October 1979 I/2
CAN WE AGREE?
Medical history shows that in every age medical practice has been embroiled not only in scientific controversies, but also in ethical ones. The introduction of fascination, the use of quinine, the administration of anaesthesia, performing heart transplants, and defining death through lack of brain activity, all produced serious ethical controversies. Many of these ethical issues continue to this day and are hotly debated. The unfortunate side effect of ethical debate is that people often become discouraged with reaching an agreement. Thus they separate into diverse groups and ultimately converse only with people who agree with themselves. Health care professionals often wonder why there are such sharp differences in the realm of medical ethics.
Principles There are many reasons why ethical questions are inevitably controversial. The main reasons are:
1. Ethical questions are complex, involving many different factions such that it is possible to get different results by emphasizing different aspects of a problem. Thus, in the abortion issue, one group emphasizes the rights of the mother and the other group emphasizes the rights of the unborn child and little dialogue results.
2. Ethics deals with profound and mysterious issues of human life such that our knowledge of values involved is incomplete and always open to further study.
3. Ethical matters cannot be completely universalized into rules because they involve the individual and individual situations, so there is always a difficulty in apply general-rules to concrete cases. Thus ethics is not relativistic because we do have much in common. But applying principles to individual cases is more than a mathematical procedure.
4. Ethics treats questions not only of fact but also of value. Values influence both our thought and our feeling and will. They involve an essential element of subjectivity as well as an objective foundation in human experience.
5. Ethical decisions not only affect abstract questions, but also directly change our personal lives. Because such change is painful, it is difficult not to be prejudiced in ethical judgment since "no person is a good judge in his or her own case." Usually, we try to defend our prior ethical positions rather than subject them to criticism.
6. Ethical perceptions depend upon our concrete experience, and all persons or groups have their own history and special culture which profoundly influence their ethical outlook. Thus we are intimately involved in our ethical viewpoints.
7. Fundamental to all particular ethical judgments is the religion or its equivalent philosophy of life with its value systems to which the individual or group consciously or unconsciously adheres.
8. Besides the difficulties which arise from our human finitude are also the difficulties that have their origin in what is called human sinfulness which darkens our understanding and distorts our motivation. Whether this sinfulness is the result of human history embodied in social structures or of our own individual contribution to this human condition is in a sense immaterial. It is present in our lives, whether we look upon it as primarily social or primarily personal.
Discussion In view of these difficulties, how are we to develop a satisfactory and mature approach to ethical controversies in medical discussion? A hint of an answer can be derived from the psychological studies of 3ean Piaget and Lawrence Kohlberg which have shown that in most groups of adults there are persons at different levels of development in ethical thinking, corresponding to the phases through which a child must pass to full moral maturity. These phases can be summarized in three main topics:
1. The small child tends to make decisions on the basis of the immediate consequences of an action, or rewards and punishments.
2. The growing child begins to make decisions more and more on the basis of social approval of parents or peers. Conformity to group norms becomes paramount, and satisfactions can be delayed and suffering incurred to achieve approval of others.
3. Moral maturity is marked by an increasing internalization and independence of such moral judgment. Decisions are now made on the basis of personal standards, and the standards of society became subject to criticism. The adult acts primarily for self-approval even at the cost of disapproval by the group. It seems that most ethical controversies are carried on largely at the second of these levels. The debaters each proceed on the assumption that the value system of their group, whether it be that of a social class, a professional elite, or a church, is self-evident and they make little or no effort to understand the viewpoint of opponents who live within other, competing value systems. This mind set has been demonstrated by various groups within the field of health care as they disagree over ethical issues. But it is also demonstrated by health care professionals as a group as they disagree with other groups in society over value issues.
In the United States the four main value systems involved in most public debates are Humanism, Judaism, Catholicism, and Protestantism with their many subsystems. Because each of these groups rests its arguments on assumptions the others do not share, public controversies on medico-moral matters., for example, on abortion or therapy for the dying, tend to end in stalemate. However, with patience and fairness it may sometimes be possible to pursue a question to the third and mature level of ethical thinking in which it becomes possible to subject even these assumptions to examination, reinterpretation, and, we hope, eventual ecumenical convergence. Ethical discourse of this nature requires patience, understanding, and generosity; Let us hope these qualities will characterize ethical investigation at the St. Louis University Medical Center.
Kevin O'Rourke, OP
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