A brief note on medical ethics

2012
I.

Elsewhere on this website the subject of ethics is defined in German and English variously, the different definitions being consistent with each other and serving to counter misapprehensions to north & south, east & west. In most of those definitions, ethics is counterpoised to the realms of rules (the law, established custom, individual rationality). But this is too narrow. Ethics must also provide an account of the virtues and of character, which are indeed touched on.

The contentious area of medical ethics does not fitwell into this scheme. We have derivatives of the Hyppocratic oath, but there are good reasons that the code of Antiquity has been revised extensively. The grand principle of doing no harm does not get us very farin the difficult cases, which are those grappled over by medical ethics committees and occasionally the courts.

At the heart of most of the contention are questions about when and how and by whom decisions can be taken on behalf of people either factually incapable or deemed to be incapable of taking informed decisionson their own. There are questions of autonomy & freedom, and of the dignity of human life, its possible inviolability, and its value especially in the light of degrees of suffering beyond commonplace imagination.

There are questions about the rights of family members to have a say, and it is also surely fitting to raise questions about the right of carers, rather than management or distant professional bodies, to exercise their judgement. There are moreover political and economic issues about the resources available and the competing demands made on these.

One observation to be made in the light of this panoply of dilemmas is that many of them have what is best termed a religious dimension. This is not simply because adherents of the different religions often hold strong opinions about the rights & wrongs involved. Problems about the beginning & end of life, and indeed aboutthe role and nature of suffering within human life, are perceived as serious and intractable even by peoplewith no religious affiliation.

If not as religious, the problems might otherwise be described as metaphysical or existential; or say they straddle a borderline between ethics and ontology. Often an attempt is made to resolve the dilemmas by ascertaining what is the case (e.g. when does an embryo become a human life), and to this end there is recourse to neurological or other biological evidence. What is striking, though, is that, in fact, these issues come down to matters of belief. Personal convictions get concealed behind a veneer of scientific fact, but the facts are so wide open to interpretation that they cannot, in principle, ever resolve what is at stake.

Some of the problems have to do with what can be known, i.e. they are epistemological. Here one crucial consideration is that of the timeat which something may be known. We cannot know the future; that is in the nature of time. We can sometimes make reliable predictions or engage in reasonable speculation. But there is always much room for doubt. And where there is doubt, there is the possibility of faith. But faithis, at heart, a religiousconcept, as in hope against hope, and as in prayer, in contrast to a reasonably rational expectation, which might seem to be a counsel of despair. Even for hardened secularists, there are, thus, areas of human experience that are religious in nature, albeit without recourse to any established religionor doctrine.

The hardened secularist might reclassify the attitudes as matters for psychology, but there is little reason to take Ockam's razor to the matter. That is, reductionism here would seem to deprive us of a useful category, since hoping against hope, for instance, is hardly in thesame league as, say, a psychological complaint (or "condition"). Religion is not a disease. This does not make religion right or compel credence; but it is unhelpful to disregard or dismiss attitudes that have been profoundly rooted in the minds of a majority of people over space and time. Elsewhere the author takes religion severely to task, but then of the bad variety rather than, that most precious and rare of things,true religion, which escapes easy identification or characterisation.

If we dig a little deeper, we might come to question a widespread model of reality. The commonplace idea is that reality is out there, whether we like it or not, i.e. most of the time independently of our will (that iswhat reality is all about), and that we can sometimes have knowledge of reality. On this conception, in principle, if there were not so very much reality and our brain capacity were not so tiny in comparison, we could know everything.

This model of knowledge and reality serves us very well most of the time. It is like the idea that language(i.e. sentences) map reality, not unlike the way an ordnance survey map depicts the streets in town and the hills & dales in countryside.

