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The Scylla and Charybdis of Medical Ethics: Not Enough Medicine, Not Enough Ethics

I was at a conference last week in
medical ethics, and I was surprised by, or perhaps appalled at, the attitude
displayed by many of the philosophers regarding the importance of medical
knowledge in medical ethical decision making. Several of them proudly announced
a total ignorance of the medical issue they were speaking on, and also showed
no interest in what I would call “real world” implications of their
  Although I have a PhD in
philosophy, I am not a philosopher in the sense that I am capable of, or
interested in, spinning arguments from “thin air” with no grounding in medical
facts, and no implications for real medical practice.
  Medical ethics must begin in real life issues
and problems, and end with equally real and meaningful conclusions that can be
applied, and sometimes even empirically tested.

is not to say that philosophers cannot make good, or even great,
medical/clinical ethicists. But they need to begin with a healthy respect for
the way in which the “facts on the ground” inform the ethical
decision-making.  A brief example
illustrates my point.  In Hilde Lindemann
Nelson’s famous
article explaining narrative ethics, she discusses the case of
Carlos and Consuela. Carlos is an HIV positive gang member
wounded in gang violence, who is recovering from his injuries in a
hospital.  He is now ready for discharge,
but needs dressing changes at home.  He
wants his sister Consuela to do the dressing changes, but he insists that she
not be told about his HIV status.  While
Dr. Lindemann Nelson uses this case to make several excellent points about the
limitations of principle based ethics, one aspect of the question, crucial to
any ethical reasoning on the case, is obviously the transmissibility of HIV
infection through dressing changes.  This
“fact” is an essential aspect that underpins any ethical judgment regarding the
case.  The conflict between patient
confidentiality and duty of nonmaleficence (toward Consuela) pivots in part on
the fact that HIV is not readily contagious, and simple universal precautions
should make the risk to Consuela essentially nil.

if it is problematic when philosophers inveigh on issues of medical ethics
without a proper respect for the way medicine itself has something to say to
ethics, equally frustrating are physicians who think that ethics is just
“opinions” or that the principle of patient autonomy is the only thing that
decides all questions of medical ethics. Physicians sometimes use a simplistic
unnuanced version of principalism that places patient autonomy hierarchically
over the other principles of bioethics. 
This absolute support of patient autonomy is ethically unjustified and
often disingenuous, in that when physicians claim they cannot overrule a
patient’s choice no matter how ill advised or potentially dangerous this choice
may be, it often also serves the physician interest as well.  For example, in my specialty this argument is
sometimes invoked when a physician is justifying a hysterectomy that doesn’t
meet accepted medical indications or when a physician does a cesarean delivery
on patient request.  In both cases, the
patient and physician interests align, and the physician is justifying her
decision by claiming to respect patient autonomy, while conveniently forgetting
that the principles of beneficence and nonmaleficence may also have something
to say in these cases.

questions of medical ethics are wide ranging, and they require attention to
both the medical details, and the ethically relevant principles. Being a good
ethicist, and being a good clinician requires sailing between the six-headed
monster and the whirlpool (Scylla and Charybdis).  There is a successful path between, but it
entails attention to both medical facts and ethical theories.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website. 

This entry was posted in Clinical Ethics, Health Care and tagged , . Posted by Hayley Dittus-Doria. Bookmark the permalink.

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