The “New” Medical Morality: Hippocrates or Bioethics?by admin on 02/20/2019 8:19 PM
By Jeffrey Hall Dobken, M.D., M.P.H.
David Rothman, the author of “Strangers at the Bedside,”1writes that the most “distinguishing characteristic of medical ethics [is] the extent to which it was monopolized by practicing physicians, not by formal [trained] philosophers.…”
He asserted that serious social, behavioral, and cultural issues had to be confronted. These issues served as the basis for the development of bioethics and for attacking traditional Hippocratic medical ethics.
Medical ethics discussions of the 21st century have become partitioned as political, social, religious, cultural, academic, economic, governmental, and business issues, while attention to the actual medical ethical content of any given patient-specific circumstance may be proscribed or very narrowly defined.
The notion of American “healthcare reform” has empowered a community of non-medically as well as medically trained philosophical theorists, also called “bioethicists,” as the stewards of progressive medical ethics and thus the guardians of medical care. This is a complex, interwoven story and not simply, as an ethics argument might imply, a simple formulaic method establishing “right” from “wrong.”
The “Failure” of Traditional Medical Ethics
Jerome Kassirer, former editor of the New England Journal of Medicine, articulated in 1998 that the reorganization of healthcare (referring to managed-care organizations and the Clinton Administration’s proposed healthcare reform policies) had profoundly influenced physician roles, responsibilities and loyalties.2 Kassirer suggested then that American physicians were unable to balance the kind of care delivered against the cost of care, creating an inequity between fee-for-service patients, covered patients, and noncovered patients, and that only outside (central) authority could craft a solution. Kassirer concluded that “until we physicians demanded a national health system (single payer), there could be no equity” and that our medical delivery system was, in fact, unethical.3 This style of rhetoric attracted a following of academics and other supporters, some trained medical professionals and some not, to advance bioethics and its role in furthering “health care reform.”
Kassirer’s derogation of American medicine has been tested in the crucible created by the passage of centralized healthcare financing/insurance reimbursement reform, the Patient Protection and Affordable Care Act (PPACA or ACA). Along the way, bioethicists have volunteered their expertise and have, in large measure, enabled the transition from Hippocratic ethics to post-modern bioethics.
I now witness and experience the results as both a physician and a patient with a terminal disease. My case raises questions such as, “Is this really the best professionals can do?” and, by extension, “Has replacement of traditional Hippocratic ethics actually improved patient care?”
Since the enactment of PPACA and the subsequent remodeling, re-assigning, and displacement of the physician’s role, the probability that a stranger will be at the bedside during the moments of critical decision-making or terminal crisis predicts that classic Hippocratic values will likely not apply. Instead, the decision process will pass through current (sometimes mandated) bioethics guidelines.4 In this context, the neo-discipline of bioethics must be examined for moral effectiveness as well as clinical outcome. Perhaps the more acute question should be: Whose needs are being served, or whose interests being protected—those of the patient, the “system,” or the bioethics community? What is the actual moral, ethical goal?
Ethical Conflicts and Dilemmas
Framing ethical questions has passed from the physician to the bioethicist, medically trained or not, and falls into two broad categories: what decision is “needed,” and who should make the decision. Consider the hopelessly complicated and acrimonious debate surrounding the management and care of persons with life-limiting diagnoses and prognoses. The modification of language from “physician-assisted suicide” (PAS) to the “more acceptable” euphemism “physician assisted death” (PAD) characterizes how the bioethics community controls the lexicon and gains ownership of an issue,5 while marginalizing the physician.
In analyzing the results of their approach, bioethicists do not consider the outcome for the patient. Rather, they ask, “How effective is this bioethical approach?” . . .
Issues such as theistic beliefs, sexual identity, marital definition and fidelity, debate about rights, social “injustices” (or, broadly, “justice”), racial harmony, definition of honor and truth-telling, and fidelity to a code, have all morphed into circumstantially defined concepts. Moreover, our dominant post-modern values definitions often seem to be conflicting or evolving (such as “gender identification,” sexual orientation, diversity issues, white privilege, black privilege, personal responsibility, illegitimacy, motherhood vs. womanhood, etc.). This moral quicksand predicts confusion in general conduct and fosters intergenerational sociocultural conflict,6 which then leads to the loss of a medical moral compass.
The Premises of Bioethics
The four core principles of bioethics are patient autonomy, provider beneficence (doing “good”), provider non-maleficence (doing no harm), and justice (treating equal cases equally). Tom Beauchamp, Ph.D., and James Childress, Ph.D., developed these four principles as derivative replacement values in their critique of what they considered to be an outdated and outmoded Hippocratic Oath, which in their view had been lost or diluted over time.7
Bioethicists consider themselves politically diverse guardians of social justice, and ultimately stewards of correct thinking and ethical experience. As such selfless, incorruptible individuals, they consider themselves well positioned to lecture those of us less educated in moral matters.1
The Evolution of Bioethics
In the mid-1960s Beauchamp and Childress provided debate rules with their core principles that established a checklist to solve moral ethical dilemma, with a focus on social and cultural issues.8 These principles have evolved to control how bedside medical ethics are to be applied in the progressive, post-modern, post-Hippocratic era.
