians were often philosophers as was Hippocrates (c. 400 BC) and secondly, the study of ethics was a branch of philosophy, e.g., Aristotle’s (389-322 BC) Nichomachean Ethics, which stated the doctrine that human behavior should be in accord with the natural law. Indeed, in some way medicine and medical ethics preceded and gave impetus to further philosophical and metaphysical thought2.
I. Hippocratic Era
The Hippocratic Tradition was grounded in Aristotelian realist philosophy. The human person sensed objects and derived knowledge of external reality. The human mind with its intellect and will appreciated the characteristic truth and goodness in beings outside of itself. Ethics arose when it became apparent that some human acts were concordant with what it was to be human and some acts were not. It was obvious that life was good and to destroy it was evil. For humans the innate desire to conform to the natural law, or law of nature, was normative and to frustrate that inclination was unethical.
The purpose of medicine for the Greeks was to restore human wholeness, whether physical or mental, to individuals who were diseased. To destroy or damage life and health was therefore obviously unethical. That is why the Hippocratic Oath prohibited abortion, because it was the destruction of life.
Inherent in the Hippocratic Oath was the development of virtue in the physician. Virtues are the habits of the will whereby a person conforms to his human nature. Beneficence, non-malfeasance, and confidentiality are virtues that perfect a physician in the art and practice of medicine. The Greek tradition was continued and perfected by St. Thomas (1224-1274) in his further development of "virtue ethics." Virtue ethics is about the formation of character during the course of a moral upbringing such that a good person "instinctively" chooses the good and avoids evil, and therefore has the habit of will that enables one to conform to moral laws. Thus, morality is a practical art of living in conformity with the moral good, and is parallel to medicine as a practical art that is learned in the doing of that which serves health as the physical good.
The doctor-patient relationship was initially defined during the Hippocratic period. While the physician was in a position of knowledge and skill relative to the sick patient, who was dependent upon the ministrations of his physician, the Hippocratic covenant governed that relationship. It was characterized by beneficence and the operative rule was "primum non nocere" (first, do no harm). The physician was to be governed by laws of nature and the virtues that he was heir to. The Hippocratic Oath served physicians well for two millennia. While modern scientific knowledge was lacking, there was a doctor-patient relationship that provided both psychological and physical resources to cope with illness for 2,000 years.
II. Deontological Era
With the Enlightenment came Descartes' (1596-1650) idealism and a divorce of the human mind from nature. That shift from a realist world view to the idealist one that characterizes modern thought has had profound ethical implications. Nominalism, developed by William of Ockham (1300-1349) laid the ground work for Descartes' idealism. But it also contributed to the rise of modern science because of its emphasis on quantification and measurement. The depreciation of objective causality, which had been the basis of Aristotelian science, allowed Bacon and Newton to develop modern science which emphasizes observation and statistical relationships. Modern science has also given us remarkable technological innovations such as anesthesia and antibiotics which profoundly changed, in the mid-1800s, what had been essentially Greek personal medicine, into the high-tech medical science we have now.
The idealist divorce of the mind from reality had an ethical impact by diminishing the importance of virtue. Kant (1724-1804), in his Critique of Practical Reason postulated a categorical imperative that obligated a person to perform his duty. Physicians therefore had a duty, for instance, not to participate in euthanasia. Duty ethics eroded the Hippocratic virtue-ethics.
The doctor-patient relationship also was influenced by the zeitgeist of the Enlightenment. The separation of the mind from matter and nature led to the isolation of the individual person and the development of the "autonomous self.” This was to find fuller expression two centuries later.
III . Utilitarianism Era
Positivism is the philosophy that grew out of empiricism which emphasized experience over ideas. The positivists relied on observable facts to provide their ethics. Bentham (1748-1832) and Mill (1806-1873) developed the English version of positivism which was labeled utilitarianism. What is useful is good. Their observation of human behavior led to the principle of utility: the ultimate aim of human action is pleasure. This concept was carried forward by the pragmatists, especially Dewey (1859-1952) in the United States. The pragmatists helped to develop value theory. Values are what are desirable. Unfortunately, when ethical principles are based on the pleasurable or desirable they become relative. Human nature, based on natural law, is subverted.
Utilitarianism is seen on medical ethics in two areas. Situationalism was developed by Joseph Fletcher, one of the pioneers of bioethics. For Fletcher, the rule of "love" is paramount and can be employed to justify abortion. Consequentialism is a form of utilitarianism and has perhaps been the prominent ethical system in the United States where the greatest good for the greatest number has been a political as well as an ethical shibboleth.
