Commentary Magazine


Bioethics

To the Editor:

Sally Satel and Christine Stolba are doubtful about the work of medical ethicists [“Who Needs Medical Ethics?,” February], and count me among these characters, quoting an article I wrote some 30 years ago when I began working in the field. They blame me and others for “encouraging doctors to give full consideration to certain key principles in resolving clinical dilemmas,” among them, the principle of autonomy, that is, gaining the consent of patients for medical procedures.

After three decades of following “the little party of doctors, nurses, and medical students to the bedside of very sick people” (as the authors quote me), I am more convinced than when I started that medical ethicists are doing some good. At the same time, I could not agree more with the authors’ argument that doctors themselves are responsible for the patient’s life and must make the tough decisions. They are correct to say that doctors must have the same abilities as bioethicists: creative problem-solving, listening well, communicating interest and respect, and distinguishing ethical dimensions of a problem from other overlapping dimensions.

But medical doctors need to be taught these skills. They cannot operate on their instincts, even good ones, in a complex world of technological and bureaucratic medicine. Bioethicists are principally teachers. By far the majority of us are employed as faculty in schools of medicine. We do not make medical decisions in any sense whatsoever. Instead, we help to place those decisions within the context of moral and religious beliefs, cultural attitudes, legal constraints, financial pressures, and historical precedents that may influence, often unconsciously, a physician’s perception of the medical situation.

The authors relate several cases in which they see an ethicist’s advice as outrageous or unnecessary. I might agree with their critiques, but I also know that such cases often occur in a context that can explain the ethicist’s advice. Women have been coerced and imprisoned for endangering their fetuses; patients refusing treatment have been deemed insane on no evidence but their refusal; persons with a history of alcohol abuse have been removed from lists of transplant candidates. These are not simple questions to be resolved by the moral instincts of a good doctor. They require a thoughtful review of the circumstances of the case within a broad understanding of the nature of the problem.

Bioethicists are supposed to teach that broad understanding, and doctors are supposed to draw upon it to make informed, compassionate decisions. Far from taking anything from physicians, my colleagues and I have helped them to perform better their own responsibilities.

Albert R. Jonsen
University of Washington
Seattle, Washington

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To the Editor:

As one of the medical ethicists targeted by Sally Satel and Christine Stolba, I am glad for the opportunity to respond to their account of a case discussed in my recent book, Genes, Women, Equality. The authors describe my view of the case as “ideologically blinkered.” After checking in the Oxford English Dictionary, I am happy to acknowledge that their characterization is correct.

The OED defines “blinkered” as “having a limited range of outlook.” Because I am human and finite, my range of outlook is as limited as that of other finite humans, including Sally Satel and Christine Stolba. The OED defines “ideological” as “belonging or relating to the study of ideas” and as “occupied with an idea or ideas, especially of a visionary kind.” Either definition captures the fact that my research and teaching as a philosopher have long focused on ideas, particularly on the idea and ideal of human equality or justice. This ideal necessarily includes gender justice.

After describing Julia Smith Andre’s failure “to follow a restrictive diet to keep her child from having serious birth defects,” the authors pronounce their “verdict on her behavior”: “she violated her duty to her unborn child.” This verdict, they claim, “would seem straightforward.” Those familiar with further details of the case (discussed in my book, Genes, Women, Equality) might not agree. Among the unmentioned and potentially relevant details is the fact that the diet alone, consisting solely of fruits, vegetables, cereals, fats, and bread, was inadequate to support fetal development. In her first pregnancy, the diet had nauseated Julia, and her husband, an unemployed chef, detested its blandness. That pregnancy had produced a healthy daughter even though Julia had not been informed of diet recommendations until she was six-weeks pregnant, when damage to the fetus might have already occurred. At ten weeks of pregnancy, she had agreed to nasogastric tube feedings; this was followed by a gastrostomy, to allow percutaneous feedings, and by months of hospitalization.

