|
||||||
|
|
|
|
|
|
|
|
||||||
 |
Medical ethics in today's societyby LaSalle D. Leffal, Jr. , MD, FACS, Washington, DC I want to express my great thanks to the Board of Regents for the high honor to be chosen as the 1993 Ethics and Philosophy Lecturer. Cognizant of the great importance of ethics in surgical practice and the implications of our decisions, I accepted this challenge with alacrity but also with humility. On occasions such as this lecture, this speaker wonders if he will say the correct things or at least say them with the conviction and vitality that surgical and ethical principles demand. However, being in the company of colleagues—Fellows of the American College of Surgeons—makes my task an easier one in this regard. The College is deeply indebted to John Conley, MD, FACS, who proposed and financially supports this lecture, which is devoted to the essence of medicine—its character, style, discipline, and philosophy. Further, it allows us to consider the ethical dilemmas that confront surgeons today. Core values There are certain core values or eternal verities that form the basis of an ethical society—traits such as honesty, integrity, loyalty, courage, and respect for the dignity of others—that have been described in various ways as representing the foundation of moral character and behavior. This article is not intended to provide answers to ethical problems, but rather to present principles that should form the basis and framework upon which we make our decisions. With these fundamental principles in our hearts and minds, we can make judgments that will benefit our patients. Medical ethics is derived from core values, and an examination of these values places medical ethics in coherent perspective. Michael Josephson, founder and president of the nonpartisan, not-for-profit Joseph and Edna Josephson Institute of Ethics, states that the institute was designed to gather and focus the moral energy of people who want to do something to make our society more honest, free, caring, and accountable. Since its founding in 1987, the Josephson Institute has advocated that our American culture was built upon a foundation of 10 consensual ethical values that form the basis of an ethical society: honesty, integrity, respect, caring, fairness, promise-keeping, pursuit of excellence, civic duty, accountability, and loyalty. The institute contends that these 10 core ethical values form the philosophical basis for ethical judgment and define the moral duties and virtues implicit in ethical behavior.1 In July 1992 the institute, in what is now termed the Aspen Declaration, called for character education based on six core values: trustworthiness, respect, responsibility, justice and fairness, caring, and civic virtue and citizenship. The institute emphasized that these values—called the Six Pillars of Character—transcend cultural, religious, and socioeconomic differences. Of these six values, the first five have definite applicability to the practice of surgery, emphasizing the special relationship that exists between the patient and the surgeon. These values are not just to be mouthed but to be lived every day of our lives. The popular term health care provider, though readily understood in the context of health care delivery, is one that we as surgeons should cower from using. We are surgeons who care genuinely and deeply for our patients and don't just provide care—a small point perhaps, but an important one. It seems as though the term health care provider depreciates the truly special surgeon-patient relationship that forms the basis of trust between them. To aid physicians and surgeons in their professional duties, the American Medical Association publishes a "Code of Medical Ethics," which in cludes fundamental elements of the patient physician relationship and principles of medical ethics that involve the professional responsibilities and obligations of physicians.2 This manual provides guidelines, not absolutes, that help physicians in their ethical decisions as they confront a myriad of vexing problems. Moral issues and ethics Ethical issues will be among the most important as our national health policy is formulated. On September 22, 1993, President Clinton outlined to the nation the Administration's proposal for health care reform that seeks universal health insurance coverage for all Americans. In his proposed American Health Security Act of 1993, the President stated that the principles guiding the reform of America's health care system are: security, simplicity, savings, choice, quality, and responsibility.3 Much debate and discussion will take place before a national health plan is enacted, but demonstration of high ethical standards by all involved parties is essential. We must insist on ethical principles that will help to ensure the best surgical care for our patients. But implicit in this proposed national program, with its universal health coverage, is rationing—a word that is anathema to many surgeons. Rationing is not only an economic but also an ethical issue that would force surgeons to deny care to some patients. What is our charge as physicians? To cure when possible, to relieve pain and suffering always. Sometimes we fail in our charge, but when we fail and if we fail, we must always fail while trying. Yet pragmatism dictates that some prioritizing of our resources must be undertaken if we are to help the greatest number of patients. The Hastings Center Project on the Teaching of Ethics, held in 1980, emphasized moral issues—moral obligation