ETHICS & MEDICINE – INTERNATIONAL JOURNAL OF BIOETHICS

ME

On why medical ethics is exciting

‘I don’t have a lot of time for thinking about things’ he said with a defensive edge creeping into his tone. ‘I just scatter my hundreds and thousands before the public. Philosophy I leave to the drunks.’

(Ice-cream stall owner, in Malcom Pryce, Aberystwyth Mon Amour)

Modern medical science creates new moral choices, and challenges traditional views that we have of ourselves. Cloning has inspired many films and much concern. The possibility of making creatures that are part human and part from some other animal is not far off.

Reproductive technologies raise the apparently abstract question of how we should think about the interests of those who are yet to be born – and who may never exist. This question leads us beyond medicine to consider our responsibilities towards the future of mankind.

Medical ethics ranges from the metaphysical to the mundanely practical. It is concerned not only with these large issues but also with everyday medical practice. Doctors get caught up in people’s lives, and ordinary life is full of ethical tensions.

An elderly woman with a degree of dementia suffers an acute life-threatening illness. Should she be treated in hospital with all the drugs and technology available; or should she be kept comfortable at home? The family cannot agree. There is nothing in this case likely to hit the headlines; but, as Auden’s Old Masters knew, the ordinary is what is important to most of us, most of the time. In pursuing medical ethics we must be prepared to grapple with theory, allowing time for speculation and the use of the imagination. But we must also be ready to be practical: able to adopt a no-nonsense, down-to-earth, approach.

My own interest in medical ethics started at the theoretical end of the spectrum when studying for a degree that included philosophy. But when I went to medical school my inclination turned more to the practical. Decisions had to be made, and sick people had to be helped. I trained as a psychiatrist and the ethics remained only as a thin interest squeezed into the corners of my working life as doctor and clinical scientist. As my clinical experience grew so I became increasingly aware that ethical values lie at the heart of medicine. Much emphasis during my training was put on the importance of using scientific evidence in clinical decision-making. Little thought was given to justifying, or even noticing, the ethical assumptions that lay behind the decisions. So I moved increasingly towards medical ethics, wanting medical practice, and patients, to benefit from ethical reasoning. I enjoy the highly theoretical, and I like to pursue reasoning back towards the general and the abstract; but I keep an eye to what makes a difference in practice. I discuss the philosophical minefield of the non-identity problem, for example, because I believe it is relevant to decisions that doctors, and society, need to take.

The philosopher and cultural historian, Isaiah Berlin, begins an essay on Tolstoy with the following words: There is a line among the fragments of the Greek poet Archilocus which says: ‘The fox knows many things, but the hedgehog knows one big thing’.

Berlin goes on to suggest that, taken figuratively, this distinction between the fox and the hedgehog can mark ‘one of the deepest differences which divide writers and thinkers, and, it may be, human beings in general’. The hedgehog represents those who relate everything to a central vision, one system less or more coherent or articulate, in terms of which they understand, think and feel – a single, universal, organizing principle in terms of which alone all that they are and say has significance.

The fox represents those who pursue many ends, often unrelated and even contradictory, connected, if at all, only in some de facto way, [who] lead lives, perform acts, and entertain ideas that are centrifugal rather than centripetal . . . seizing upon the essence of a vast variety of experiences . . . without . . . seeking to fit them into . . . any one unchanging, all-embracing, . . . unitary inner vision.

Berlin gives as examples of hedgehogs: Dante, Plato, Dostoevsky, Hegel, Proust, amongst others. He gives as examples of foxes: Shakespeare, Herodotus, Aristotle, Montaigne, and Joyce. Berlin goes on to argue that Tolstoy was a fox by nature but believed in being a hedgehog.

 Are you a hedgehog or a fox?

I am a fox, or at least would like to be. I admire the intellectual rigour of those who try to produce a unitary vision, but I prefer the rich, contradictory, and sometimes chaotic visions of Berlin’s foxes. I do not, in these papers, attempt to approach the various problems I discuss from one single moral theory. Each paper considers an issue on which I argue for a particular position, using whatever methods of argument seem to me to be the most relevant. I have covered different areas in different papers: genetics, modern reproductive technologies, resource allocation, and mental health, medical research, and so on; and have looked at one issue in each of these areas. The one perspective that is common to all the papers is the central importance of reasoning and reasonableness.

I believe that medical ethics is essentially a rational subject: that is, it is all about giving reasons for the view that you take, and being prepared to change your views on the basis of reasons. That is why one paper, in the middle of all papers, is a reflection on various tools of rational argument. But although I believe in the central importance of reasons and evidence, even here the fox in me sounds a note of caution. Clear thinking, and high standards of rationality, is not enough. We need to develop our hearts as well as our minds. Consistency and moral enthusiasm can lead to bad acts and wrong decisions if pursued without the right sensitivities. The novelist, Zadie Smith, has written: There is no bigger crime, in the English comic novel, than thinking you are right. The lesson of the comic novel is that our moral enthusiasms make us inflexible, one-dimensional, flat. This is a lesson we need to take into any area of practical ethics, including medical ethics.

What better place to start this tour of medical ethics than at the end, with the thorny issue of euthanasia?

* Professor Doctor Mike Gaze