Bioethics, medicine, and the moral ground.

Bioethics, Medicine, and the Moral Ground

Aristotle taught that "good-ness" is a quality, a virtue, a generic attribute--not simply "what is good to do" in a specific instance or for a particular issue. It is not systematically legal or coercive. In fact, there are often tensions between bioethics and the law. In the delivery of health care, the awareness of the bioethical "good" sets the moral tone in the thinking and behavior of nurses, doctors, patients, families, researchers, hospital administrators, and social workers. These are the persons who are the moral agents in bioethics. They face the bioethical issues of our time and the quest for "good-ness."

There is a lengthening agenda of moral issues in medicine, seen, for example, in Bioethics Literature Review, a periodical published monthly by University Publishing Group, Frederick, Md. (The publication presents brief summaries of current literature in bioethics.) On the first page of each number is an index of subjects contained in the periodical. Taken from the February 1989 issue (volume 4, number 2) are the following entries: abortion, AIDS, brain death, cost-benefit, determination of death, drug testing, embryo/fetus, euthanasia, health services/hospitals, insurance, medical ethics, mental health, organ transplantation, patients' rights, physician/medical education, privacy, reproduction technologies, surrogacy, and treatment decisions.

Religion, law, economy, and polity all have a moral ground, just as medicine has. Each has its vocabulary, language, tone, and rationale. Each is a guardian of many virtues and, to a large extent, of the status quo. But setting aside the tragedies of history, religious institutions and the state--no matter how secure and rich their moral ground may be--are incompletely equipped to work through the lengthening agenda of issues in medicine today. Their vocabularies and their rationales, even their methods, are not always suited to the dilemmas they confront in medicine. (Where particular forms of religion, law, economy, polity, and medicine have lost their moral ground, chaos ensues. Bolshevik Russia, Jazi Germany, and, on a smaller scale, the Jonestown Community in Guyana are examples of moral chaos.)

The vision of medicine and its moral ground are strong. Science, technology, humanities, experience, and moral values are richly interwoven in medicine as in no other calling. These elements give the profession an ideal, a vision of itself that is both humbling and exalting--humbling in that we as persons can never be the measure of the ideal; exalting in that we can conceive of the ideal's tasks and moral obligations.

Physicians share the sorrows of humankind in an imperfect and perplexing world. Things in medicine are often unclear or ambiguous. We know this intuitively, dealing intimately with imperfection. Meeting illness face-to-face, trying to understand disease and doing our best to treat patients, and being imperfect ourselves, we need to be reminded that diseases and patients are not the same. We know that the reasons for illness may be obscure. We know that for many patients with cancer and for other illnesses with uncertain causes and uncertain outcomes, treatment may be measured as a statistical probability. Uncertainty begets perplexity. Commonplace language underscores the point: "There's no good answer," or "It's a lose-lose situation," or "You're damned if you do and damned if you don't."

Spectacular perplexity (often on display in courts of law and referred to as a "case") gains the attention of the media. But in most instances, the moral agents are making tough decisions in clinical situations that do not attract public notice because they are not sensational. A common reason for the "spectacular case" is the presence of conflict and tension. Conflict is inherently attention-getting, and there often seems to be tension between bioethics and law, bioethics and religion, and bioethics and the state. Why? Because the status quo is assailed. Bioethics--spectacular or not--deals with new issues, with dilemmas previously unknown. It also deals with old issues, compelling us to revisit our values and principles and to sort out our experiences. Bioethics marshals the moral agents and provides them with a systematic approach to both the new and the old.

Those commonplace statements quoted above are spoken when there are tough choices--where options exist, none of which upholds all the values at stake. An ethical approach to these options provides the tools, the method, or the system to deal morally with perplexity. This ethical approach is sorely needed, to improve both our thinking and our state of mind.

When we are faced with choices, there may be a sense that only poor choices exist. Desiring to embody "good-ness" and "do the right thing," the moral agents involved may feel deep regret that perfect solutions are not to be found. But moral discourse helps us to wrestle with alternatives, maybe even to create new ideas, that place our dilemmas in perspective.

To encourage moral discourse, many hospitals have established ethics committees. The very existence of an ethics committee is in itself a moral challenge. Does the ethics committee exist for the right reason? It should understand why it is assembled, and it should be able to give an account of itself. An ethics committee should appreciate that:

* There is a difference between ruling on an issue and having an opinion.

* It is not in the nature of ethics to be coercive, to have the force of law.

* Its power is its process, respect, gentleness, compassion, understanding of suffering, willingness to search for "good-ness," and capacity to teach and to reveal the bioethical literature.

* Its great utility is reinforcement of the moral ground in dealing with each patient as a person.

An ethics committee should avoid thoughts of "power" in contemplation of its obligations and importance. There should be no intent to command, to order, to direct, or to mandate. (These words sound alien and dissonant in the language of ethics.) The agenda of an ethics committee is not a "docket of cases" to dispose of or to decide. (Note the "legal" tone created by these words: "docket," "dispose of," and "decide"!)

If the first question of an ethics committee is, "Do we exist for the right reason?", the second question should be, "Can we help?" If the answer to the second question is no, the committee is doing something wrong or an inhospitable environment exists. We should hope, of course, that every hospital is sensitive to moral issues and is open to ethical questions. Bioethics illuminates and informs medicine in ways not always given to religion, law, and the state, and as much as any other discipline, bioethics is needed to address the lengthening agenda of the moral ground.

Shattuck W. Hartwell Jr., MD, FACPE, is Director of the I.H. Page Center for Creative Thinking in Medicine, Cleveland Clinic Foundation, Cleveland, Ohio. He was Chairman of the College's Forum on Bioethics and of its Roundtable when this article was written. He is a member of the Forum on Bioethics.