The Case Against Ethics

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Hospitals across the nation are irreversibly mutilating the bodies of children. I hear people wondering why the ethicists employed by the hospitals (yes, most children’s hospitals have ethicists on staff) are staying silent. The good news is that I can reassure you that medical ethics has not been corrupted by the transgender movement. It’s been corrupted for years! I wrote this for my med school paper over 10 years ago now. Apologies for the occasional outdated reference, but I think you’ll find most of it stands up pretty well. Hope y’all enjoy it, and have a great weekend!

I hope you’re sitting down, because I have some shocking news: I was rejected by many of the med schools that interviewed me. I know! I couldn’t believe it, either. My first instinct was to chalk it up to understandable jealousy over my movie star looks, but I am beginning to suspect that something else may have been at play. I realize now that my answers must have sounded simply scandalous. When asked why I chose medicine, I talked about wanting to help people, to fight for my patient’s lives, and so on. In all honesty, at the time, I had no idea how controversial I was being! Today, better acquainted with medicine and its ethics, I see that if I wanted to be part of the club, I should have replied instead that nothing gives me greater pleasure than taking another man’s life. For his own good, of course. Maybe I could have mussed up my hair a bit, worked on developing a glint of the ol’ bloodlust in the eyes, cackled maniacally once or twice – yep, that would have been the ticket. But there I was like an idiot saying I wanted to go into medicine to save people, not shuffle off their mortal coil. In my defense, I was never a pre-med, so how was I to know?

Can I be the only one creeped out by this strange ethics curriculum our school puts us through? If it disturbs you, too, don’t feel weird, this “biomedical ethics” stuff is pretty new, so maybe we’re just not used to it yet. Before the early 1970s, these ethical principles we’ve been learning so much about did not even exist, because everyone who ever lived before then, aka The Man, was unethical – do you need any proof besides the damning fact that He never even took a biomedical ethics course? Records dating before that time are a bit unclear, but it is theorized that these people, many of whom we believe looked much like we do, were able to function by clinging to some sort of ‘moral code’ or ‘tradition,’ that experts claim may have been as much as a century old, and involved such primitive beliefs as – sorry, that’s usually about the time I start spacing out and playing Angry Birds. But the point is that I guess at some point people approached these life and death decisions in a different way. I have to admit, it does sound crazy to believe that ideas so old and musty, ideas that probably love wearing tracksuits and watching Matlock and just will not stop asking us when we are going to bring a nice girl home to dinner, could ever hold a candle to the kind of brave new thoughts that college professors came up with while listening to Abbey Road backwards and voting for Jimmy Carter. Still, who knows, maybe the foundations of our biomedical ethics course are not that strong, and we should not fear questioning them.  

Promises, Promises

If you’re at all like me, you probably spend most of lecture daydreaming over the sketches of the perfect beach wedding that you keep in your binder labeled “Anatomy Notes.”  If so, you may have noticed how pointless half of the marriage vows are. Why do you need to promise someone you’ll stick with them through all the good times? Fairly self-evident that as long as you’re having a blast, you won’t be storming off in a huff or absconding with the nearest cocktail waitress. The meaningful part of the promise isn’t ‘for better,’ it’s ‘for worse.’ The harder it is to keep, the more important the promise – which really is the whole point of promises, isn’t it? That an entire industry, and practically an entire culture, exists to help extricate you from your oath does not render the vow meaningless; quite the opposite, in fact. Speakers and support groups have not been sprouting up across the nation to help folks feel better about breaking their cable provider contracts. It’s only the important promises that one must bother to undermine. Precisely because they are so hard to keep, because so many decent people will be grasping for a way out, a way that gives them the support and justification they need to be able to live with themselves afterwards, to move on despite knowing what a sacred vow they have broken. In medicine, as in marriage.

