An overdose of medical ethics
Doctors are expected to play God, but seem unwilling to play doctor.
Two recent court cases have put medical ethics at the forefront of public debate in the UK.
In Newcastle, doctors sought legal sanction to treat a baby with a severe facial deformity against the wishes of her parents. Elsewhere, a 43-year-old woman went to court to demand that her doctors switch off the ventilator that has been keeping her alive since she was left paralysed by a ruptured blood vessel. In the former case the parents acquiesced; in the latter, judgement has been postponed until after Easter.
These cases illustrate the paradoxical position of the medical profession in modern society. While, on the one hand, doctors are called upon to play the role of God, on the other, they are increasingly reluctant to play the role of doctor.
As a result of the long-term decline of religious authority, doctors are expected to make judgements on matters of life and death that individuals – and society as a whole – lack the moral framework to resolve satisfactorily. When the woman on the ventilator was asked by her doctors whether she would be prepared herself to switch off her life-support machine, she indicated that she would not (1).
When pressed over whether she would consider this to be committing suicide, she explained that though she would not consider it as such, she was concerned that others would: ‘I have a godchild who is struggling with this.’ In other words, she wanted her doctors to take actions that would lead to her death, actions that she was not herself prepared to take.
The sphere of medical ethics has expanded to fill the vacuum left by the demise of conventional morality. In response to the burgeoning ethical dilemmas of our time, a new cadre of medical ethicists promulgates codes of principles and conduct with as much zeal as any traditional preacher. In the absence of any wider moral consensus, such guidelines inevitably have a more pragmatic – and more contested – character than familiar doctrinal commandments. This creates great scope for ethical entrepreneurs to offer different interpretations, but does not contribute to the emergence of clear responses to particular problems.
While doctors relish their position of moral authority in society, when it comes to taking a stand, they are beset by insecurity. Hence they seek the endorsement of wider sources of authority – ethical committees, courts, the state. The consequence of the involvement of these external agencies in clinical decision-making is that relations between doctors and patients inevitably become embroiled in wider controversies.
So in the case of the Newcastle baby, the doctors invited the courts to intrude in their management of this complex case with a view to coercing the parents into accepting their proposed treatment. The question of how this baby should be treated became the subject of debate, not merely in the court, but throughout the media. Given the state’s enthusiasm for invoking the paramount interests of the child to justify the suspension of parental rights, a decision in favour of medical intervention could be confidently anticipated.
However, as some commentators have pointed out, this action must have had a damaging effect on relations of trust between the doctors and the family (which are of particular importance given the need for continuing treatment).
The trend for doctors to resort to ethical advisers and the courts to decide clinical problems reflects a profound loss of professional confidence and an abdication of professional responsibility. Doctors are using the courts to bully patients into accepting treatments when their powers of persuasion have failed. They are also allowing the courts to enter into the sphere of clinical decision-making.
This process begins with the involvement of ethics advisers, often moral philosophers or ministers of religion (sometimes both), in the day-to-day work of hospital care and medical research. Some object that these advisers know little about medical matters (but of course, this is regarded as a virtue). A more pertinent objection is that they know little about any of the important problems of modern society (hence the declining status of both academic moral philosophy and the established churches before the boost provided by the recent boom in medical ethics). In relation to the Newcastle baby, rival medical ethicists argued in the media for and against the provision of a tracheostomy – a subject about which we can safely assume they know nothing either in general or in particular (2).
One of the doctors involved in caring for the woman on the ventilator told the court that ‘we have all got to know her over the year and this is now more than a doctor-patient relationship’ (3). What this really means is that the doctors have allowed sentiment to overwhelm professional judgement, with the result that their relationship with the patient has become something less than a doctor-patient relationship. This violation of professional boundaries is presented as a badge of virtue and as a justification for allowing the court to decide how the patient should be treated. But doctors have a professional responsibility to maintain a degree of detachment, precisely because that is necessary so that they can make clinical decisions dispassionately and advise patients on the basis of what they consider to be in their best interests. Medical deference to third-party intrusion in doctor-patient relationships culminates in the surrender of professional responsibility.
In her comments on the case of the woman on the ventilator, Dame Elizabeth Butler-Sloss, the presiding judge, criticised the paternalistic attitude of the doctors, a theme that has been widely echoed in the media (4).
It is true that in neither this nor the Newcastle case do the doctors emerge with much credit. It was arrogant of the doctors to suggest that the patient’s anger impaired her judgement, and there was an unmistakable element of bullying in threatening the Newcastle parents with the might of the courts. But I would argue that in both cases an even bigger failing of the doctors was their abdication of professional responsibility. They allowed clinical problems to be transformed into ethical dilemmas and invited third-party intervention in a form that was more likely to make things worse and damage doctor-patient relationships.
At a time when society is confused over what is right and wrong, there is a tendency for people to turn to others to provide direction. Medical ethicists – with the ultimate sanction of the courts – are now offering to establish new standards for doctors and patients who cannot be trusted (and do not trust themselves) to do the right thing. The result is the sort of prurient and bullying intrusion in to individual freedoms that we have seen in these cases. The ultimate loser from the inflation of medical ethics is the patient.
Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
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(1) Guardian, 8 March 2002
(2) See Doctors who play God, Guardian, 8 March 2002
(3) Guardian, 7 March 2002
(4) Guardian, 9 March 2002
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