Issues and Problems

When you read biomedical ethics journals, speak with ethicists, sit in an ethics committee meeting at a hospital, the primary way of gaining resolution is by figuring out what principles are involved in the case.

Examples of ethical principles are: honesty, benevolence, non-malevolence, compassion, autonomy, and respect. Furthermore, committees (et. al.) might have a hierarchy of principles. For example, the hospital might have a structured list of these principles whereby one is emphasized more than the others. This helps when there are "conflicts of duties", since the issue will be resolved in favor of the principle that is deemed "more important."

There is an extraordinarily intense focus upon ethics in medicine and in society at large. This is partly due to the development of medical and technological tools which deal with life and death and reproduction and other stuff that gets at the core of humanity. Medical technology gets at the heart of human experience -- or that part of experience in which questions of "ultimate meaning" are raised.

But the forefront of ethics is not dominated by the various churches, nor the local politicians, nor the doctors themselves, nor moral philosophers. Instead, the leading documents in medical ethics are produced more frequently by institutional boards, and often international institutional organizations. One of the most influential boards is the New York State Task Force on Bioethics. An illustration of an American national board is President's Commission on Bioethics An illustration of an influential international body is "UNESCO". What is UNESCO? "The main objective of UNESCO is to contribute to peace and security in the world by promoting collaboration among nations through education, science, culture and communication in order to further universal respect for justice, for the rule of law and for the human rights and fundamental freedoms which are affirmed for the peoples of the world, without distinction of race, sex, language or religion, by the Charter of the United Nations."

The documents of these institutions have become more influential in the decisions that are made in hospitals and clinics, and in the policies that are enacted at the governmental level.

This is both good and bad. It is good in that there are important and influential and informed and thoughtful people who are collaborating on projects designed to reflect on the deeply human and ethical aspects of medicine and the applications of biomedical technology. This is better than not so reflecting. It is better than having every doctor, every researcher do whatever s/he feels like. (There are too many research projects and medical decisions that have been horribly unethical -- simply letting doctors to do what they want, without collaborative decision-making and ethical reflection is far too simple.)

What is bad is that these documents often do not contain much detailed ethical argument. They are, basically, sets of principles that the committees have agreed upon as important. But how they came about, and how they are to be implemented are too often undeveloped, unsophisticated, and unclear. This has another result: when policies and decisions are legitimated on these documents, the justifications are often based on very brief passages of these brief documents. Again, the difficult work of detailed ethical reflection (theorizing) is lacking.

Medicine has given us great power and control over our own lives, both individually and communally. It is far from clear, however, that we ought to allow every technology be used by doctors.

CPR, for example was developed to help otherwise healthy people to escape the death sentence of drowning or electrocution. It has unfortunately become routine for every enfeebled elderly person to be shocked back to life everytime their heart stops, unless they have given a "do not resuscitate" order. Doctors have come to use every technology to put off death as long as possible -- often longer than is reasonable, and longer than they should.

In vitro fertilization, designed in order to assist infertile married couples to have children, is currently used to give virtually every woman of every life circumstance the opportunity of bearing (more) children. This includes post-menopausal women in the 50's, daughters serving as surrogates to their own mothers' babies (in which they are both sisters AND parents to the forthcoming babies), etc.

The case is particularly clear today with genetics. What had begun as research designed to relieve victims of genetic-based diseases is being pushed to develop clones of oneself (or one's children) in order to be an "organ farm."

Medicine, thus, is becoming far more than it ever had been -- not only is it called upon to cure disease, it is called upon to "perfect" or optimize otherwise normal biological functioning. We are on the verge of having "designer babies", and bootstrapping our babies' brains to be engineering geniuses.

We can control -- more or less -- when folks die. Who should live? Who should die? And who should decide?

But there are many other aspects of the practice of medicine that urges us to reflect in ethical ways. For instance, the relationship between doctor and patient is a very complicated on. First of all, the doctor is in a position of power. Real power. Power over life and death, pain and suffering. Because of this power, doctors have corresponding responsibilities that other people don't have. Should doctors always be honest with their patients? Should they make decisions for their patients? Should they withhold information if they are convinced that their patient will not make a decision that is in their own best interest? On a similar line, what obligations of confidentiality does the doctor have to the patient?

Let us not forget that all this great technology and care costs a lot of money. Who should pay? Who should benefit? There is a limited amount of medical resources -- who should receive the organs for transplants? Should all care be fee-for-service? Should the govt. pay for health care for those who cannot afford it or who cannot afford insurance? Or is basic health care a fundamental human right? Should a drug abuser who otherwise is an appropriate candidate for a liver transplant, and yet who has ruined his own liver through his own behavior, receive a liver transplant if there is strong reason to believe that he will not stop his drug habit? Now these things are not particularly medical in nature. They deal with medical decisions, but the sources of moral tension and complexity is not just because of what medicine can do -- it has to do with the social and political and economic aspects of the environment in which medicine is one among many goods.