In her second pregnancy, when Julia’s efforts to conform to the restrictive diet were unsuccessful, she was asked to consume 240 pills a day or undergo repeated intravenous infusions to promote fetal well-being. Apparently, she was not faithful to the diet and she did not consume all of the pills. Julia also refused intravenous infusions and hospitalization, and eventually gave birth to an affected daughter. At a conference discussing the case, one of her doctors indicated that Julia would probably become pregnant again because her husband insisted on having a son.

When they render their verdict on what Julia should have done, Sally Satel and Christine Stolba do not distinguish between absolute and prima-facie duties. Absolute duties are obligatory in all circumstances; prima-facie duties may be overridden by other duties in particular circumstances. I agree that women (and men) have a prima-facie duty to promote the well-being of their future children. It does not follow, however, that others have a moral right to coerce them to undergo treatment, especially such invasive, prolonged, and burdensome treatments as Julia faced. Nor does it follow that this prima-facie obligation is as ethically compelling in Julia’s case as it would be if the treatment imposed only a moderate burden upon her.

While objecting to the claim that those most affected deserve a “privileged status” in determining whether medical interventions are performed, the authors seem to have missed an important caveat in my account: “granting privileged status does not imply that their decisions should always prevail.” Respect for patient autonomy is a prima-facie duty, not an absolute one. This prima-facie duty is supported on epistemological as well as ethical grounds: the standpoint of those most affected, whose input might otherwise be lost, offers a corrective lens to the inevitably blinkered vision of those who judge their behavior.

Mary B. Mahowald
University of Chicago
Chicago, Illinois

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To the Editor:

Sally Satel and Christine Stolba raise some interesting points in their criticism of medical ethics and medical ethicists, but they make a fundamental error by taking examples of poor ethics and poor ethicists and pejoratively generalizing from them.

In particular, the authors criticize “the relentless emphasis of bioethicists on the idea of personal ‘autonomy.’ ” But it is now accepted, not least by many doctors, that patient autonomy and “shared decision-making” are essential for the good practice of medicine. The old-fashioned paternalistic view that doctors always know best can no longer be justified, especially since there is a great deal of doubt about the clinical effectiveness of many treatments offered by healthcare professionals.

The authors also complain about ethicists who could not reach a consensus in deciding how to deal with a patient in a permanent vegetative state. They suggest this is analogous to doctors not being able to agree on the treatment of someone with appendicitis. Unlike in the case of appendicitis, however, there are huge ethical issues involved in the treatment of patients in permanent vegetative states. In both Great Britain and the U.S., such cases have been referred to the highest courts.

Sally Satel and Christine Stolba imply that ethicists have no role that could not be performed by doctors. But this presupposes that doctors have been trained in ethics in the first place. Although medical ethics is now being taught in most medical schools (certainly in England), it is only for a few sessions a year. And many doctors currently practicing have had no training in medical ethics at all. It took me seven years to study medical ethics while completing a master’s degree and a Ph.D. Are the authors really suggesting that such training will be of little use to either doctors or their patients?

In fact, not only is there an essential place in medicine for medical ethics, but, arguably, ethics should lead medical practice. Discussion of subjects such as consent, confidentiality, euthanasia, and the rationing of health care cannot be meaningful without consideration of the ethical issues involved, and we should not rely on the intuition and prejudices of doctors or the public to make informed decisions in such matters.

There is certainly a need for doctors to understand ethics, but until the medical curriculum is extended to include more instruction on the subject, it will be unrealistic to expect doctors to be as knowledgeable as they should be.

Michael M. Rivlin, M.D.
University of Leeds
Leeds, England

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To the Editor:

Sally Satel and Christine Stolba appropriately criticize some aspects of the burgeoning enterprise of “medical ethics.” But they also bring narrow partisanship and inaccuracy to their judgments.

The proximate cause of applied-ethics programs in universities was not, as they say, the campus upheavals of the 60′s but rather the new availability of funding from government and foundations. The founders of the field did not want philosophers to “leave behind the historical and technical questions that had long dominated their discipline,” but to extend those skills to other areas. Philosophy has long involved different emphases on exploring abstruse questions versus “living a good life.” Applied philosophy, especially in the American pragmatic tradition, is not, as the authors say, a euphemism for political agitation.

