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Abolish Medical Ethics

Written by Charles Foster

In a recent blog post on this site Dom Wilkinson, writing about the case of Vincent Lambert, said this:

If, as is claimed by Vincent’s wife, Vincent would not have wished to remain alive, then the wishes of his parents, of other doctors or of the Pope, are irrelevant. My views or your views on the matter, likewise, are of no consequence. Only Vincent’s wishes matter. And so life support must stop.’

The post was (as everything Dom writes is), completely coherent and beautifully expressed. I say nothing here about my agreement or otherwise with his view – which is comfortably in accord with the zeitgeist, at least in the academy. My purpose is only to point out that if he is right, there is no conceivable justification for a department of medical ethics. Dom is arguing himself out of a job.

If he is right, autonomy is the only ethically relevant principle. There are no queasy questions about identity, personhood or authenticity. And our boundaries are easily defined: we bleed into nobody, and nobody bleeds into us.

By ‘autonomy’ is evidently meant the expressed wishes of the capacitous and the previously expressed or presumed wishes of the incapacitous. If the principle is so self-evidently true for end-of-life situations, it is hard to see why it is not the key that unlocks all problems in clinical ethics. Questions about embryo manipulation evaporate once one observes the benefit that can accrue to already autonomous creatures from the use of non-autonomous creatures. Questions about abortion are similarly trivial. Questions about organ donation and other post-mortem use of tissue are determined in exactly the same way as Dom urges that Lambert’s fate should be decided. There are no remaining philosophical questions. Even resource allocation questions become ethically easy. The value system relevant for the utilitarian calculus is autonomy: one simply has to work out how to maximise the amount of autonomy in the world.

There is still plenty to discuss, of course. But the remaining discussion is for lawyers, public policy makers, and health economists. The lawyers will need to devise procedures to enable capacity to be assessed, to ensure that those all-important wishes have been made freely and expressed with sufficient clarity, and so on. The public policy people will agonise about the tension between individual rights and societal interests. The health economists will create indices for autonomy and plug them into their Bayesian algorithms. But the philosophers’ work is done. It would be kind, but hardly essential, to invite them to meetings (in the Law Faculty) about medical law. But a department of their own? It can’t be justified in these straitened times.





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8 Comment on this post

  1. Anthony Drinkwater

    Sorry to reply so late to your post, Charles, but I thought that others might do so. In the absence of Dominic or other medical ethicists who might wish to defend their jobs, here’s my view, for what it’s worth.
    First, you write : « I say nothing here about my agreement or otherwise with his view – which is comfortably in accord with the zeitgeist, at least in the academy. »
    I’m afraid you are exposing yourself to the criticism of being a little disingenuous here, Charles. What this rhetorical phrase implies, it seems to me, is that you are standing up against what is just a fashionable prejudice, prevalent especially amongst the intelligentsia who know what zeitgeist means. Hence, despite your « statement of neutrality » you are very clearly in disagreement. But although I have not seen opinion polls on the matter, I doubt very much that here in France the view you are attacking is a minority one held merely by Parisian intellectuals.

    Secondly, instead of arguing against Dominic’s position your rather obessional crusade against autonomy as a (in your eyes solitary) principle of medical ethics leads you to offer what you believe to be a reductio ad absurdum which doesn’t hold water.
    It seems to me that if I offer even one single example of an ethical issue that doesn’t depend on autonomy, Dominic (and others, no doubt) willl continue to have a reason for doing their job and medical ethics will not enter the dustbin of history.
    So here goes, rather arbitrarily :
    How about the debate on whether or not to operate surgically on those rare babies born with no, or little, genital differentiation ? How does the concept of autonomy dominate, or even enter into, this sphere? And is this not a sphere in which medical ethics has a role to play?

  2. Thank you, Anthony.
    What you characterise as my ‘statement of neutrality’ was simply there to indicate that this post was nothing to do with the substantive debate about what autonomy’s contribution should be. As you observe, I have not been silent in that substantive debate, and if, which I doubt, anyone wants to know my position, it’s not hard to find out.
    I doubt that anyone in the business would take very serious issue with my characterisation of the zeitgeist. Look at the opening chapters of undergraduate textbooks. Things have changed a bit over the last ten years or so, though, and you’re probably right that in continental Europe there are (relatively) more dignitarians and communitarians, and (in France in particular) an interest in the relevance of identity.
    I have no ‘crusade’, obsessional or not, against autonomy. For the umpteenth time: any system of ethics or law or politics or education or just about anything else that doesn’t accord a very prominent place to autonomy is dangerous and obscene. But humans and human societies are complex entities: their complexity is not fully captured by any of the iterations of autonomy that dominate the market.
    Re surgery on babies with no genital differentiation: I think that most mainstream ethicists would regard such surgery as justified, and would do so because it increases the child’s valency: increases the possible suite of autonomous choices that the child could make. Pretty classic autonomy-dominated thinking. With which, in that case, I happen to agree.

