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Morals and Medicine
The Moral Problems of: The Patient's Right to Know the Truth, Contraception, Artificial Insemination, Sterilization, Euthanasia
By Joseph F. Fletcher
PRINCETON UNIVERSITY PRESSCopyright © 1979 Princeton University Press
All rights reserved.
HUMAN RIGHTS IN LIFE, HEALTH, AND DEATH
Ethics and Medical Care
Medicine and religion have always been closely associated, until comparatively recent times. Long after the disappearance of the primitive medicine man or priestly witch doctor the alliance still continued as a self-conscious and openly embraced affair. It was a long journey from the savage belief that the diseases afflicting men had a divine origin and served as punishment, hex, or magic (the art of healing therefore being a priestly task) to the blunt opinion of Martin Luther that "no malady comes from God." Their marriage in the past ceased to be completely harmonious once medical studies and -practice began to assert a certain measure of scientific independence of both religion and priestcraft. But for a long while they were like "an ancient Romulus and Remus, suckled at the lugs of a common wolf mother, the superstitious fears of the people." Even in modern America, only one generation before our own, it was not impossible to read on a rabbi's card, left on the table of a hospital waiting room, "Weddings and circumcisions respectfully solicited." Indeed, so ancient is our up-to-dateness that medical specialization first-began among the priests, for in the fifth century B.C. each Egyptian physician treated a single disorder under a divine (polytheist) charter, and the early Romans (before the Greeks won their prestige) had a deity for each disease. "Even the itch was not without its goddess," they used to say.
If we press the analogy of marriage as between medicine and religion, then we must recognize their divorce. Perhaps a better analogy is separation, a separation, however, which has not led to complete alienation. Perhaps they never come together anymore in the common bed of faith, but at least they face each other frequently in the drawing room of morals. Ethical values, morals and conscience, right and duty, the pursuit of life's store, simple existence itself — these matters are still common to both medicine and religion. In many more ways than most people suspect, not excluding physicians and clergymen themselves, medicine and religion have conscience and its claims at stake and in their keeping. We need not argue any longer, as Aristotle once did, whether moral law or medicine is nobler; whether it is a higher goal to make men virtuous or to make them sound of health. (Plato stated the position typically, putting morality before health.) In our times we have come to understand that the two go together, each a buttress for the other. This much at least is made clear in the fundamentals of modern psychosomatic medicine, whatever may be its future course of development. A few men felt the marriage was still valid even on the threshold of modern times. One Giles Fermen, a physician of Ipswich in the Massachusetts Colony, for example, wrote about 1650: "I am strongly sett upon to study divinitie, my studies else must be lost: for physick is but a meene helpe." Later he went back to England and took holy orders.
The very first medical treatise published in America, and the only one to appear in the seventeenth century, was written by a clergyman of Boston in 1677. The Reverend Thomas Thatcher, first minister of the Old South Church, wrote a broadside describing smallpox and urging its quarantine as a moral obligation upon both individuals and the community. In the early decades of the next century his precedent was followed by Cotton and Increase Mather, and by fellow parsons who gave moral support to Dr. Zabdiel Boyleston, then making "scandalous" inoculation experiments in which his own son was a guinea pig. Their moral defense of inoculation roused a storm of popular excitement and protest, ending in the destruction by arson of the first hospital for inoculation at Cat Island, Marblehead, in 1773. Such is the technical specialism of our own times, two and a half centuries later, that no non-medical writer would (or should) attempt to follow Mr. Thatcher into the field of medicine, even though we still claim the right to invade the ethics of medical care. Whether fireworks will result when we do, remains to be seen.
It would be well to be quite clear about the scope of this inquiry. We are dealing with the ethics of medical care. This means we are not dealing with medical ethics, a term which is usually used for the rules governing the social conduct and graces of the medical profession. The American Medical Association, in its Principles of Medical Ethics, has formulated the essential rules of the fraternity. They are not elaborate. Medical ethics is the business of the medical profession, although certainly it has to fall somewhat within the limits of social obligation. The literature on professional medical conduct is relatively sparse. Dr. Richard C. Cabot declared in 1926 that he knew "of no medical school in which professional ethics is now systematically taught." That situation remains in force in pretty much the same degree today, except in the Catholic medical schools. The most consistent treatment of the subject, based upon experience of a high order, is to be found in the George Washington Gay Lectures delivered from time to time at the Harvard Medical School. To be quite frank, a typical discussion of medical ethics is not a very serious or challenging enterprise in moral judgment. The extant literature on it consists for the most part in homilies on the bedside manner and such calculated questions of propriety and prudence as shined shoes, pressed trousers, tobacco odors, whether to drink Madeira, and the avoidance of split infinitives! It is composed, in a phrase, of manuals or exhortations on competitive success.