and personal responsibility. The project members stated that in teaching ethics in professional schools, attempts should be made to have students develop perspectives useful in addressing moral and ethical issues while refraining from efforts to force their behavioral change. The members believe that with moral reflection and greater insight into ethical issues, changes in attitudes and beliefs are more likely to occur.4 Edmund Pellegrino, a noted medical ethicist, states that ethics is defined as the science of human conduct and that medical ethics refers to the whole medical arena—including care of the sick, prevention of illness, and cultivation of health for individuals and society. He firmly believes that ethics, a discipline with its own content and method, can be taught. Ethics deals with concrete judgments in situations in which action must be taken despite the uncertainty that must often be a part of clinical medicine. The attainable objectives are: (1) to teach the skills of ethical analysis essential to making medical moral choices, (2) to raise sensitivities to ethical issues in everyday clinical practice, (3) to enhance critical reflection on one's personal values and obligations as a physician, and (4) to identify the substantive ethical assumptions underlying clinical decisions.5 Moral considerations override others and all members of the profession are responsible for their moral credibility and that of their profession. Further, Pellegrino believes that medical ethics can be reconstructed and must be based on the "one irreducible foundation of all clinical medicine—the relationship between the one who is ill and the one who professes to help and heal."6 The concept of the "good of the patient" is the final criterion of whether a decision is morally sound.7 Spiritual values Spiritual values play a major role in ethhical behavior. Paul Tillich, a distinguished theologian, believed that courage was the ultimate answer to the meaning of life. He said, "Courage, as a human act as a matter of valuation, is an ethical concept. The courage to be is the ethical act in which man affirms his own being in spite of those elements of his existence which conflict with his essential self affirmation"8. And courage has been called the virtue that gives meaning to all other virtues. Often one sees patients swinging from self-pity to mordant bravado trying to muster the courage to confront a bewildering illness. As surgeons, we must have the courage to make the hard ethical decisions that will positively affect our patients' lives. Howard Thurman, who was professor of theology at Howard and Boston Universities and the author of 22 books of spiritual inspiration, was cited by Life magazine in 1953 as one of the 12 "great preachers" of the century. He emphasized "discipline of the spirit to deal with the possibility of failure related to the threat of error—to be victimized by error and at the same time keep on making choices with integrity is to grow in grace."9 And such is the lot of the surgeon making difficult ethical choices. Elie Wiesel, Nobel Laureate, writes and speaks movingly about peace, atonement, and human dignity. In his novel, Twilight, which is about hope, redemption, and friendship, Wiesel again emphasizes respect for the dignity of man.10 And high ethical principles in medicine must always be concerned with human dignity. Writing about physicians lying to the sick and dying, Sissela Bok, the author of numerous articles on medical ethics, states that there is no evidence that patients in general will be debilitated by truthful information about their condition. Rather, she says, we are all coming to learn much more about the benefits such information can bring patients. For the great majority of patients, the goal must be disclosure and the atmosphere one of openness. She states further, " . . . the perspective of needing care is very different from that of providing it. The first sees the most fundamental question for patients to be whether they can trust their caretaker. It requires a stringent adherence to honesty in all but a few carefully delineated cases. The second sees the need to be free to deceive, sometimes for genuinely humane reasons. It is only by bringing these perspectives into the open and by considering the exceptional cases explicitly that the discrepancy can be reduced and trust restored."11 Reminiscent in the thoughts that Bok expresses are the views represented by Leo Tolstoy in his powerful "The Death of Ivan Ilyich," in which Ilyich was deceived and lied to by his wife and his physicians.12 Such duplicity and hypocrisy made Ilyich's last days even more painful and agonizing. Would not the truth have been the more humane and ethical approach, allowing for a dignified death? Too often, we treat patients in their terminal phases of life, not as though they are dying, but as though they are already dead. We must show these patients our sensitivity and compassion. We hear so much about death with dignity but we must also realize that there is a need for life with dignity. And dignity for our patients must be preserved. Without the moral compass of our duty and obligation to our patients, we can be hurled quickly into the abyss of inappropriate behavior. Ethical lessons loom large here. Certainly attention to caring, truthfulness, and the concept of the good of the patient come more sharply into focus. Generally, telling the truth with hope, compassion, and sensitivity seems the best course to follow in these circumstances. High ethical