If a patient’s heart stops, the doctor can resuscitate them. But how does the doctor decide if it’s the right thing to do? Medical knowledge changes swiftly, and technological changes make new and expensive investigations and treatments possible that were only theoretical a few years ago. Life has been extended in length, but not in quality, and the debates about end‑of‑life decisions show us how much the notion of a “good life” is bound up with the absence of disease, illness and suffering. The practice of medicine is not purely technical. It involves a relationship between a person who is seeking help, and who may be vulnerable, and a person who has the skills and knowledge to help. Relationships that involve disparities of power, knowledge and vulnerability require some degree of external oversight and regulation. Traditionally, in medicine, this oversight has taken the form of codes of ethics, starting with the Hippocratic Corpus. Today, bodies such as the General Medical Council and the Royal Colleges define the standards of good medical practice. There has been much discussion of how we make moral choices, but what do we mean by a “moral” decision in medicine? Conventionally, we are distinguishing what is clinically and technically possible from whether it is “right” to intervene at all. For example, if a person’s heart stops, we know we can resuscitate them, but should we do so? To answer that question, we do not expect to rely solely on numerical data and we do not anticipate getting an obvious and single answer. We are aware that there may be more than one answer to the question, and those answers may conflict with each other. We will want to get clinical information about the situation: why did the heart stop? Will restarting the heart make things better or worse for that person in medical terms? We will also want to know what the patient thinks about the situation: did they anticipate this? Do they want to be resuscitated? And if we don’t know these things, we will want to ask some questions about how best to make a complex decision if we have not heard the wishes of the person concerned. Moral reasoning differs from those types of reasoning that are purely computational, logical or algorithmic. To answer ethical questions, we engage in a process of reflection and discussion: we begin a discourse that uses the words “ought” and “should”, as opposed to “can” and “must”. If the patient’s heart has stopped because they are losing blood, then a doctor may say: “We must give the patient more blood or his heart will stop, and we can do so because the blood is here and we know it will work.” However, that statement does not answer the question: “Should we resuscitate the patient if his heart stops?” The doctor’s statement about what can be done is not irrelevant, but it is only a part of the reasoning process involved in deciding whether it is right to resuscitate. If the patient had left instructions that they did not want to be resuscitated if their heart stopped during surgery, then the facts of successful resuscitation practice would be irrelevant to what the doctors should do. What we are distinguishing here are facts and values – a distinction developed by David Hume in the 18th century. Hume says that it is a fallacy to think that because things are a certain way (facts), then they should be that way (values). We cannot derive values from facts, but we do evaluate facts and make moral judgments about them, and this reasoning and reflection process is crucial to medical ethical decision-making. Ray Tallis, a physician of older age care, writes movingly of how painful it is to be accused of cruelty and ageism when he does not support treatments and interventions that will prolong an aged person’s life for a short time, but cause them more suffering before their inevitable death. In 1979, a model of medical ethics was proposed that has become a basic starting point for discussing and teaching healthcare ethics. It proposed a set of principles that would address both consequences and duties in medicine. Doctors should respect the principle of doing good and doing no harm, but they should also have respect for the patient’s views and choices about their condition and treatment, and respect their autonomy over decisions that affect them directly. Doctors should also respect a principle of justice in healthcare, where justice implies fairness of access to treatment. This model is known as the “four principles” approach, and is now often used as the basis of training in healthcare ethics. Possibly its greatest value is that it has enabled the study of healthcare ethics to become more central to the training and development of doctors. Doctors used to learn about ethical reasoning by watching their trainers and seniors in a purely clinical context, but the four principles gave them a structure for thinking about their ethical decisions that was based on arguments from moral philosophy, not clinical medicine. A good ethical decision in medicine could be said to be one that takes account of the clinical consequences for the patient and embodies a duty to respect the views of the patient and the justice of the process. Respect for patient autonomy has grown with the consideration of human rights and dignity, and developments in the law on consent and personal ownership of identity. But there is a problem with giving more weight to autonomy. Many medical conditions impair the capacity to be autonomous, even if only temporarily, which gives rise to considerable debate as to how to make good-quality ethical decisions in cases where people cannot express their views. In many cases, it will be possible to wait until the patient has regained the capacity to make their own decisions, in other cases, the patient may have left advance instructions as to how to be treated, or there are substitutes (usually family members) who can make a choice for the patient. The problem of lack of capacity deepens where people have long-term problems with autonomy, either because they are developing it (children and young people), they have lost it through physical and mental injury (the elderly and disabled), or where it fluctuates, owing to psychological distress (which occurs in a wide variety of mental disorders). ‘A moral decision is a complex process, and like many medical treatment decisions, involves both facts and values’ Autonomy is sometimes seen as a type of cognitive skill that one either has or doesn’t, like being able to read. But some have argued that it is an expression of identity and experience that is organic, formed by family and other relationships. From