Case example

Metropolitan Medical Center (MMC) is a private, not-for-profit 500-bed acute care hospital. MMC clinicians and administrators are wrestling with a serious problem. Over the past year, MMC has admitted eight different patients who presented to the MMC Emergency Department with severely damaged heart valves that have required valve replacement surgery. In each of these patients, the damaged valve was the result of endocarditis, a bacterial infection of the inner surface of the heart, including the heart valves. All of the patients report intravenous (IV) injection of a homemade liquid preparation of Opana® (oxymorphone hydrochloride), a potent narcotic pain medication designed for oral ingestion. All of the patients are from the same nearby town, all are indigent, and none have health insurance. Despite strong warnings from their physicians that continued IV drug use would likely cause reinfection of the implanted heart valves, four of the patients have returned to MMC with recurrence of endocarditis requiring repeat valve replacement.

MMC medical staff members have sharply divided opinions about how to respond to these patients. Several cardiovascular surgeons have argued that these patients should be warned that they will not be offered repeat surgery if they continue IV drug use and present to the hospital a second or third time with damaged heart valves due to endocarditis. Several infectious disease specialists have argued that these patients are suffering from an addictive disease and that they are therefore not responsible for their condition and should receive life-prolonging surgery. A psychiatric consultant reports that these patients meet statutory criteria for involuntary commitment and treatment for their substance abuse, but that no substance abuse treatment facilities are currently willing to accept them for the extended treatment they require.

The president of MMC has charged the chief medical officer (CMO) to develop and implement a consistent approach to caring for these patients. What approach should MMC adopt?

As mentioned in the Preface, the aim of this book is to provide a concise introduction to fundamental concepts, methods, topics, and arguments in health care ethics. Each chapter begins with a case example in which health care professionals, patients, or others confront a specific moral problem or question in a health care setting, and each chapter ends with an analysis of that case. This first chapter will examine basic concepts of ethics and health care and will consider the role and significance of ethics in health care relationships and practices.

What is ethics?

One might claim that the answer to this simple question is so obvious that it needs no discussion. We frequently encounter the terms ‘ethics,’ ‘morality,’ ‘ethical,’ and ‘moral’ in our daily lives; popular media outlets regularly feature stories about moral conflict, moral failure, and, occasionally, moral heroism in health care, business, politics, and other areas of public and private life. Many times each day, we make decisions and take actions that have moral significance, although we usually do not consciously consider the moral dimension of our decisions and actions.

Despite the ubiquity of ethics in our lives, when I ask students, in the first meeting of an ethics course, to give me a concise definition of ethics, I am virtually always met with silence and puzzled looks. The students appear to share the view expressed by US Supreme Court justice Potter Stewart in a pornography case – Justice Stewart wrote that he would not attempt to define pornography, but claimed “I know it when I see it.”¹

Although they may not realize it, my students’ initial reluctance to propose a definition of ethics may reflect the fact that ‘ethics,’ ‘morality,’ and related terms are commonly used in several different ways. ‘Ethics’ can refer to various members of a family of related concepts. Among the various concepts of ethics are (at least) the following:

Each of these different but related concepts of ethics will figure in this book. Although they are different, all of them address questions of what kind of people we should be, what actions we may or should undertake, and how we should relate to one another and to the world around us. Some scholars maintain that there is a significant difference in meaning between the terms ‘ethics’ and ‘ethical’ on the one hand, and ‘morality’ and ‘moral’ on the other. These terms may have slightly different shades of meaning, but I believe that they are very commonly used as synonyms, and therefore I will use them interchangeably throughout the volume.

Sources of moral guidance

If we recognize that ethics offers guidance about what kind of person we should be and how we should act, an obvious follow-up question is “Where does this moral guidance come from?” Unlike the first question mentioned above, students have a number of ready answers to this second question. Many credit their parents or teachers for providing this guidance, some cite the role of their religion and its doctrines, others recognize the influence of their peers and their cultural communities, still others appeal to social norms, especially norms embodied in the law, and a few mention the inner voice of conscience. Students with particular backgrounds may add that moral philosophy, or the moral standards and principles of their profession, offer further guidance.

