If you think Ethics in Medicine are very simple, or even dull, you haven’t thought about them enough. The more you think about them the harder they get.
When I was taught ethics as a student it wasn’t too inspiring. As I butted up against ethical issues as a clinician it was inspiring. How can I not care about a right to life or a right to death, a right to choose or the lack thereof?Lets think about how we learn medicine.Traditionally we learn medicine from great big textbooks, lectures by established experts and by an apprenticeship model as a clinical student and continuing as a junior doctor/nurse/paramedic. That means that if you didn’t love ethics as a student you would have learned most of it on the job as an apprentice. The person who taught you may well have learned it the same way. My favourite teacher from my early days as a doctor was my boss, Professor Robert Cohen.Prof Cohen was a hero of mine. He was a calm and diplomatic genius. I certainly learned ethics and more from him. He would have learned from his teachers. He was a junior doctor in London in the 1950’s.
Too often I use intuition. Too often I use vague rule based ethics (deontological ethics) without a true understanding of where that rule came from. I am the product of educational and cultural systems that are almost exclusively based on Judaeo-Christian dogma. I work in Australia, a country where 8 out of 21 million inhabitants do not even identify as Judaeo-Christian.
I am Irish so lets take Roman Catholicism as an example. The biggest religion in Australia by far at the last useful census (2011) was Roman Catholicism with 5.4million. By the Roman Catholic churches own estimate only 662 thousand people regularly attend mass. (The Catholic Church base this on the Catholic National Count of Attendance, which is a count of attendees on a preset and well publicised weekend and includes services with or without priests, it includes services in gaols, boarding schools, migrant centres.) So being generous let us say 1 in 30 Australians goes to mass each week. How many of that fraction believe all Catholic Dogma? If my ideas of ‘rights’ and ‘wrongs’ are derived from Roman Catholicism, or Judaeo-Christian dogma more generally, does that equip me to deliberate on modern ethical problems, the ones that are current for my multicultural patients and my multicultural colleagues?
How about reading the mainstream media? Don’t laugh just yet, they do publish articles about serious medical ethical issues. The Murdoch owned media published on Saturday 24.9.16 a two page spread on Euthanasia in the Herald Sun. (The Herald Sun is read by 1.3 million Victorians every weekday, that’s twice the weekly attendance at Roman Catholic mass.) There were two articles, both by Kathryn Powley. The second is a personal account reprinted from 2012 about the death of the authors mother. The first article was interestingly titled “The Right to Choose”. It was largely built on the opinions of Assoc. Prof Natasha Michael, who is director of palliative care at the Cabrini Health. Cabrini Health is owned and operated by the Missionary Sisters of the Sacred Heart of Jesus, a Roman Catholic order. I do not know if A. Prof. Michael is a woman of faith. There were also quotes from the Victorian Premier and the widow of Mr Bob Dent who availed of the euthanasia laws in the Northern Territory before they were effectively over turned by the Commonwealth in what is often called the “Kevin Andrews Bill’. I do know that Kevin Andrews is a man of faith. He has a lot of faith. The Herald Sun article ended with several quotes from Margaret Tighe, President of Right to Life Australia and a formidable pro-life campaigner.
People that have listened to my podcasts will know that I have huge respect for Palliative Care as a specialty. The most interesting thing that the above article illustrates to me is that when we do move towards some form of legal Voluntary Medically Assisted Death we should not assume that most Palliative Care Physicians would be supportive of such a thing. Neither would I assume that Palliative Care Physicians would be the professionals best placed to deliver Voluntary Medically Assisted Death. I do not know what proportion of Palliative Care Physicians are persons of Faith. It may have to fall to another group of clinicians to deliver this kind of medical assistance to people who request it.
I have become aware that I need to learn more. It is a conclusion that almost everyone interested in #FOAMed has reached. But where to start.
I have spent the last week in the Melbourne University School of Law studying Medical Ethics with one of the worlds most conspicuous experts in Bioethics, Prof. Julian Savulescu. I have been trying to keep up with a room full of very smart women and men, lawyers and doctors, academics and policy makers, local and international.
There is a lot more to Medical Ethics than being able to define the 4 basic concepts of Autonomy, Beneficence, Non-Maleficence and Justice. Julian has become famous for a his position on doping in sport. When you actually listen to his reasons it is hard to argue against. If you just listen to the way an opponent of his might frame his reasons then its easy to argue against. I would suggest that understanding what a given person is saying is a minimum requirement in most ‘grown-up’ discussions.
The good news is that Julian is already a #FOAMethics hero and he didn’t even know it. A huge amount of his work is available through blogs, podcasts, vodcasts and more. In fact quite a few of the leading lights in Medical Ethics, both Faith Based and Secular, can be found through the Uehiro Centre for Practical Ethics website. iTunes U also hosts plenty of Uehiro Centre content. If you still appreciate good old fashioned journals he is also the editor of the Journal of Medical Ethics, which is the pre-eminent journal for the subject. I have no problem with Ethics based on belief systems that don’t mirror mine. I do have a problem with fundamentalism in all its forms.
Of course if you are going to say something controversial you should expect a debate. The debates come thick and fast when you are arguing against someones ethics, they come thicker and faster when you are arguing against someones faith based ethics. This is okay. The “ad hominem” attacks are not okay. We have already had a few #FOAMed controversies related to this sort of tactic. An ad hominem attack is analogous to a ‘low punch’. Prof Savulescu has had to deal with more ad hominem attacks than anyone else I have ever met.
Sometimes I know what the right thing to do is.
Sometimes I just think I know.
Sometimes I just haven’t thought enough.
I am not trying to be rude.
I am trying to suggest you might want to figure out your own ethics.
I know I do.