The authors do not think much of “informed consent” or the concept of patient autonomy—labeling such concerns “liberal.” Some of the examples they choose do indeed show that people make self-destructive and stupid choices, and can be, as the authors say, “plainly incapable of deciding matters for themselves.” But what follows from the truth of this claim—taking such choices away?

The authors are also concerned that medical ethicists have impinged on “the traditional duties of physicians.” But everybody has impinged on them—patients, families, nurses, feminists, hospitals, lawyers, HMO’s, the government, even other physicians with different clinical and political views. This glorious interaction, including what ethicists bring to it, is just possibly a salutary thing. One physician cited in the article complained that medical ethicists make it seem that the doctor “is looking for affirmation elsewhere” and “can’t make up his own mind.” This might be the beginning of wisdom.

Morris Grossman
Fairfield University
Fairfield, Connecticut

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To the Editor:

As a senior practicing geriatrician who has recently completed a master’s degree in bioethics, I have observed the serious problems caused by leaving “ethics” to physicians and the limitations that nonclinically trained ethicists exhibit when confronted with bedside dilemmas. The studies that show discordance in opinions among ethicists do not detract from the substantial benefits that knowledge of ethics brings to the clinical domain. The error lies in considering an ethics consultation to be a clinical consultation.

I prefer to think of ethics as a framework by which each of us involved in difficult care decisions can contemplate whether or not we have considered perspectives that may not be part of the standard clinical approach to problem-solving. Certainly physicians who are responsible for institutional policy regarding resource allocation benefit from the conceptual frameworks provided by knowledge of ethical principles.

One of the important questions that must be addressed is whether the future of clinical ethics lies within the purview of non-clinicians trained in bioethics or should be shifted to clinicians who receive subsequent education in bioethics. I suspect the latter will result in a more robust interplay between the knowledge that comes with clinical practice and the important principles that provide the underpinnings of bioethics.

Michael Gordon, M.D.
University of Toronto
Toronto, Ontario, Canada

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To the Editor:

The only way to make sense of “Who Needs Medical Ethics?” is to conclude that it is an excerpt from something that might be respectable in its fuller form. Instead of a dispassionate intellectual or journalistic analysis, the authors give us only a diatribe based on a severely limited and even biased perspective.

The Catholic and Jewish legal-moral traditions, for example, are highly developed systems of principles—and values—that can be brought to bear on medical decisions. But one would not know this from the disparaging remarks of Sally Satel and Christine Stolba about “self-styled” ethicists. Unmentioned by them, incredibly, are such issues as sanctity of life versus quality of life. Instead, among the targets of the authors’ dyspeptic attack is the concept of patient autonomy, which I am happy to inform them finds no place in the values of the Jewish and Christian religious systems.

[Rabbi] David M. Feldman
Jewish Institute of Bioethics
Teaneck, New Jersey

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To the Editor:

Hooray for Sally Satel and Christine Stolba and their efforts to expose the injustice befalling America’s sick as a result of medical-ethics “experts.” As a resident in surgery at a large teaching hospital, I am baffled by the interference of medical ethicists in patient care. By vesting medical ethicists with a pulpit from which to sermonize and influence care, hospital administrators fail to understand that the art and science of medicine are intimately related.

The intervention of a third party in the doctor-patient relationship reduces the physician’s role to that of mere technician. Most troubling, the delegation of ethics issues to lay people implicitly compels physicians to abandon their patients, often during their greatest time of need. Patients do not want an automaton unguided by ethics caring for them. They want a well-trained humanist who can help alleviate both their physical and emotional suffering.

As I complete my medical training, I can only hope that I grow more able to treat my patients as whole beings and not as a collection of separate problems. Abandoning my patients by “consulting” others on issues of medical ethics is simply not a responsible option—I took an oath that prevents me from doing so.