this perspective, a person’s capacity to make important ethical decisions (such as terminating a pregnancy or refusing treatment) changes naturally with time, within a range of relationships, and degrees of vulnerability. For example, parents help their children to become more autonomous over time by providing them with a network of secure relationships. Autonomy to make important decisions reflects personal identity and values, not just an ability to understand or take in information. For those people who live in relationships of long-term dependency on others, the autonomy of the patient is located in the relationships with those who care for them, and facilitated by those carers. It might be argued that any state of being ill or distressed entails a type of vulnerability with which the doctor must engage. The good doctor does not always wait for the patient to regain autonomy, or turn to a substitute decision maker, she works with the patient, seeing their compromised autonomy as a type of reflective bedrock for ethical decision-making. Vulnerability and neediness are not indicators of low status or even disability, but are aspects of a person’s identity that make up essential human transactions. A moral decision is a complex process, and like many medical treatment decisions, involves both facts and values. One view of the capacity to make any complex decision is that it involves a process of taking in information and believing it, weighing up of the perceived risks and benefits, and evaluating advantages and disadvantages, a process which is then followed by a selection of the outcome most beneficial in terms of life advantage. No doubt some decisions can be made this way, but what such an account seems to leave out is any discussion of the feelings that are involved in such a decision, or the way the subjective experience of the decision-maker influences her thought process. The surgeon, public health researcher and writer Atul Gawande has described the complexity of treatment decisions in people with conditions that were going to end their lives, and the importance of thinking about what individual people value in their lives when making these decisions. He argues that doctors have been poor at making these kinds of discussions possible because of the emotional discomfort that they entail. We might infer from this that emotional discomfort is often an important part of the moral decision-making process, and the more complex the moral decision, the more emotional discomfort there will be. The idea of coolly weighing up alternatives seems implausible in relation to decisions like, “Shall I keep this pregnancy?” or “Shall I refuse this treatment that is keeping me alive?” There is evidence to support a more complex and emotional account of moral decision-making. A 1977 study by Carol Gilligan explored how women approached the decision to have an abortion. When making their decision, they reflected on their moral identity over time, and the kind of person they wanted to be, both now and in the future. They also considered the impact of their decision on the people they were closest to: family, friends, partners. Gilligan suggests that these women located their ability to make a complex moral decision within a narrative of who and what they valued as people. This focus on relationships complemented the type of rights‑based argument that asserted a woman’s right to choose what happens to her body. Another study, by JO Tan and others, explored the capacity of young women to refuse treatment for an eating disorder. The study found that these young women could take in information about the consequences of their decisions and appeared to be able to weigh it up – that is, their capacity to make such a decision was not obviously cognitively impaired. But the study also identified a profound difference between the way the clinicians saw the problem, and the way the young women saw the problem. The clinicians saw the young women as having a disorder that was threatening their lives, whereas the young women themselves described experiencing the eating disorder as part of their identity, and thus to give it up was to give up a part of themselves. Their capacity to make an autonomous decision about life-saving treatment was tied up with their identity and personal values, not just an analysis of consequences. A 2012 study of people who repeatedly self-harmed produced similar findings: the participants also expressed real ambivalence about their decisions. They acknowledged that the decision-making process involved in self harming was unsettling and complex. Improved techniques for brain scanning have led to great interest in what happens in the brain when people make moral decisions. Areas of the brain that are known to be active in emotional experience and regulation are also activated in moral decision-making and the experience of moral emotions. Not only are these processes and experiences complex, they involve different neural pathways and networks between different parts of the brain. Disruptions of different processes may lead to variations in moral reasoning, and altered experience of moral decision-making. There is little doubt that most people know the difference between right and wrong. However, it appears that some people seem not to have the feeling of what is right and wrong. This “moral feeling” is thought to translate the cognitive recognition that an act is immoral into inhibition of that action. Work by neuroscientist Antonio Damasio suggests that good quality moral decision-making involves a type of rapid unconscious intuitive process, which is distinct from information processing, and that if this is absent (for example, after some types of brain damage), then people will struggle to make moral decisions at all. The doctrine of double effect is an old one in moral philosophy. It effectively says that it is morally justifiable to carry out a good action with a bad side-effect, if the bad side-effect is not the main intention of the action. A famous example is given in Philippa Foot’s thought experiment from 1967, commonly referred to as “the trolley problem”. The experiment involves a scenario in which a tram (“trolley” in the US) is heading towards a line of track on which five people are trapped. You can pull a lever that will switch the tram’s course on to a line of track where only one person is trapped. Essentially the question facing the decision-maker is whether it is justifiable to act in a way that prevents the death of five people, even if that means bringing about the death of one. A simple utilitarian calculus (if