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The usual line on medical ethics goes something like this. In the old days, ethics and medicine weren't often in conflict. The physician intervened to save lives when he could, but his main limitation was technological. You didn't encounter deep ethical dilemmas when hacksaws, leeches, bleeder knives and snake oil were the only equipment.
Blurring the line
Nowadays, however, we have the technology to keep life going for an indeterminate period, blurring pat distinctions between life and death. This reality necessitates that doctors and families make difficult decisions about when to pull the plug. And since finances are always an issue, making those decisions requires us to think not just about life itself but preeminently about the quality of life.
Herein lies the supposed ethical difficulty. The patient cannot decide issues of quality of life; others, especially those who pay the bill (it can be society as a whole) must intervene. As we intervene, we must remember that it's not only the line between life and death that is no longer clear; it is equally difficult to distinguish between what might have once been called murder and what is now more correctly seen as passive euthanasia. And voila, the unthinkable is now permissible and even ethical.
To be sure, not everyone takes it this far. Professional journals are filled with very thoughtful articles dealing with the ethical issues that arise in a variety of difficult situations. Moreover, it would be foolish to overlook the real conflicts that financial considerations do impose on how to proceed when a loved one has no chance of survival apart from artificial means. And truly quality of life must be a consideration in many of these instances.
What's missing in these discussions is, first, an awareness that it is not the advance of medical technology by itself that creates these conflicts, and second, a basic framework to guide us, based on time-tested rules, in making ethical decisions.
To the first point. Imagine you are physician living in a rural area in 1910, and a patient needs internal surgery to correct an intestinal blockage, surgery which can only be performed in a city it takes two days to get to by horse and carriage (autos not yet being affordable).
You face a choice imposed by the ever-present reality of scarcity. You can stay with your patients, some of whom desperately need your care, and risk the prospect that the blockage is caused by a food supply problem you might be able to correct; or you can neglect your other patients, take a risk, and take the patient to the city.
You have to pay for it yourself, but in doing so, you are forgoing the purchase of surgical equipment you will need in order save other lives in the future.
This case contains all the elements that are said to be imposed on us only by modern medical technology. Presumably, it would affect the doctor's decision whether this person is 14 or 90 years old. If the doctor had financial resources to spare, he might pay someone else to take the patient to the city. If he does not, he might try the surgery himself and thereby risk the death of the patient. Or he may just choose to give the patient food and water, knowing that death is imminent. These are dilemmas that admit no obvious solution.
Whatever decision he makes, there are ethical difficulties. This was as true in ancient Greece as it is today because human nature itself remains constant. Indeed, the ethical troubles introduced by modern medicine as such have been wildly exaggerated. We always confront the same objective: to do the best that we can to preserve life given the material world in which the means to save life are always limited while the demands are unlimited. Physicians can always do more; the question of whether to do more has always been with us.
Right and wrong
So why do we hear so much about the moral burden that comes with technological advance? It's a cover for what is truly absent from modern discussions of medical ethics: a coherent framework for telling right from wrong.
To illustrate, let's return to the case of the rural doctor. Let's say that this doctor, faced with an unconscious patient on the examination table, turned out the lights in the office and went on vacation. The next week, the patient is found dead. Would the doctor have been at fault? Indeed. He is a murderer because he did not even attempt to give the patient the basic requirements to preserve life: food and water.
There is a crucial difference, then, between deliberate abandonment of a patient —which is what denying food and water implies—and failing to go the extra 100 miles to get to the nearest hospital for surgery. But what precisely is this difference? It comes down to the most basic element of medical ethics, accepted from the earliest centuries of the Christian era to our own: the distinction between ordinary and extraordinary means of sustenance.
Ordinary means include food and water, what is needed to preserve life under ordinary conditions. Extraordinary means anything above that, which should be taken if conditions permit it but which morality doesn't necessarily require if economics or other considerations intervene. The reason why the rural doctor can be a responsible physician in one case and a murderer in the other boils down to this distinction.
Yet today, the field of medical ethics is dominated by endless fretting over technological woes but precious little discussion of even this basic distinction. In particular, I'm struck by an astounding article in the June 28, 1997, edition of the New York Times entitled: "`Passive Euthanasia' Is the Norm In Today's Hospitals, Doctors Say." Gina Kolata reports that 70% of hospital deaths take place after someone has made the decision to withhold treatment—with no distinction made for ordinary or extraordinary means. People are often sent home to die through starvation and thirst. This is unconscionable.
Technological advance, like economic progress, contains no inherent moral logic to guide. To serve the betterment of human life, objective moral norms must serve as guideposts. This is why all social development must take place within a culture that defends human life—the only possible reason for either scientific or economic progress.
If basic moral teachings don't always provide obvious answers in the most unusual medical cases, they at least orient us toward making ethical decisions based on a clear set of values. These choices have always confronted medical workers and always will.
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