  3. Anthony Drinkwater

    Thank you, Charles, for your reply. If I over-characterised, excuse me, but it was a reaction against your presentation of what seemed to me to be a manichean choice between accepting the principle of autonomy and closing down medical ethics !
    Personally I don’t read Dominic’s post as claiming, nor implying, that autonomy is the only ethical principle – only that it is the dominating one in the particular case concerned.

    Re early surgical intervention in non-sexually-diffentiated babies, I am much less certain that you seem to be on this issue : not at all certain that the claim that most ethicists would justify it is in fact true; and less certain than you that the question of autonomy is a major factor in the debate (at least in your definition of it as “the expressed wishes of the capacitous and the previously expressed or presumed wishes of the incapacitous”).
    But I am in full agreement with you that humans and human societies are complex entities! I would, however, change the end of your phrase to ” their complexity is not fully captured by any of the iterations of any one single principle that seeks to dominate the market.”

  4. Hi Charles,

    I’m not sure I see why it should be true that, if autonomy is the dominant or only value in medical ethics, we should adopt a maximising consequentialist approach to autonomy. For one thing, that doesn’t sit well with many existing defences of the value of autonomy (whether or not they are good defences is another matter), which deny that autonomy is a value to be maximised (since we cannot, automatically, pursue A’s and B’s autonomy by overriding C’s, or promote D’s greater future autonomy by undermining D’s present autonomy). And of course, if maximisation isn’t the answer, then we need to consider how to navigate between different individuals’ autonomous preferences.

  5. Many thanks, Ben. I agree. I was careful to say that my comments related to autonomy only in the way that it was understood and deployed by Dom in the post I cited – which was a ‘maximising consequentialist approach.’

  6. Thanks Charles – Perhaps we’re looking at different posts, but I see nowhere in Dominic’s original any reference to maximisation, implicit or explicit. I also think that if you are restricting yourself to a maximising view it’s rather less plausible to claim that this is in line with the academic zeitgeist, since as I said, many accounts of autonomy’s central value are not maximising accounts.

  7. It seems to me that that’s the gist of Dom’s assertion. At any rate there’s not much room for any of the qualifications that you (rightly) say could and should be accommodated within any account of autonomy that regards humans as complex organisms.

  8. “My purpose is only to point out that if he is right, there is no conceivable justification for a department of medical ethics”

    While I share some of your reservations about autonomy as an overriding principle, we do have to consider whether patients and their problems exist to support departments of medical ethics, or whether we should look at it the other way around. One would hope that departments of medical ethics exist to support patients and other involved parties in making decisions.

    I rather suspect that you may have ‘verballed’ Dom in implying that he was saying that autonomy was always the only principle needed, when it seems rather that the argument was that it was the most important principle in this case, in which we have a fairly reliable indication from Mr Lambert’s wife of what his views would have been, had he the ability to express them.

    When I am lying like a pithed frog in intensive care, unable to express my views, I would like the person best acquainted with my likely wishes to make the decisions on my behalf, accepting the risk that she may be wrong or conflicted – she has put up with me for many years without killing me yet ( a minor miracle ), so is probably going to make the best and most loving decision, or at least do better than anybody else. We have to accept the risk that she has been secretly plotting my demise so that she can run off with the gamekeeper, but life is imperfect and one has to play the odds, hoping to get as close to the best decision as possible. It is she and I who will bear most of the consequences of any decision.

    Clinical decision making is inherently messy and imperfect and we are doing well if we get it 80% right, the quest for perfection/certainty leads to paralysis and greater problems for the person at the centre – the patient.

    Autonomy is imperfect, but as one Australian politician put it: ” always back self-interest – at least you know it’s trying hard ”

    Autonomy works for me – I am a stroppy, tolerably well-educated, financially secure, well-connected, dominant culture white male. Things are designed to work for people like me. Were I to be a 16yo aboriginal single mother who has been abused by every authority figure in her life, my ability to access autonomy as a protection in dealing with institutions and decision making may be rather different.

    Or were I to be Muslim, approaching EOL decision making, an autonomous decision to die, or for my child to die, may simply not be on the table as an available choice , at least on a literal interpretation of the Quran – ” It is not given to any soul to die, save by the leave of God , at an appointed time” Q 3:145 This is a simplistic reading of the texts, but one held by many.

    So autonomy is neither universally appropriate nor available in decision making, but it works well for most of us most of the time and has to be accorded a high value. Surely the rôle of medical ethics ( and other ) departments is to tease out when it may not be the deciding principle.

    I rather suspect that neither Dom nor Charles have to fear the tender mercies of the local labour exchange. There will be more than enough to keep all gainfully employed for quite some time, life would be boring without you.

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