standards There are few character traits that exceed loyalty in importance. Loyalty is one of man's highest virtues. It implies integrity and honesty, and integrity is the essence of our being. We must be loyal to high ethical principles as we treat our patients, but loyal to individuals only if they embody these same high principles. In the murky arena of ethical decision making, all surgeons must maintain their moral compass—their ethical talisman—to lead them ever on the course of what is best for their patients. A lack of ethics can blight the sacred relationship that exists between surgeon and patient. Maintaining that high standard of surgical discipline—equanimity under duress—prevents us from acting in a rash, intemperate manner that may often/lead to improper ethical decisions. These decisions are often difficult even after much time has been taken for deliberation and reflection. For the benefit of our patients, we must ever be seeking new ethical guidelines as different problems present themselves. Some individuals will say that now is not the time to embrace certain ethical principles. But time is neutral and we must decide the proper time to reinforce our concepts of ethics. Morality is what ethics represents and must dominate the relationship between surgeon and patient. We must demonstrate an intellectual suppleness that will allow us to be flexible and not rigid in evaluating the different points of view expressed in arriving at ethical decisions. Sometimes unpopular positions may be taken that some people will consider too radical or too new or as attempts to do too much too quickly, and we should be urged to restrain ourselves. These persons then ally themselves with the principle of the dangerous precedent mentioned by Francis M. Cornford, the English philosopher, in his lively university satire, Microcosmographia Academica, "Every public action which is not customary, either is wrong or, if it is right, is a dangerous precedent. It follows that nothing should ever be done for the first time."13 Although the statement is satirical, its moral, ethical, and pragmatic vacuousness needs no amplification. In making ethical decisions we must often consult with others to determine the best course of action to follow. We must do so with an open mind, weighing all factors in order to make the correct decision. Surely, we must avoid what Ambrose Bierce, the iconoclastic satirist and author Of The Devil's Dictionary, defines as consult—"seeking another's approval of a course already decided on."14 It is in this situation that the role of the ethical surgeon is vital. We must remember that there is no statute of limitations on retribution for some human transgressions—for example, not doing what is in the best interests of our surgical patients. Subtle threats are not intended but adherence to high ethical principles is mandatory. In taking care of our patients we should have boundless optimism leavened by proportion. Any apostasy from the principles of high ethical and moral behavior is unacceptable. As surgeons we must maintain a strong sense of ethical principles. We cannot be found wanting morally but must earnestly strive to demonstrate the highest ethical standards in our practice. When we see patients bereft of promise and hope, we must extend ourselves to them. Young surgeons are often motivated by the exuberance of inexperience and the romance of the novice, but in time this enthusiasm gives way to reasoned thought and judgment. Yet, we often have the experience but miss the meaning of what has happened. Walker Percy's essay, "Lost in the Cosmos," is a story of how we often lose the chance to experience things for ourselves, and how reality becomes what other people tell us it is." We must enter the fray and embody high ethical principles ourselves. In the thrust and parry of mental engagement that takes place often when ethical decisions are being made, those surgeons whose actions are guided by high ethical and moral principles usually win their case—not with invective but with reason, not with bombast but with eloquence, and not with specious argument but with sound judgment. For high ethical principles annealed in a surgical crucible of honor serve as moral beacons for us. Words are often incapable of expressing the real meaning of ethical concepts with certainty because each has a penumbra of uncertainty. More often than not, these high principles are resplendent in their elegant simplicity. Ethics and the patient The principles upon which the American College of Surgeons was founded in 1913 were high-quality care for the surgical patient and the ethical and competent practice of surgery. High ethical standards have always been an integral part of the College's philosophy. Today the ethical issues confronting the Fellows have becom. more numerous, tenuous, and amorphous—ofter defying ethically correct answers. We must re main steadfast in our devotion to high ideals and principles if we are to give our patients the best care. Some of the proferred answers to the searing ethical questions seem to lack the moral symmetry that fairness demands. For example, despite the advantages of universal coverage in the Oregon plan or the proposed national health plan, if any group is treated unfairly, the plan is morally and ethically unacceptable. We must then be even more vigilant in listening to the entreaties of our conscience to do what is in the best interests of our patients. Pellegrino states that a fundamental difference between a business and a profession