Elan B. Singer, M.D.
New York City

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To the Editor:

Bravo to Sally Satel and Christine Stolba for a long-overdue critical look at the dubious need for medical ethicists. To be fair, though, it is not so much that these practitioners have invented themselves as that the need for them has been created by the conflicting moral signals that have arisen from various judicial rulings and state laws. The result is a perplexed society that is seeking clear guideposts in a labyrinthine mess.

None of this should be surprising, given that “patient autonomy” is the sacred cow of our time and that the traditional role of physicians as medical decisors is seen as unacceptably paternalistic. Though committing suicide is still illegal in most states, statutes exist guaranteeing the right of a patient or proxy to make decisions regarding the withholding or withdrawal of care that are tantamount to suicide but preserve “autonomy.”

While it is true that mind-boggling medical advances coupled with longer life-expectancy have created new “gray areas,” it was not that long ago that physicians well understood their charge of prolonging life and mitigating suffering. Now, they are asked to temper medical decisions once made on the basis of medical necessity with extraneous considerations such as family wishes and directives left in advance by patients. Ever mindful of the new bottom-line mentality that has overtaken the healthcare industry, hospitals force doctors to be the allocators of limited medical resources by triaging admissions to intensive-care wards. Throw in ethics jargon, with terms such as “wrongful life,” “personhood”, and “futurity,” to muddy the mix, and you have a situation to confound the most well-meaning physician or family member.

Eli J. Kleinman, M.D.
Riverdale, New York

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To the Editor:

The discussion of medical ethics by Sally Satel and Christine Stolba jolted me into the realization that I have harbored similar perceptions for some time.

Now retired, I practiced neurosurgery for 40 years. Starting about 1970 or so, I was a member of the first ethics committee at a large local hospital. The first incarnation of the committee, made up only of physicians, functioned well. The second committee was chaired by the hospital chaplain, and it, too, until the hospital lawyer persuaded his law partner to join, was composed entirely of physicians.

Then in the early 80′s, as medical ethics became chic, the hospital’s board of directors appointed a lay businessman and board member as chairman; he felt a need to educate himself as well as the rest of the committee, so we were treated to meetings devoted to discussing reading lists. The committee had less actual involvement with real cases, and, over the years, other physicians and I lost interest and wandered away.

Thanks to Sally Satel and Christine Stolba, I now see that this issue is probably more serious than I realized. Doctors have not fully understood what has happened to them and to the practice of medicine over the last few decades.

C. Keith Whittaker, M.D.
Kansas City, Missouri

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To the Editor:

Sally Satel and Christine Stolba provide a thoughtful analysis of the new profession of medical ethics. As a practicing physician for over 30 years, I have noted that many of the cases discussed at the meetings of hospital ethics committees, which I occasionally attend, seem to result from a failure to communicate.

Consider this example: an eighty-year-old man is dying of lung cancer and emphysema, and the hospital staff is trying to decide whether he should be placed on a ventilator. The patient has left incomplete instructions and is now unable to communicate. Everyone agrees not to do “too much,” but then his youngest daughter, who has not seen her dad for ten years and has little awareness of his failing health but a great deal of guilt over her own absence, arrives on the scene and insists that “everything” be done.

The situation quickly deteriorates and enemy camps form. Some nurses join the newly arrived daughter in insisting that the patient can and should be put on a ventilator. Nobody approaches the daughter to ask how she is feeling or to empathize with her concerns. Soon it is time for an ethics-committee consultation.

How might such a situation be handled better? Most of all, it is essential for the doctor to turn his attention to the daughter as a person with feelings, values, and hopes. Her emotional concerns must be taken into account before she can hear what the doctor has to say about medical treatment. A physician, in short, must seek first to understand before trying to be understood. But perhaps communication is harder than ethics.

Frederic W. Platt, M.D.
Denver, Colorado

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To the Editor:

Sally Satel and Christine Stolba raise important issues in “Who Needs Medical Ethics?” Their skepticism about bioethics needs to be heeded.