Dr. George Jacoby gives medical ethics a somewhat loftier definition. He has expressed the view that it deals with "the question of the general attitude of the physician toward the patient: to what extent his duty obligates him to intervene in the patient's interest, and what demands the physician has a right and duty to make upon the patient's relatives in regard to obedience and subordination for the purposes of treatment." Dr. Jacoby's use of such essentially ethical terms as "right" and "duty" brings us much closer to what we mean by "the ethics of medical care," as distinguished from medical (professional) ethics. But first it is worth our while to take full note of Dr. Jacoby's words: nowhere among them is there anything about what demands the patient has "a right and duty to make" upon his physicians. It is from this other perspective, from the patient's point of view, that we shall try in this book to examine the morals, principles, and values at stake in medical care.
We are not to suppose that doctors are tyrants or megalomaniacs. These maladies operate as occupational hazards in other professions as often as in medicine. Professional medical ethics in this country has come a long way from the attitude expressed in the American Medical Association's code of 1847, in which it was urged that the physician should "study ... to unite condescension with authority" because "reasonable indulgence should be granted to the mental imbecilities and caprices of the sick." There is very little disposition (or possibility) of preserving what Dr. Cabot once called rather shortly the "old tradition of aristocratic, benevolent autocracy in medicine." On the contrary, with the advances we have made in the psychology of therapeutic relationship there is today a general understanding that a person-centered approach to illness is superior to the problem-centered approach, and consequently the doctor's work is more deliberately predicated upon "the recognition of the worth of human personality" and its rights. A hundred and fifty years ago the English physician Parry said that it is more important to know what manner of man has the disease than to know what disease he has. After all, it might not be stretching logic too far to say that the spirit of the modern age would reverse the old anti-medical saw, "The operation was a success but the patient died." Recent developments in the dynamics of medical care would almost be content with, "The patient was a success, but the operation failed." Most dictionaries recognize that the word "patient" comes from pati, to suffer or endure; suffering is a personal experience, and therefore a primary factor in illness. It raises the physician's problem from a merely technical one to the level of moral and spiritual values. Sir William Osier said that medical care is founded on the age-old desire of man to help his suffering brethren, a motive that makes the relationship of doctor to patient a moral one at bottom.
As Dr. Francis Peabody of the Boston City Hospital once told the Harvard medical students, "One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient. ... The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal." The moralist's interest in the ethics of medicine has to do with the care of a patient, not with the treatment of a disease. We are concerned with medical care rather than with medical treatment. Dr. Peabody's phrase captures the heart of the matter; the care of a patient "must be completely personal." And the person cared for is vastly more than a patient. "What is spoken of as a 'clinical picture' is not just a photograph of a man sick in bed; it is an impressionistic painting of the patient surrounded by his home, his relations, his friends, his joys, sorrows, hopes and fears." What is this, but to say that a patient's moral and ethical rights and interests must weigh as heavily in the medical scales as his physical needs and condition?
Fatality versus Morality
What, to turn directly to our subject, are our human rights in health, life, and death to which the patient may lay claim ? Health, life, and death are parts of a single continuous process of human existence. Life and death are the original and terminal points, and health lies in between them as our defense against "the thousand natural shocks that flesh is heir to." The media, vita of the burial office in the Book of Common Prayer says that "in the midst of life we are in death," and this poetic way of putting it has full medical authority. Dr. Alfred Worcester has explained that "in point of fact we are always dying." Health, life, and death are a continuum, a single web of being. In the nature of the case nothing is more decisive for us than life and death, being born and "giving up the ghost" again; nor is anything more precious than the health of mind and body which makes our passage between these two crises one of beauty and joy rather than of ugliness and crippled being. Too much of the time (as we shall see) these decisive events lie outside human consciousness and rational control, which is the ethical significance of Dr. Osier's remark, in an Ingersoll Lecture, that most people die as they were born, not knowing what is happening.
