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Mortal Choices: Bioethics in Today's World.

Mortal Choices: Bioethics in Today's World

For some members of the medical profession, the recent entry of philosophers into the hospital setting as teachers, committee members, and consultants has not been an entirely welcome development. Philosophers have been viewed as intruding on the domain of physicians, disrupting the special nature of the physician-patient relationship, and usurping responsibility for moral decisions in medical care. Their methods and concepts have been criticized both for doing too little, because of their abstract nature, and for promising too much in the way of providing answers to moral quandaries. Such criticisms of philosophers call to mind Dr. Rieux's cutting observation of Father Paneloux in Camus's The Plaque:

[He] is a man of learning, a scholar. He hasn't come in contact with death; that's why he can speak with such assurance of the truth--with a capital T. But every country priest who visits his parishioners and has heard a man gasping for breath on his deathbed thinks as I do. He'd try to relieve human suffering before trying to point out its excellence.

In Mortal Choices, Ruth Macklin draws on her extensive experience as a "metaphysician among physicians" to rebut effectively the claim that philosophers are of little value in the clinical setting. A rich variety of cases of both "big" (termination of treatment, for example) and "little" ethics (informed consent and determinations of competence), originally presented at hospital conferences and consultations, provide points of entry for ethical reflection, as well as the background for Macklin's delineation of the philosopher's role in the physician's domain.

Macklin identifies the unique contribution of the bioethicist as consisting in "providing an ethical analysis." This includes specifying the ethical principles in conflict in a situation or that may be available to resolve the conflict; clarifying concepts and correcting moral reasoning; and furnishing an "objective frame of reference" to which various parties can appeal in discussion. The purpose of bioethical inquiry is not to provide "instant answers" to hard cases, nor is the moral philosopher primarily a problem solver. Rather s(he) is one who facilitates a "deeper understanding of the nature of moral conflict." Yet, an important question here is whether it is valid for the philosopher to move from identifying or describing the moral problem to defending a normative resolution. Indeed, there seems to be some tension in Macklin's position, since in her role as an ethics teacher and ethics consultant in a clinical setting she identifies her typical position as that of "advocating for the patient" (emphasis added). The ethical analysis provided by the philosopher in the hospital, then, may not be as morally innocuous as first appeared.

Macklin's evident skills in formulating an ethical analysis are effectively displayed in a broad range of areas, including informed and proxy consent, aggressive treatment and termination of treatment, determinations of competency and best interests, the allocation of scarce medical resources, and human subjects research. Her refreshingly accessible discussions, including consistent translation of "medicalese" so as to make matters comprehensible to the lay reader, typically begin with the presentation of one or more problem cases that are then used as reference points for substantive observations about various conceptual and ethical considerations. Indeed, although her title suggests bioethics is primarily about decisions, Macklin seems also to make a significant methodological point: cases in bioethical literature should be used not simply as a resource for problem solving, but also for training in problem setting, perception, and reasoning.

Of equal interest and moral importance are Macklin's comments about how health care practitioners approach moral decisions. Though "genuinely troubled" by both the frequency and the nature of moral problems that arise in medicine, practitioners are for several reasons "ill prepared" to address them. Macklin portrays a profession that is structured in ways that inhibit ethical reflection. A "hierarchy of power and authority almost military in its rigidity" persists, which places a premium on enlightened self-interest, and permits but minimal communication on morally troubling issues. In this hierarchy, nurses, residents and interns, and students find themselves easily intimidated by senior physicians, and patients often feel "subordinated, diminished, and reluctant" to be anything other than "good patients." The language used by practitioners to facilitate concise communication among themselves not only functions to define the boundaries of the profession, but also to conceal information from patients. Not surprisingly, therefore, many conflicts between professionals and patients or other "outsiders" are attributable to failures in communication, a problem reinforced by inadequate medical education.

It is perhaps because of the pervasive paternalism that she finds in medicine that Macklin advocates--and even errs on the side of--the patient's perspective and autonomy. She is particularly adept at exposing the self-serving assumptions that underlie physicians' peternalistic

Courtney S. Campbell is associate editor of the Hastings Center Report, and associate for religious studies.
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Author:Campbell, Courtney S.
Publication:The Hastings Center Report
Article Type:Bibliography
Date:Jun 1, 1988
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