The discipline of medical ethics sees its own history as the triumph of enlightenment and informed moral expertise over the insulated naiveté of medicine. Yet in examining the particular topics with which the emerging bioethics movement justified this shift in ethical authority, I have found its version of history to be simply wrong. In the case of brain death, for example, early exponents of bioethics in the late 60′s and early 70′s pointed to the work of Harvard’s so-called “brain-death committee” as an instance of physicians inappropriately assuming that they had expertise over philosophical questions. But even a cursory examination of the work of the committee shows their longstanding and fairly ethical commitments, commitments developed in the context of decades of practical concern about the unnecessary intrusiveness of medical technology.

As this history suggests, and as Sally Satel and Christine Stolba emphasize, bioethics has earned its authoritative standing not because of the rigor of its arguments, but because of its practitioners’ simple faith in those arguments.

Gary S. Belkin, M.D.
Harvard Medical School
Boston, Massachusetts

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To the Editor:

Thank you for the article on medical ethics by Sally Satel and Christine Stolba. Despite being a philosopher myself, I have to say that philosophers are not necessarily the best people to advise others on ethics, in part because they are so blind to the flaws in their own profession.

Most philosophers are employed in academia, yet they seldom discuss moral issues related to higher education. In the latest version of the Philosopher’s Index, a search for the term “medical ethics” yields 1,930 entries, while a similar search for “academic ethics” yields only nine. Why should a profession unwilling to confront its own ethical problems be an ethical adviser to another profession?

John Pepple
Kenyon College
Gambier, Ohio

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Sally Satel and Christine Stolba write:

Albert R. Jonsen is no doubt right that doctors benefit from being taught such skills as “creative problem-solving,” “listening well,” and “communicating interest and respect.” But there is no reason to think they cannot learn these things in medical school and through professional experience. There is nothing wrong, of course, with having medical students discuss difficult cases with a trained ethicist in a classroom setting, and if a doctor wishes to explore the deeper philosophical dimensions of his work, he should by all means engage an academic colleague with a background in the subject.

What we question is the claim that medical ethicists are indispensable to clinical decision-making. In this regard, Mr. Jonsen is incorrect to say that medical ethicists “do not make medical decisions in any sense whatsoever.” A vocal minority within the field endorses the so-called “authoritarian approach,” which, according to a 1998 report by the American Society for Bioethics and Humanities, emphasizes the need to make ethics consultants “the primary moral decision-maker.” Among the examples cited in the report is an ethicist who recommended that a Jehovah’s Witness be given treatment against his wishes.

Mary B. Mahowald’s elaboration of the case of Julia Smith Andre further reinforces our view that Andre behaved unethically toward her unborn child—though probably not illegally—when she refused to follow a special diet. Having already been through one pregnancy, Andre knew precisely the risks she was taking. The regimen may indeed have “nauseated” her (and—heaven forbid—offended the palate of her epicurean husband), but the harm to her child was avoidable, and is now irreparable.

Michael M. Rivlin points out that some clinical cases have posed such vexing problems that they have ended up in court. We did not argue that doctors hold the answer to every medical dilemma, only that bioethicists, as a group, have no particular skill in resolving them. Dr. Rivlin may have devoted seven years of advanced study to medical ethics, but the profession also includes many graduates of “intensive” university programs who, after as little as ten days of instruction, are sent into clinical settings to “do” medical ethics.

Morris Grossman is gravely mistaken: we consider patient autonomy very important, but not when patients are mentally incompetent. As for Michael Gordon, though we do not share his high opinion of formal instruction in medical ethics, we too hope that the future of the field lies with doctors who are more broadly trained rather than with nonclinicians.

David M. Feldman is correct to note the longstanding Catholic and Jewish legal-moral traditions and their insights into medical ethics. Indeed, some of the earliest and best work in bioethics was produced by theologians and religious leaders. Unfortunately, as secular academics have come to dominate the field, religious views have been marginalized, particularly with regard to questions concerning the sanctity of life—a trend that has been discussed with great insight by the physician-ethicist Edmund Pellegrino of Georgetown University.

Our thanks to Elan B. Singer, Eli J. Kleinman, C. Keith Whittaker, Frederic W. Platt, Gary S. Belkin, and John Pepple for their kind words and useful observations.

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