The doctor-patient relationship began feeling the stress that was occurring in moral philosophy. Those questioning the worth of abstract virtues called into question the concept of beneficence. With slipping moral anchors, the doctor relied on technology. Once again, the Hippocratic tradition was eroded.
IV. Era of Ethical Autonomy
Following World War II there has been a breakdown of the broad assumptions which led to the Enlightenment. The Inevitable empiricism and skepticism led to postmodernism and the deconstruction of Derrida and Foucault. Science and technology are no longer worshipped. Social cohesiveness has eroded and society, which has reduced the individual to an automaton, does not, at least in the West, have a unifying principle.
The present generation is experiencing ethical autonomy, or more properly, an ethical vacuum. This began in the 1960s in the United States which, as the ideological leader of the world, has been the focus of moral change. The cause is partly the disillusionment with modernism that resulted from the horrors of two world wars. The material prosperity following the second world war did not lead to a moral renewal but rather to the opposite. The reaction to the Vietnam war was a symptom. The most egregious result has been the sexual revolution fed by contraception and, of necessity, abortion. The "autonomous self," or the individual free of any restraints, reigns.
In the process the relationship between the physician and the patient has continued to undergo profound changes. Not only has utility superseded beneficence, but now material and economic factors intervene. Third party payors are making clinical decisions that were previously made by the doctor and the patient. Medicine has been caught between the ethical autonomy of the patient and the bureaucracy of the state. Following the Depression, the Federal Government has become monolithic and unresponsive. In 1965, Medicare and Medicaid legislation were passed. The health care industry responded by coalescing hospitals and insurance groups into health maintenance organizations. When these parties make clinical decisions the physician’s responsibility is, if not eliminated, at least greatly diminished. The doctor becomes little more than a technician and his bond with the patient no longer exists.
Coincident with, or perhaps because of these changes, a bioethics establishment has arisen. Prior to the 1960s, the medical ethics arena was dominated by physicians. Since the 1960s, either because physicians became more specialized and less broadly educated, or because of the expansion of academic programs in bioethics and the graduate theological community, doctors of philosophy rather than medical doctors began to direct the course of medical ethics. A review of the facilities of the principle bioethics centers (emphasizing those with a Catholic orientation) confirms this trend (Table 2). Of 41 staff members, over half are Ph.D.s, only 12 percent are M.D.s.
Table 2- ACADEMIC DEGREES OF FACULTIES OF BIOETHIC CENTERS
|Pope John Center, Braintree, MA||4||0||3||1||0||0|
|Kennedy Institute Bioethics, Georgetown||13||2||7||1||2||1|
|Center for Health Care Ethics, St. Louis||7||1||2||2||0||2|
|Hastings Center, Briarcliff, NY||13||2||7||0||1||3|
|Center for Bioethics and Human Dignity, IL||2||0||1||0||0||1|
|Center for Bioethics, U. Pennsylvania||2||0||2||4||0||0|
Medicine is a practical art, the insights of which are not available to the non-physician scholar. Without the practical insight that has been available for the past 2,500 years through the clinical experience of the physician, medical ethics lost its moorings.
Due to a combination of the above reasons, difficult ethical decisions, particularly in the life areas of sex, birth, and death are not being made by physicians and patients but rather by bioethical committees. This process has taken on the adversarial tone, as one might expect, of the legal system because bioethics committees commonly include lawyers. Consequently, medical moral issues are being decided in an adversarial setting by academic scholars without the invaluable and essential insights and wisdom of the doctor-patient relationship. Natural law and virtue are ignored.
In answer to the opening question: Has medicine lost the ethics battle? The answer would appear to be "yes." The Hippocratic tradition, that is the cultivation of a virtue ethic and a respect of natural law are becoming irrelevant in contemporary biomedical decision making. This is unfortunate because the virtue ethic tradition of the Hippocratic Oath bound the physician and patient to nature. Without respect for, and observation of, the natural law, the human patient is unprotected in life’s ultimate situations. The human experiences of birth and death may have lost their most appropriate advocate: the ethical physician.
1. Pemberton, B. “A Comprehensive Understanding of the Doctor-Patient Relationship," J Religion and Health 11:252, 1972.
2. Pelligrino, E. “The Metamorphosis of Medical Ethics,” JAMA 269:1158, 93.
, MD, MPH is a member of the Board, Region VII, Catholic Medical Association. A 1962 graduate of Marquette University Medical School, the author went on to a graduate degree in Public Health from Columbia University in 1965. He is presently an Associate Professor in the Department of Urology in the College of Medicine of the University of Illinois at Chicago and serves as Chairman of the Board of the Hektoen Institute of Medicine.