In today’s diverse and multicultural societies, all of these sources, and many others, offer valuable moral advice. This multiplicity of guides can encourage us to lead thoughtful and committed moral lives, but it also poses an obvious problem. In a variety of situations in which we confront a difficult moral choice, different sources of guidance on which we rely may disagree about what we should do, and none of these sources is likely to have a convincing claim to priority or infallibility. How, then, should we determine what to do when our trusted sources of moral guidance disagree? This problem can arise for individuals seeking to make a responsible decision and carry it out, and it can obviously also arise when two or more people disagree about what joint action they should take, as, for example, a physician and patient considering what treatment plan they should adopt for that patient’s illness. Because contemporary societies are culturally, religiously, and morally pluralistic, we frequently confront uncertainty and disagreement about what course of action to pursue. What can we do in such situations?

Resolving moral disagreements

Recognizing the fact of moral disagreement need not result in moral stalemate or paralysis; when we confront a difficult situation, we may recognize that doing nothing as well as taking some action is a conscious choice with significant consequences. We may, therefore, attempt to resolve the disagreement. Methods for resolving moral conflicts include rational argument, what I will call “moral persuasion,” and negotiation and compromise. When these methods are unsuccessful, it may sometimes be appropriate to resort to a kind of coercion. In other situations, the parties may conclude that they cannot reach an agreement and therefore cannot engage in a joint endeavor. Let’s consider each of these options in turn.

Rational argument. The most powerful method for resolving moral disagreement is appeal to a compelling rational argument. The proponent of one conclusion about how to resolve a disagreement may be able to present an argument showing that that conclusion follows, according to established rules of formal logic, from premises that both parties accept as true. Refusal to accept the conclusion of such a compelling moral argument would be an irrational decision. In many, if not most situations of moral disagreement, however, it may not be possible for either party in the dispute to construct a logically valid argument from shared premises. So, this method of resolution of disagreement will not be available in those situations.

“Moral persuasion.” The proponent of one position in a situation of moral disagreement might appeal, not to a compelling rational argument, but rather to characteristics of his or her position that she believes will be attractive or persuasive to other parties, and invite them to embrace that position because of those attractive characteristics. One might, for example, claim that a particular course of action will likely have certain beneficial consequences, or that it is the kind of action a virtuous person would choose. Even if such invitations to view the action in a positive way do not constitute a logically sound argument, they may persuade others to endorse that course of action.

Negotiation and compromise. Despite the fact of moral pluralism and the frequent occurrence of moral uncertainty and disagreement, we obviously also have strong interests in making and acting on moral choices, both individually and jointly. If health care professionals and their patients, for example, cannot agree on a treatment plan for the patient’s illness, central interests and goals of both parties will likely be frustrated. When we encounter differences in moral beliefs and preferences, therefore, we often choose to examine the situation more thoroughly, in an effort to find a course of action that both parties can accept and undertake together. Such an examination may uncover shared values and goals that can form the basis for agreement, or it may motivate the parties to accept limitation of some individual preferences in order to achieve common goals. A process of moral negotiation and compromise may achieve agreement on a joint course of action that is not optimal for either party, but that does enable the parties to work together to achieve shared goals.

Coercion. If a moral disagreement cannot be resolved, one party may attempt to force the other to act in a particular way. Though such a coerced action obviously does not resolve the moral disagreement, it may be morally justifiable in certain contexts, especially contexts in which one party has legitimate authority over another. Consider, for example, the relationship of parents and their minor children. Parents and children sometimes disagree about whether the children should be permitted to act in certain ways. When these disagreements cannot be resolved, it may be permissible for parents to constrain the behavior of their children, based on the parents’ considered judgment. Such authority relationships also commonly exist in employment settings. In entering military service, for example, a person may agree to be bound by the orders of a superior officer.

Agreeing to disagree. Even the best efforts of the parties to resolve moral disagreements by means of rational argument, moral persuasion, and negotiation and compromise have no guarantee of success. The moral beliefs and values of the parties may be so deep-seated and divergent that there is little or no basis for agreement on a common course of action. Unless one party has legitimate authority over the other, therefore, the parties may decide that they can only agree to disagree. As a consequence of this decision, the parties will not be able to cooperate on a course of action in the situation about which they disagree. Patients, for example, may refuse treatments recommended by their physicians, and physicians may refuse to provide services requested by their patients.

This book will identify and examine central ethical issues and problems in health care. It will review and evaluate a variety of reasons, arguments, and procedures offered to address those issues and problems. The book is designed to give readers an understanding of the issues and arguments, and to enable them to engage in moral deliberation and to develop and defend a considered position on those ethical issues.