When we become doctors, we make a promise to our patients – to all our patients, including the vulnerable and the forgotten, not just the popular ones. Modern medical ethics seems built upon finding exceptions to that promise, exploiting loopholes and crafting justifications to help us break it. Sure, the ethicists are right behind us in fervently upholding certain commitments: when it comes to patients who want to die, we are assured, autonomy is key. Trouble is, when it comes to patients who want to live, all of a sudden autonomy ain’t so hot, the ethicists start hungrily eyeing those feeding tubes, and we are treated to sophisticated disquisitions about futility of care and quality of life. It may very well be that ethicists are sincere deep thinkers who spend many a long night of the soul agonizing over these ideas, and that it is simply a remarkable coincidence that, on every single issue – babies, the elderly, the disabled, the suicidal, the comatose – they end up choosing death over life. When every flip of a coin turns up heads, though, you’re not paranoid to suspect it’s weighted. Are ethicists truly the conscience of our profession, or are they the little cartoon devil hovering over its shoulder? This is not to say there is no role for ethicists in medicine. I for one know that they will play an important part throughout my career: the more eloquently and assuredly ethicists reassure me that I can break a certain promise, the more imperative I will know honoring that promise to be.

The Myth of Sisyphus

            In the dark ages that befell America before 1980 or so, feeding tubes were considered humane care and were not habitually withdrawn. But then modern medical ethics came into prominence, and the contents of feeding tubes were carefully deconstructed and given fancy sounding chemical names so that the whole procedure could be reclassified from humane care to medical care. As medical care, there was more leeway in withdrawing it. Still, even the ethics community was reluctant to give in completely to their more sanguinary impulses, so the initial recommendation by the AMA ethics panel in the mid-80s was that it was okay to withdraw a feeding tube, but only in the most extreme cases, when there was no doubt that the patient was in an irreversible state of unconsciousness. The ethics panel believed so strongly in that crucial qualification that it took them almost ten whole years to completely ignore it in their mid-90s guideline, when they said, actually, it’s kinda okay to withdraw a feeding tube even if the patient isn’t permanently unconscious or even terminally ill. In fairness, though, it’s not like their reversal meant all that much, since they never had any way of knowing whether patients were permanently unconscious anyway. In any case, so began the golden age of medical ethics, when all manner of impressively credentialed experts could get together on a panel and agree on two things: first, that treatment could be deemed futile and thus withdrawn from patients judged to have an inferior quality of life so that these disabled patients could be left to die, and second, that it really hurt their feelings when people used the term ‘death panels.’

Look, we can bring in the experts and have patients declared vegetables, certify their lives as futile, judge their existences unwanted and burdensome, and do it all just as easily and ethically as we rule them incompetent. We can dutifully apply the Peter Singer/rambunctious puppy rule, and measure the degree to which a patient thinks she’s people. And hey, if philosophical consistency demands that such a category exclude young children, generally unreflective individuals, and, oh yeah, every single human being who ever lived in the history of the world before Descartes cogito ergo sumed and the modern conception of the self took hold, well, tough. Alternately, though, we could, after making sure the thinking classes have ample supply of smelling salts, do something far more difficult: treat every human life with respect.

            Far more difficult it is, and therein lies the dirty little secret of medical ethics: all that line-drawing, all the discussions, all those brilliant thinkers arguing, the sound and the fury of the whole enterprise, well, it’s the easy way out. Want to know what the hard way is? It’s the man who spends decades lovingly caring for his completely unresponsive wife. Deep down, I think we all know that is the right thing to do, but none of us think we’d ever be able to do it.  How hard it must be, to sacrifice your life, to throw away your goals, in caring for another – even more so when all the time the temptation is there to turn your back on your duty and find affirmation in the writings of ethicists and understanding in the nods of grief counselors. Do ethicists truly find such a man hopelessly out of touch, or do they find him scary, frightening because of the light his goodness shines on us, what it reveals about our own very human selfishness? Nobody – not even Toronto Maple Leaf fans – wants to admit that they’re a bad person; easier to coin a new philosophy with all sorts of clever arguments to show what you’re really being is ethical. Easier to claim that a sense of self is all that matters, that you are all that matters, rather than to admit that sacrifice of self for another is the most loving and beautiful act in the world.