Medical care is provided for persons. As Paul Tillich says, "'Person' is a moral concept, pointing to a being which we are asked to respect as the bearer of a dignity equal to our own, and which we are not permitted to use as a means for a purpose, because it is purpose in itself." This is of course a restatement of Kant's second maxim, "Act so as to treat humanity, whether in thine own person or in the person of another, always as an end, never as a means only." If medicine is completely personal it takes account of our human rights. We have certain rights, each of us, in our health, life, and dying. Justice, the philosophers say, consists in giving to all their due, their rights, that to which they are entitled. And to what, exactly, are we entitled in being born, in seeking and keeping health, in dying and "shuffling off this mortal coil"? To answer Hamlet's question, none of us has it in his power, to begin with, to choose whether "to be or not to be." Whether we are born at all or not lies entirely with others to decide, not with us. But whether we shall continue to be, to live, and upon what terms of life and health we make our choice, these are matters in which we can exercise some freedom, some choice, as responsible creatures.
Choice and responsibility are the very heart of ethics, and the sine qua non of a man's moral status. While it is true that we have no responsibility for our own birth, and therefore no moral stake in it, we do have a moral stake in the conception and birth of others, of those whom we bring into this world as we ourselves were brought. Life, health, and death are therefore moral issues. We can "do something about them" and therefore we have to decide what to do. It is this fundamental truth about our human existence which sets us apart from the rest of the animal order: the fact that so much of our destiny is or may be a matter of deliberate decision, of rational conduct, rather than of merely instinctive behavior. The whole history of man's moral growth since what Breasted called "the dawn of conscience" and classical or old-fashioned theologians call (so curiously) "the Fall," has been our steady march upward in the scale of responsibility from predetermined to self-determined action, from customary to reflective or rational morality. In moving beyond brute existence man (who is so much weaker physically than many of the vertebrates) has had only two biological advantages with which to emancipate himself from nature's irrational limits and habits. One, and the more important one, is the higher intelligence to help him choose between ends, as well as between means. The other is his upright carriage, which has freed his hands, and gained him his Greek genus-name anthropos, meaning "the one who walks with his face to the heavens."
The dimensions of our moral responsibility expand, of necessity, with the advances made in medical science and medical technology. Almost every year brings with it some new gain in our struggle to establish control over health, life, and death. There are far fewer reasons for us, in this generation, to be fatalistic about these crucial episodes of our existence than there were for our forefathers. Fatalism, which reflects a lack of control, is the outlook of those who are helpless to prevent or to put an end to what they might not choose had they the power of choice. Just as helplessness is the bed-soil of fatalism, so control is the basis of freedom and responsibility, of moral action, of truly human behavior. A "human act" in ethical theory and moral theology is defined as one which is free and understanding, not limited invincibly by ignorance or constraint. It is for this reason that science, in spite of its frequent tragic misuses, contributes to our moral range and the magnitude of our ethical life; technology not only changes culture, it adds to our moral stature. The "technology" of sex, as a part of medical care, illustrates the general rule. For example, prophylactic and contraceptive devices have eliminated the old restraints upon extramarital sexuality, the old triple terrors of conception, infection, and detection, which once held people in line. These risks are almost a thing of the past. Science tends to remove moral compulsions. This means, by a significant paradox, the moral responsibility is being enhanced; our moral stature is heightened. It may not seem so, at first sight, to those who learn that in the final stages of the Second World War the U.S. Army was giving out 50,000,000 individual prophylactics each month. Here is, admittedly, a measure of the promiscuity in our culture at the level of military and official practice. There is no way to estimate it for the civil populace as a whole. The widely debated taxonomic studies of sexual behavior in the American male and female, made by Dr. Alfred C. Kinsey and his associates, are a big step in the direction of more exact knowledge of our sexual mores, and their findings to date certainly seem to confirm the view that heterosexual practices are not at all restricted to monogamous marriage. Nevertheless, when external sanctions such as fear of consequences are minimized by medicine, then our internal controls are thereby raised to a higher power of importance. And, of course, with every such increase of personal responsibility and free choice, the chances of moral failure are also increased. The fact of failure raises a problem of religious resources, of "grace" and moral strength, but that would be the subject of another book.
Excerpted from Morals and Medicine by Joseph F. Fletcher. Copyright © 1979 Princeton University Press. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
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