An excerpt from Rethinking Health Care Ethics.
Health professionals have not been well served, or at least not well enough served, by the academic community of bioethicists — the philosophers, theologians, lawyers, and social scientists of various sorts who have come to dominate, worldwide, the diverse fields of health care ethics over the last half-century. The theoretical, philosophically oriented approaches of bioethicists generally leave clinicians feeling somewhat at a loss, not knowing exactly how to proceed. Daniel Callahan is especially critical of the “all too common” mistake by philosophers that good ethics comes down to good arguments. It is as if an anatomist thought that human nature could best be understood by stripping all the flesh off a body to uncover the hidden bones … Rationality at the least needs the help of the imagination. At the clinical level this means, for instance, an ability to enter into the needs, pain, and suffering of others, to grasp their situation and respond appropriately to it. At the policy level it means understanding—for example, how a proposed health care reform might not only improve health or access to health care, but how it could play out in the larger political and social scene.
The models of ethical discourse presented by bioethicists regularly fall short of connecting with the clinical milieu and with clinicians’ own well-developed, intuitively engaging modes of ethical thinking. Persons training to be health professionals are not blank slates waiting for input. They have at least a couple of decades of interpersonal experience behind them—with parents, siblings, other relatives, friends, teachers, classmates, teammates, health professionals, policemen, shopkeepers, workmen, and service personnel of various sorts, among others, not to mention countless brief encounters with strangers in schools, stores, busses, trains, planes, and on the street. They have read novels, watched television, listened to the news, read newspaper stories and magazine articles about current events, and had extended discussions with friends and family about all and any of these. This range of pre-professional human experience is diverse and rich, and provides all of us with wide-ranging exposure to the challenges and conflicts presented in everyday life. Over time, prospective trainees in health care develop, through that experience, their own distinct patterns of thought, emotion, and action—their own relatively stable, though still evolving, personality styles and ways of adult functioning. Embedded in these stable patterns of functioning is each person’s mode of relating to other people and of thinking about himself or herself, others, and society—in effect, an implicit ethical framework.
Considered as an aspect of the mature or maturing self, this implicit ethical framework is part of what makes each of us a unique person. It influences, if not determines, how each trainee, like any mature adult, thinks, feels, and acts in relation to the world, hour by hour, day by day. As examples, one might be joyful in response to a friend’s success in helping out another individual or group; one might be disappointed in oneself for failing to help another person when the opportunity presented itself; one might be pleased at one’s courage in standing up against a bully; one might reflect that another person’s behavior was mean or selfish or abusive; one might feel distress at something one reads in the paper about some public figure or government official or public policy; one might be appalled to see that a new federal health care program retains barriers to access for the poor; or one might be proud of having published an article that exposed a lie and that presented a needed, and truthful, corrective to a simmering controversy.
For the most part, we experience this full range of states and judgments, along with the accompanying feelings, moment by moment, and without moving to a higher or more abstract level of awareness or judgment. It would be wrong to infer, however, that clinicians can and should simply sort things out as they see fit and that they should act by their own lights. Empathy, respect for persons and their autonomy, attention to the interests and rights of patients and families, presumptive efforts to benefit patients and protect them from harm, cost efficiencies and savings, and all the other principles, values, and goals of bioethics are already embedded in the [health care] community’s informal ethical discourse and in baseline rules for clinical management, in processes for dealing with patients and families, in the need to work collaboratively with other health professionals, and in methods of resolving conflicts when they arise. An interpretive community, so defined, allows for disagreement and for freedom of action, but both are constrained and channeled by the goals, values, and standards of the community itself. In health care’s various interpretive communities, these goals, values, and standards all orient themselves around the care of patients.
Stephen Scher is senior editor, Harvard Review of Psychiatry, and co-author of Rethinking Health Care Ethics.
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