is that at some point in the professional relationship, when a difficult decision is to be made, you can depend on the one who is a true professional to efface his own self-interest.16 This principle has been and must remain inviolate if we are to maintain the trust of our patients. For we know that respect and trust are not given in perpetuity but must be earned each day of our lives. Current medicine rejects immutable boundaries to human existence, for modern technology can extend life—even with quality—but ethical considerations are paramount if meaningful life is envisioned. Sometimes our success with technological accomplishments brings forth a hubris that is demeaning to patients and to our profession. Genuine concern for the surgical patient has been a valued principle for Fellows of the College for many years. So when we see ethical transgressions in any area, it is appropriate to ask if the embers of moral rectitude and probity are kindled. In the world of ethical objectivity and correctness, with its indistinct boundaries, we will make errors in some of our decisions—sometimes egregious ones—but we must never err in our purpose and our resolve. Infirmity of will and purpose is to be decried. We must maintain the requisite faith to do our job well, practicing high-quality surgery with concomitant high ethical principles, for the constant pursuit of these principles is ennobling. But we must never forget that the object of our affection is the surgical patient. If we ever forget that, then the Ethics and Philosophy Lecture and all other similar lectures will amount to naught. We will have forgotten the most important person—the patient. For we know that it is not just that we live but how we live. The quality of life remains most important. High ethical principles represent the grace notes of our profession and involve not so much intellectual rigor but a disciplined spirit. Ethics represents not just what we do or what we say but what we are. And probity and moral rectitude will always remain assets. What is important in our surgical practice is something the Romans called "gravitas"—moral and temperamental weight—that binds us in an ethical way to our patients. As a surgeon treating patients, I have seen the stubborn persistence of hope when under ordinary circumstances there should be no hope; I have seen patients who seem to regard life as a divisive and fractious experience devoid of hope and dream; I have seen the eyes of patients that seem to ask questions with the dignity of mute entreaty. Yes, I have seen a demonstration of courage that defies description and when I see these and more it lets me know that I must be more caring, more compassionate, and more sensitive to the patients who are committed to my care. Perhaps the French Jesuit philosopher, Pierre Teilhard de Chardin, expressed it best when he said, "Someday after mastering the winds, the waves, the tides and gravity, we shall harness for God the energies of love and then for the second time in the history of the world man shall have discovered fire."17 And it is that love and that fire that highly ethical surgeons exemplify so well. References 1. Josephson M: Making ethical decisions. Los Angeles, CA: The Josephson Institute of Ethics, 1992. 2. American Medical Association: Code of medical ethics, current opinions. Council of Ethical and Judicial Affairs. Chicago, IL: American Medical Association, 1992. 3. Clinton W: "The American Health Security Act of 1993." The White House, televised address, September 22, 1993. 4. Hastings Center Project on the Teaching of Ethics: Summary Recommendations. In: Callahan D, Bok S (eds): Ethics teaching in higher education. New York, Plenam Press, 1980. 5. Pellegrino ED: Teaching medical ethics: Some persistent questions and some responses. Academ Med, 1989. 6. Pellegrino ED: Toward a reconstruction of medical morality: The primacy of the act of profession and the act of illness. J Med Philos, 4:32-56, 1979. 7. Pellegrino ED: "The common devotion"—Cushing's legacy and medical ethics today. J Neurosurg, 59:567-573, 1983. 8. Tillich P: The courage to be. New Haven, CT: Yale University Press, 1952. 9. Thurman H: Disciplines of the spirit. New York: Harper & Row Publishers Inc., 1963. 10. Wiesel E: Twilight. New York, NY: Summit Books, Simon & Schuster Inc., 1988. 11. Bok S: Lying—Moral choice in public and private life. New York, NY: Pantheon Books, 1978. 12. Tolstoy L: The death of Ivan Ilyich. In: A Russian Proprietor, The Death of Ivan Ilyich and other stories. New York, NY: Thomas Y. Crowell Co., 1899. 13. Cornford FM: Microcosmographia academica, v. 7. In: Oxford Dictionary of Quotations, Oxford, Enland: Oxford University Press, 1979, p. 162. 14. Bierce A: The devil's dictionary. New York, NY: Albert and Charles Boni Inc., 1911. 15. Percy W: Lost in the cosmos. New York, NY: Farrar, Straus & Giroux, 1983. 16. Pellegrino ED, personal communication, 1992. 17. Teilhard de. Chardin P: On love and happiness. San Francisco, CA: Harper & Row Publishers Inc., 1984. Dr. Leffall is the Charles R. Drew Professor and chairman of the department of surgery, Howard University School of Medicine, Washington, DC. He is also a former Secretary of the College. Dr. Leffall originally presented "Medical Ethics in Today's Society" as the Ethics and Philosophy Lecture during the 79th Clinical Congress on October 13, 1993, in San Francisco, CA. Bulletin of the American College of Surgeons
Ethics and Philosophy Lectures
by the American College of Surgeons, Chicago, IL 60611-3211 |