Bioethics defines itself as the field of study of the moral dimensions of the life sciences, derived from multiple ethical modalities in an interdisciplinary setting9 and carried out by scholars who migrated to the field from diverse academic disciplines. The majority of the original academic philosophical scholars were not medical professionals, but moral philosophers, theologians, clergy, attorneys, hospital administrators, nurses, therapists, and others. Their academic degrees were in law, business, economics, health policy and management, public health, social science, political science, or allied health sciences such as pharmacology or nursing.
A short list of the ancient and contemporary philosophical approaches used to fabricate the ethical foundations of bioethics was synopsized by Diego Gracia.10 The list demonstrates just how arcane and inaccessible the field is for those not intimately literate in pedantic philosophy: “phenomenology, hermeneutics, existentialism, care ethics, gender ethics, virtue ethics, communitarianism, discourse ethics and deliberate ethics have all been used to examine and explore medical ethics.”10 Expert bioethicists distinguish themselves from general members of society using language patterns or shibboleths.
An ex-president of the American Society of Bioethics and Humanities (ASBH), Mark Kuczewski, Ph.D., advanced that bioethicists serve as surrogates for the general public when issues of “ethical uncertainty” arise.8 From the website of the ASBH:
The Society is an educational organization whose purpose is to promote the exchange of ideas and foster multi-disciplinary, inter-disciplinary, and inter-professional scholarship, research, teaching, policy development, professional development, and collegiality among people engaged in all of the endeavors related to clinical and academic bioethics and the health-related humanities.11
The extension of this notion of an exchange of ideas, a “social ethical discussion,” has evolved to co-opt medical database facts. Use assessments in the bioethics paradigm balance “cost versus value”12 calculations by the Centers for Medicare and Medicaid Services (CMS) and the insurance payers. Acquisition of the medical database (lab tests, radiological assessment, biopsy, etc.) and treatment regimens (pharmacological to surgical to rehabilitation, etc.) have likewise been subject to bioethics scrutiny and judgment.13
The means to address ethical uncertainty, as defined by the bioethics community, is conceptualized as analytical thinking that is open to multiple interpretations and is based on a set of standards. These standards are set forth in the core competencies that ASBH members are expected to master and teach at the university or medical school level. There is also a specific code of conduct to which bioethicists are expected to adhere.14
The expectation of uniformity and conformity to this code contradicts any pretense of political diversity. There is demonstrable unanimity of techniques and purpose. In Kuczewski’s words, bioethicists have “become a professional and academic community that engages in practices that include shared narratives, values, and virtues”15 and thus will perform in a predictable and stereotypical manner. Establishing “bioethics considerations and guidelines” narrows the range of legitimate choices and limits physicians’ autonomous choices.8
The stated aim of preserving and protecting individual autonomy in medical decision-making for patients and their families has not only become limited in such a climate, but has been effectively negated, even though it is still presented as a core principle.7 Is this a subterfuge, or the inevitable unintended consequence of centrally planned and controlled health care decisions under the cloak of “moral authority and ethics”?
ASBH members are well-regarded, influential, and academically situated. They are employed by institutional review boards (IRBs), contribute to and edit medical and bioethical journals, testify in court, act as legislative consultants, and are often media and internet celebrities. They demonstrate that, as H.L. Mencken said, “What men value in the world is “not rights, but privileges.”16
The “demi-discipline” creation of Albert Jonsen, which is now independently powerful and politically progressive, has successfully displaced the traditional Hippocratic moral mile markers employed by the medical profession in virtually all the interactions that once defined the patient-physician relationship. This evolution was presumably needed to correct the traditional Hippocratic paternalism, portrayed as the adversary of autonomy. “Heroically,” in its own estimation, bioethics oversaw the reformation of antiquated, inadequate Hippocratic ethics in the evolving and messy technological environment of the late 20th century.
Turning these progressive moral philosophers into practical “professional” medical ethicists who adjudicate complex medical practice standards, has in large part advanced the machinery needed to promote the “reform of American healthcare.” . . .
According to the bioethicists’ view, the defects in AMERICAN Medicine and physicians flow from the Oath of Hippocrates: its antiquity, paternalism, ignorance of social justice, and its fostering of a greedy, self-interested and monopolistic medical profession.
What Is Hippocratic Medicine?
Hippocratic medicine is an historical construct achieved by picking out themes and theories in a framework that was unknown during its own time but synthesized in retrospect by historians. The so-called Hippocratic Corpus was not a sole authorship, but rather the product of many authors over more than two centuries.22 It is actually a library, or rather, the remains of a library . . .
Medicine and idealism have always been comfortable companions. There have always been and likely always will be practitioners whose medical practice was and is self-serving and exploitative. In the main, however, the Hippocratic ideal sets a moral standard that survived the centuries. It envisions the care of the sick as individual occurrences in the context of the needs of society. But collective society is not the patient. Bioethics represents a radical shift in focus away from the individual to the collective. The implications for patient care deserve sharp scrutiny, not blind acceptance of bioethical premises based on prestige and proclaimed lofty intentions.
Jeffrey Hall Dobken, M.D., M.P.H., holds a dual appointment as adjunct assistant professor, Departments of Epidemiology & Community Health and Environmental Sciences, School of Health Sciences and Practice, New York Medical College. He was a practicing allergist in N.J. and holds a certificate in bioethics from the Center for the Study of Society & Medicine, College of Physicians and Surgeons, Columbia University.
Read the entire article at http://www.jpands.org/vol23no2/dobken.pdf to obtain the full perspective.
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