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The Elephant In the Room

Posted in Uncategorized on November 8th, 2010 by David – Be the first to comment

I enjoy conversations about deep and meaningful stuff. As you may have noticed, if you’ve been reading back through this blog.

I enjoy conversations about life, the universe and everything. I enjoy conversations about the state of the economy. But most of all, I enjoy talking about the big three taboos:

Sex, Religion, Politics. 1

However, it seems lately that there’s a fourth. One that doesn’t just not get talked about, but doesn’t even get recognised as a topic that isn’t being talked about.

The Ethicsphant in the room.

Now, ethics is certainly not a dirty word. We all like to think that we’re ethical people, in one form or another, and consider the reasons that we do things carefully.

No, the problem appears to be a little more fundamental – we don’t talk about ethics because we don’t know how.

There are about as many ideas of what ethics is as there are university places for moral philosophers 2, but many of these models seem to me to be a little too abstract to be useful in my everyday life.

So, I revert to a model of medical ethics that I read about a few years ago and was reminded of earlier this year as part of the clinical ethics component of my university course. Basically, it refers to five values. In no particular order:

  1. Beneficence: Try to make good stuff happen.
  2. Nonmaleficence: Don’t be evil 3.
  3. Autonomy: Respect others’ right to make their own decisions.
  4. Justice: Treat everybody fairly.
  5. Veracity: Tell the truth, the whole truth, and nothing but the truth. 4

The idea is that by scrupulously applying these values in each situation that arrises, good things will happen, bad stuff won’t, and if you get sued then you’ll be able to justify your decisions.

For example: The patient who comes to see me and has a significant sensorineural asymmetry 5 so I recommend that they get their doctor to refer them to an ENT. They ask ‘is that really necessary? Is it serious?’ By the principle of veracity, I need to tell them the truth (that it can be indicative of a Vestibular Schwannoma), but nonmaleficence requires that I don’t scare the s*** out of them while doing it. So, I impress on them that in rare cases this can be indicative of a deeper problem, and it’s best to get it checked out 6 just to be on the safe side.

So this model works nicely in my clinical practice 7, but how do I apply it to my everyday life?

Well, the answer comes from the fact that what this model is deal with is not primarily the medicine itself – it’s the relationships that go along with it 8. These same principles apply wherever you interact with people as part of your day. Whether you’re a bank teller or a social worker 9 or a full-time parent, wherever you interact with someone, there’s an ethically interesting situation just waiting to unfold.

In particular, now we have these values defined, a whole world of discussion about the other ‘untouchables’ opens up. Where does veracity sit when national security is at stake? Or when you fear for your own safety? Do we have a responsibility to be beneficent to convicted criminals? Is it unjust to offer social welfare to those who can’t or won’t contribute back to the system? How do we determine who is eligible for autonomy and who is too young, old, sick, unintelligent or crazy? The basic tenets of this construction of moral philosophy can be applied to just about anything.

However, this is just one way of thinking about it. There’s the Consequentialist way of thinking about things, in which the end is all that matters, not the means. There’s the Utilitarian view, in which an action is good if it serves the greatest good to the greatest number of people. Each of these views have difference precepts and different definitions, often for the same terms.

So what is good? What is ethical?

Well, I like to think that I am, and I’d like to think that you are too.

But to really understand what we mean by that, we’ve got to be on the same page.

Notes:

  1. Preferably at the same time, at a dinner party, near a large group of pensioners. But that’s another story. ↩
  2. A lot, according to my Philosophically-minded friends ↩
  3. This is the bit that most closely resembles the maxim ‘First, do no harm,’ often misattributed to the Hippocratic Oath. Like many statements both profound and trite, its true origins are shrouded in mystery. ↩
  4. In some versions of this model, the sixth value of Dignity is included as well. See Medical Ethics on Wikipedia for a good discussion of this model. ↩
  5. Kinda the Audiological equivalent of that rattling sound just before your engine falls off. ↩
  6. Interestingly enough, I was recently discussing this issue with my optometrist, when she discovered a vertical phoria which wasn’t there a year ago. Apparently that’s pretty much the optometric equivalent. No tumors, but an interesting experience for me. ↩
  7. Partly because it’s rare that anyone’s going to die from anything that I do, although mismanagement of the above situation is potentially one of those cases ↩
  8. My primary criticism of the way that this model is usually expounded is that it’s rather heavy on ‘how to treat others’ and light on ‘how to treat yourself.’ You are important, kiddies – you can’t be beneficent if you’re dead or dying. ↩
  9. Arguably a healthcare professional anyway ↩