there is such a thing) would suggest that it is right to save five lives if possible, even if it means bringing about the death of one, and this is the option that most ordinary people choose. Using the doctrine of double effect, they assert that they do not intend to kill the one person, but that a single death is an inevitable byproduct of their intention to save five people. The trolley problem has been given several variants to explore different moral responses. In one variant, you can stop the tram from killing five people by pushing one person in front of it, and thus bringing the tram to a stop (the unfortunate person sacrificed is often described as fat, but since the thought experiment is based on the assumption that your action is successful in saving the five others, the victim’s size is probably irrelevant). When people are asked about this variant, many express reluctance to push the man on to the track, even though the intended outcome is the same as pulling the lever (five lives saved). This result implies that people feel differently about physically harming someone directly, even when doing so would bring about good consequences. The distinction between pulling a lever and a physical push has an emotional effect that means something to the decision-makers, even if it is hard to articulate. One possible explanation for the distinction people make between pulling a lever and pushing a person may be to do with the sense of intention or agency that has to be owned. In both cases, the doctrine of double effect is invoked: I intend to save five people, I don’t intend to kill one person, but sadly that happens because of my primary intention to save lives. But when the saving of five people entails physically pushing an innocent person in harm’s way, it seems that the doctrine of double effect cannot allay anxiety about doing harm. It seems difficult to claim that you do not intend to kill a man when you push him in front of a train. Criminal jurisprudence would find you guilty, on the basis of the anticipated consequences alone. No doctor would accept that taking a single life is justifiable even if five lives could be saved Another possibility is that people feel a sense of injustice on behalf of the single man, and an awareness that if one of us can be sacrificed for a good cause, then any of us could be sacrificed without consent, which seems unjust and cruel. It may be of interest that people who score highly on a measure of psychopathy are more likely than low scorers to endorse more utilitarian responses, which suggests that a lack of anxiety about hurting others allows for easier focus on simple utilitarian calculus. Yet another possibility is that people do not like to think of themselves as causing direct harm to others, even if they accept that they did so. In a recent book about the life of Rudolf Höss who was the commandant at Auschwitz, he is quoted as saying of himself that he was not a murderer, he was “just in charge of an extermination camp”. The doctrine of double effect was first expounded by Thomas Aquinas, and has been especially influential in medicine because so many medical interventions are risky to the patient. The most well-known example of the doctrine of double effect occurs in palliative care, where people in the last stages of life are often given high doses of pain-relieving drugs. These drugs shorten life (often by depressing respiratory function), but doctors who prescribe them argue that they do not intend to shorten or end life, only to relieve severe and intense pain. Other common examples in medicine also involve side-effects of drugs such as chemotherapy for cancer, where harmful effects are not intended, but are an “inevitable” consequence of the intention to benefit the patient. No doctor would accept that taking a single life is justifiable even if five lives could be saved, and doctors have been and will be prosecuted where there is a suspicion that they have intentionally ended life, even where there is prior consent and family support. One report describes a tragic case where a young man was brain dead, and his organs were to be used to save several people’s lives when life was extinct. A doctor was accused of administering a drug to bring about the young man’s death so the organs could be used, although he was acquitted of this charge. When the young man eventually died, his organs were never used. One can only imagine the different emotional responses to this series of events, depending on whether you were a relative of the dying man, or a relative of those whose life might be saved by his death. The doctor is empowered to do harm to the patient in pursuit of doing good, and there is a social acceptance that treatment may entail a deliberately imposed suffering that is not the primary intention of the doctor. This acceptance requires a great deal of trust in the medical profession – and doctors are still the most trusted professional group. The trust that makes these interactions possible assumes that doctors will not be the kind of people who exploit vulnerability and exercise influence for their own ends. There is a question here about how society expects doctors not just to be good technically, but to be good personally. There are other accounts of ethical reasoning that may be helpful when thinking about doctors as good people. In his book, Justice: What’s the Right Thing to Do?, Michael Sandel has argued that moral decision-makers need to follow an ethical reasoning process that pays attention to justice and the ways that people weigh the value of their decisions. He argues that impartiality is not always the keystone of justice, but rather that justice processes need to pay attention to what people value. There remains a question about whether it is just and fair to expect a group of people who are chosen for cognitive intelligence and skills in exam-passing to become morally superior individuals. It is often said that doctors are held to a higher moral standard than other people, but how are they trained to that higher moral standard? After the Harold Shipman inquiry, it was recommended that doctors undergo revalidation every five years, but there is no evidence that the revalidation process addresses moral reasoning or the moral identity of doctors. Doctors still do “bad” things, even when they are good people in other ways, and technically good at what they do. Medicine needs a way of thinking about ethics that addresses different moral values and intuitions. What remains unclear is how we train doctors to be good people, not just to do good work and make good choices. Source