But both in physics and philosophy, this model of the relationship between knowledge and reality has been thoroughly discredited. I shall not labour the point here. That is what university degree courses in physics and philosophy are for. But, strange as it may seem, we actually sometimes if rarely decide what we know and what reality is. Or rather, at the extremes, the commonplace model of knowledge and reality breaks down. One such extreme is when we are confronting issues of life & death, or indeed of great suffering. Here we are trying to know something that is unknowable. Two things are crucial: the nature of time and the impossibility of generalisation. Sometimes knowledge emerges as time – or reality – unfolds, and then it seems in retrospect that a particular course of action was justified after all. This perspective may produce solace, or relief, or joy, depending. But this does not invalidate the reasoning at a past point in time which pointedto a different course of action; and it certainly does not justify a generalisation such that the "discredited" line of reasoning should be avoided in future

II. Determinism

At the risk of seeming to digress, consider for a moment the perennial subject of free will versus determinism. Some people are distraught by this question, while others remain indifferent. The question to ask is why should anyone be distraught.

Suppose a moment for the sake of argument (as a thought experiment) that the universe were indeed like a mechanical device, similar to clockwork or billiardballs in perpetual motion, such that all eternity were already decided. How would this conclusion, or knowledge, or insight, change our lives? We would still have to take decisions. Some people would be fatalistic about life, and others (including believers in determinism) could still be positive about their ability to influence the course of their lives and those of others. The point is that we would still not be in a position to predict what would happen, in lieu, as it were, of having to decide ourselves how we should act. The existence of a deterministic universe does not enable us to actually know the future because we cannot know everything even in the present and the past. For one thing, our brains are not big enough. And a big computer would also be too small;if it were big enough, it would constitute the universe, just as a map that detailed everything would have to be as big as whatever it was seeking to map.

There is also the problem that finding out about some things precludes the possibility of knowing others.The process of observation sometimes involves destruction; you have to interfere with the item you are trying to find out about. This happens at the subatomic ("quantum") level, but also, crucially, at the human level. For instance, if I ask you what you really think of me,my question has already changed your perception. Even if I use a clever computer imaging device to map the neurons in your brain, I will be none the wiser; atbest I could only speculate because whatever neural findings are made would have to be checked against statements or behaviour wide open to alternative interpretation. Besides, any knowledge I supposedly have must be stored in turn in my brain, which is not much bigger than yours. Moreover, any such knowledge would be unreliable, because certainty is never assured.

The error with the deterministic thesis is to thinkin the categories of reality, knowledge, the future, laws of nature, etc. and to deify these. It is a category mistake. Just because in an isolated case it may be possiblewith a degree of reliability (but not certainty) to make a prediction, does not mean it would be remotely conceivable to do so often, let alone for the whole interconnected universe. Determinism involves an illicit generalisation. Knowledge is a way of being in the world and in the human world of consensus. It is not a thing, like an encyclopedia, or even a vantage point in the the sky. It resembles – but this is only a metaphor – atool for living and making decisions and occasionally even reflecting on life. The debate on free will and determinism sounds like a scientific issue, but it is in fact only a phantasy, i.e. a piece of imaginative writing, like poetry, albeit bad poetry. Or indeed like bad religion.

III.

Thus we have returned to our core subject. In medicine, some decisions have to be taken that are of a kind that do not allow easy inference from general principleseven while there remains a desire, at least for people of a certain turn of mind, to have recourse to such principles. Judgement is required, and at the extreme such judgement will be a matter of taking decisions, including decisions about life & death. The task then is to ensure that those taking the decisions are not burdened too heavily while they also do not take the decisions too lightly. That will be a matter of character. The best we can hope for is conscientious practice.

This said, the wider conclusion I wish to press home is that, at heart, for believers and secularists alike, in the most intractable cases, our ways of thinking in medical ethics are significantly different to how we reasonabout ethics in other areas. There are convictions at play that are of a quasi-religious nature, and these convictions may well conflict.

Talk of respect for human life is perhaps better framed in terms of awe; but in terms, too, of our imagining what it may be like to be the person on whose fate we are ruling. One element of respect for human life has, it needs to be said here (as it is said elsewhere too seldom), to be a recognition and an acceptance of death. Religion might almost be defined by its preoccupation with first & last things, the beginning and end of life, and indeed of the role of sexuality in preceding a beginning. But respect for religion as such does not preclude the formation of value judgements about a particular religious belief, which may not be held in high regard. One person's faith cannot be allowed to overrule the convictions of others; or rather, some conflicts of convictions cannot be resolved. There is, in time, an outcome, one way or another, and that is that.

©2012 Paul Charles Gregory Version of August 25.