            Now, I have a hard time with this futile care discussion, but like I said, I wasn’t pre-med. I was a literature major, and can spend hours talking about books that argue that all of human existence is futile (and yet, for some reason, I can’t buy a second date). This argument for the ultimate futility of life, the Sisyphean absurdity of existence, was one of the dominant philosophical themes of the twentieth century. Since ideas have consequences, it’s no coincidence that this was also the century of totalitarianism, of death camps, of the boot in the face. Humans have had viciousness and murder in them for a long time, back even when life was considered sacred; once you take that social sanction away, once you affirm that not all lives have infinite worth, you unleash the worst. Having conceded that life is no longer inviolable, the rest is details. You might think the new limits you carefully elaborate – 18 weeks vs 32, no responsiveness vs the occasional blink, the terminally ill vs the expensively chronic, the unborn children of the hopelessly poor vs their infant siblings – make perfect sense and will last forever, but don’t be shocked if you find that, after the first limit, there are no others.

Dirty Harry, MD

Imagine a world without a justice system. The police would not only catch the (alleged) criminals, they would decide what to do with them, too. Each officer could choose, in each case, whether to kill, imprison, or release. Policemen, incidentally, are not evil, soulless machines. I have no doubt that many of them – good, compassionate, trusted pillars of polite society – would sincerely anguish over such decisions, would spend hours discussing them with wise colleagues, might even start up ethics courses and publications to address the issues involved. At the end of the day, though, regardless of the decency and the good intentions and the touching, well-written personal struggles of the individual officers, it’s still a police state, isn’t it? Not something people have historically been enamored of, to say the least. Truth is, despite all their imperfections, we need our courts and cannot have a decent society without them. Life and liberty are such fundamental rights that they must not be taken away without due process of the law, and that means a fair and public trial, a competent defense, a jury of one’s peers, an impartial judge, a system of appeals, all that jazz. Well, unless the person making the decision did well on the MCAT.

Consider that any death row inmate has received almost infinitely more due process than a single patient ever has. The most unrepentant psychopath gets such a lengthy and involved – and fair – trial that it often takes years and years before he ends up on death row. Yet even with all these precautions and safeguards, we know that innocent people have been executed. Mistakes, as they say, were made; new evidence was uncovered; people’s recollections of key moments evolved. Surely, though, a physician – acting on his own, outside the judicial system, dealing with the emotional minefields around illness and grief and depression - could never make such a mistake, right? Do you feel lucky, pu – I mean, patient? Well, do ya?

The very fact that ethicists are asking doctors to make these calls hints at how immoral such vigilante medicine is. Only physicians, with their accumulated stores of grace, could pull this stuff off and get away with it. Yet when only the presence of saints can sanctify an act, their involvement hardly speaks volumes to the act’s good character. Nor is it madness to wonder whether such ethics by association could work both ways, and see the act morally uplifted only in equal measure to the saints’ own fall.

To Infinity, and Beyond

            What does the future hold? I mean besides the machines becoming self-aware and enslaving us all. If the bioethicists get their way, I fear the doctor of the future will be judge, jury, and executioner, a hangman with a prescription pad, called upon by families to do away with their undesirables, leading our society towards a stronger, healthier, more blue-eyed future. Dystopian visions aside, there is no reason to believe the moral issues of the future will be any different than those of the past. Fundamentally, there has been, and will be, only one issue, one repeated over and over again, a variation on a theme: who belongs? Oh, we’ve always been great at respecting the dignity of human life, it’s just that defining whom we consider fully human has been a little tricky. Slaves, women, Jews, etc. – though separated in time and place and circumstance, these were not at their heart separate debates, but one continuous discussion of who belongs and who does not. So, is this it? Have we finally perfected the moral scope of our universe, included everybody who merits inclusion? Or, like the victorious abolitionist who would be shocked to learn our age considers him a small-minded, antiquated instrument of patriarchal oppression, is there something real big that we’re missing even as it’s staring us right in the face? I for one hold out hope that the vulnerable, the unwanted, the disabled, and the elderly – all those who currently find themselves in bioethicists’ crosshairs – will one day be revealed to be just as human, just as deserving of love, dignity, and sacrifice, as the rest of us. If not, if we continue along our current path beyond good and evil, I hope that we at least get the iPhone 5. Virtual reality 3D Angry Birds isn’t going to play itself, you know.