[2.] Medical Ethics: Lying to Patients.

 

[2.1.] The Hippocratic Oath.

 

The Hippocratic Oath is one of the earliest Greek texts on medicine. It is a code of professional ethics for early physicians, believed to have been written in the 4^th century BCE, but not necessarily by Hippocrates or his followers. It is not required by most contemporary medical schools.

 

I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:

To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.

I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.

In purity and according to divine law will I carry out my life and my art.

I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.

Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.

Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.

So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time. However, should I transgress this Oath and violate it, may the opposite be my fate.[1]

 

The so-called Lasgana Oath  is a revision of the Hippocratic Oath authored by the physician and medical professor Louis Lasagna (1923-2003) in 1964. It is used in some medical school graduation ceremonies today.

 

I swear to fulfill, to the best of my ability and judgment, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

I will not be ashamed to say “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.[2]

 

As weighty as these oaths are, there are several pressing moral issues that sometimes face medical professionals and upon which they do not touch. One of these is the issue of honesty and medical paternalism.

 

 

[2.2.] The Case of Mr. John Jones.

 

See the case of Mr. Jones and the two doctors, Peter and Sam (Pence 1-2).

 

According to Pence, “the physician-patient relationship constitutes one of the quintessentially moral relationships of our society, similar to the one between teacher and student. As such, violations of those relationships strike at the heart of our most basic moral principles.” (p.3)

 

He indicates that a reason for this is that the patient-physician relationship involves trust.

 

Pence asks whether it is ever morally permissible for a doctor to violate this relationship by lying to his or her patient, as Sam wants Peter to lie to Mr. Jones.

 

He goes on to consider two meta-ethical theories, ethical relativism and ethical subjectivism, each of which answers this question differently.

 

 

[2.3.] Ethical Relativism.

 

ethical relativism (df.): the meta-ethical theory according to which morality depends on the collective moral beliefs of people at a given place and time and can therefore vary from place to place and from time to time; this implies that there is no such thing as objective morality, and thus no such thing as objective moral truth.[3]

 

objective (df.): something is objective when it is independent of what anyone believes, thinks, or feels about it.

·         For example, “it is objectively true that p” = “it is true that p, whether or not anyone believes that p.” It is an objective fact that the earth orbits the sun, that 2+2=4, etc.

·         A synonym for “objective” is “real.”[4]

·         The meta-ethical view that says that there is objectivity when it comes to morality is moral realism...

 

moral realism (df.): the meta-ethical theory according to which there is objective moral truth, i.e., some moral judgments are objectively true (while others are objectively false).

 

If ethical relativism is true, then whether or not Peter should lie to Mr. Jones depends on the prevailing attitude in Peter’s society. If most people in that society believe that he should not lie, then it is immoral for him to lie; but if most people in his society think that he should lie, then it is morally permissible, maybe even obligatory, for him to lie.

 

Pence points out that in the early part of the 20^th century many physicians believed that it was morally permissible to lie to dying patients about their condition (p.3) (he doesn’t mention whether people in general felt this way). Suppose that the majority of Americans were to feel that it is permissible for physicians to lie to their patients in some specific circumstances. If ethical relativism is true, then in those circumstances, it is morally permissible for physicians to lie in those circumstances.

 

But as Pence notes, by the 1970s the attitudes of doctors and patients had changed. People came to see this sort of dishonesty as objectionably paternalistic...

 

paternalism (df..): the practice of treating someone as if she were a child and you were her parent, i.e., treating her as if she is not capable of taking responsibility for herself and making her own decisions.

·         from the Latin pater, “father.”

 

To treat someone in an overly paternalistic way is to deny her autonomy:

 

autonomy (df.): the capacity for self-governance, especially for making important decisions for oneself.

·         from Greek auto (“self”) and nomos (“rule”)

 

The currently prevailing attitude among physicians and patients is that medical paternalism (physicians behaving too paternalistically towards their patients) is objectionable, because it denies patients their autonomy.

 

So if ethical relativism is true, then, at this time and in our society, it would be immoral for Peter or Sam to lie to Mr. Jones. But things might be different at other times and at other places.

 

 

[2.4.] Ethical Subjectivism.

 

ethical subjectivism (df.): the meta-ethical theory according to which our moral judgments (judgments like “abortion is immoral,” “charity is obligatory,” etc.) are based only on our feelings and emotions; this implies that there is no such thing as objective morality, and thus no such thing as objective moral truth.

 

Like ethical relativism, ethical subjectivism denies that morality is objective.

 

This definition of the theory is pretty vague. Various philosophers have developed this rough idea in different ways.

 

 

[2.4.1.] Simple Subjectivism.

 

One development has been called simple subjectivism (SS), according to which a moral judgment like “lying is immoral” means “I disapprove of lying,” while “Lying is morally acceptable” means “I approve of lying.[5] According to this theory, when someone says that lying is wrong, what she is really saying is only that she herself has a negative attitude towards lying.

 

There are significant problems with SS...

 

Problem #1: SS does not imply a clear answer to the question, what should Peter do?

·         It is a problem with this theory that it does not provide a clear answer to this question...

·         If we, as observers of Peter’s dilemma, say that Peter should tell the truth, then (if ethical subjectivism is right) all we are saying is that we approve of his telling the truth.

·         In general, any claim about what Peter should or should not do boils down to a claim about whether the speaker (whether it is Peter, Sam, us, or anyone else) approves of Peter doing it.

·         It seems that if simple subjectivism is true, then there is no proper course of action for Peter… there are only facts about what he approves of, what Sam approves of, what we approve of, etc.

 

Problem #2: SS implies that what seem to be moral disagreements really aren’t disagreements at all.

·         Suppose that Peter says “It is wrong to lie to Mr. Jones” and Sam says “No, it is morally permissible to lie.” Peter and Sam seem to be having a real moral disagreement.

·         But if SS is true, what Peter means is “I (Peter) disapprove of lying to Mr. Jones” and what Sam means is “I (Sam) approve of lying to Mr. Jones.” And these claims can both be true—there is no conflict between them at all.

·         So if SS is true, there is really no disagreement between Peter and Sam.

 

This is an argument against simple subjectivism…

 

argument (df.): a set of statements some of which (the argument’s premises) are intended to serve as evidence or reasons for thinking that another statement (the argument’s conclusion) is true.

 

We can state this argument more formally as follows:

 

1.      If simple subjectivism is true, then there is no such thing as genuine ethical disagreement.

2.      But there is such a thing as genuine ethical disagreement.

3.      Therefore, simple subjectivism is not true.

 

This argument is valid…[6]

 

validity (df.): A valid argument is one in which

1.      if the premises were true, then the conclusion would have to be true as well.

2.      the truth of the premises would guarantee the truth of the conclusion;

3.      it is impossible for the premises to be all true and the conclusion to be false at the same time.

·         These are three equivalent ways of defining validity.

 

If the premises are true, it is also sound…

 

soundness (df.): A sound argument is an argument that (1) is valid and (2) has all true premises.

 

And if it is sound, then simple subjectivism is not true (since the conclusion of a sound argument is always true).

 

 

Stopping point for Friday January 9. For next time, read Pence pp.6-9, and review any notes you have on Kant from Intro to Philosophy or Intro to Ethics.