Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please could you tell us a little bit about medical ethics and what sorts of issues it encompasses?
Medical ethics assists healthcare professionals to make decisions respectful of persons who happen to be their patients.
Sometimes assistance is provided in clinical consultations about individual patients, but medical ethics also is concerned to develop policies that protect groups of people – for example, fragile neonates, or people at the end of life, or other groups whose history demonstrates their heightened vulnerability to discrimination by the health care system.
Responding to each patient’s own idea of the good, whether directly expressed or reconstructed by the patient(s) surrogates, is an important – and perhaps the prevailing – value in medical ethics today.
But there are many reasons why being respectful of patients in this way can be difficult, especially when medical personnel have values that differ from the patient’s or when they cannot imagine being in the patient’s situation.
Here are some of the ethical questions for which medical ethicists construct recommendations:
- On what basis should further medical treatment for a patient be declared futile – and how relevant are physicians’ evaluations about the future quality of that patient’s life? And, are there biological or medical conditions that warrant denying some living humans standing as persons who deserve respect?
- What are the most effective procedures for protecting human research subjects while enabling medical knowledge to progress?
- In what ways should information about an individual’s genome influence medical or social treatment of that person?
- How should cultural differences about such matters as giving very bad news to patients be weighed?
And an important question with answers less clear than one would expect is, what criteria should be applied to declare that an individual is dead? Although death is a biological phenomenon, social convention greatly influences when death is called.
Medical ethicists also tackle questions about health care justice, such as
- What constraints should be imposed on organ procurement, and on what principle(s) should scarce organs be allocated for transplantation?
- Do people have a right to health care, and if so what kind(s) and amounts of medical service is the system obligated to provide?
In what ways, and to what extent, should medical technology be applied to improve people’s lives: should we attempt to extend the human life span dramatically, or improve human behaviour with pharmaceuticals, or enhance people’s inherited capacities and talents? Or could making such technologies available destabilize society, constrain people’s freedom unfairly, or otherwise skew or strain social values?
How has the study of medical ethics changed throughout history?
The initial idea of medical ethics, as expressed in the Hippocratic oath in late 5th century B.C., is to reassure patients (and their families) they won’t be harmed by giving physicians access to their bodies and homes.
As healthcare professions became formalized with the rise of institutionalized medical education and credentialing in the later 19th century, various organizations developed codes of ethical conduct to demonstrate that medical professionals could regulate themselves.
In the decades after World War II, however, revelations about harms perpetrated by physicians, sometimes in the name of advancing medical science, prompted calls for stronger collective efforts to ensure ethical conduct.
During this period, moreover, patients more frequently sought redress through the justice system for medical system harms. The recent remarkable expansion of research in medical ethics, to better achieve clinical and health care system applications of fundamental ethical values, responds to these challenges.
What challenges have biomedical technological advances brought to the study of medical ethics?
Rapid advances in biomedical technology have enabled us to maintain human life even where functionality is severely compromised or extinguished, but should we do so whenever possible, regardless of medical costs, stress on families or other caregivers, and formidable difficulties the patient will have to face in future years?
How much expense should be allowed for last resort new technologies not yet demonstrated to be effective? Patients should not be viewed as means to gaining scientific knowledge, but how can we learn whether new technology will be beneficial or disastrous unless some patients are permitted – indeed, are encouraged - to try it out?
Reproduction is another area in which rapid technological advances have ushered in equally rapid social and cultural change. Human offspring no longer are restricted to two biological parents: germ material from at least two parents can be gestated by a third. On the other hand, in principle at least, one biological parent can suffice.
In order to preserve familiar social roles, should ethical constraints be placed on who may use reproductive technologies? And now that so many medical interventions for infertility exist, should the inability to produce biological offspring count as just another disease of which people deserve to be cured?
Personalized medicine promises to read off our genomes so that individuals can be better informed about the destinies toward which their biological inheritances drive. But to be informed about one’s biological dispositions is not to know one’s biological destiny. So we must devise ethical perspectives that enable medical practice to apply genomics to benefit people without exposing them to the concomitant harms of genetic determinism.
Bio-engineering is breeching barriers between organic and inorganic body parts, blurring the traditional differentiation of nature and nurture, and abandoning the dualism distancing body from mind.
While such fundamental ideas may seem abstract and therefore unimportant for practical medical judgment, altering them can be disorienting. So these sharp conceptual shifts call for careful ethical navigation when medical practice encounters new sorts of dilemmas, so as to remain guided by our most important values as lodestar distinctions fade.
There are often many questions raised about the beginning and end of life: in particular the issues of abortion and euthanasia. How do you think public policy on these issues should be shaped by the field of philosophy of medicine?
Philosophy of medicine clarifies what is at issue in regard to these topics, each of which involves complex tangles of values, now made more difficult to sort out by medicine’s enlarged facility to maintain life, albeit perhaps with seriously reduced functionality.
At its best, philosophy of medicine deflates hyperbole and imposes precision on the conflations that characterize both public, and some academic, discussions of these issues.
Philosophy of medicine should inform and elevate public policy, which is different from shaping it. Philosophy of medicine can also blow the whistle when public debate threatens to squeeze policy into illogical shapes.
How far is public policy on health issues currently shaped by the field of philosophy of medicine? In what ways do you think this could be extended?
Public policy on health issues is shaped by philosophies, but not so much by contemporary philosophy of medicine. For example, U.K. health care policy is shaped by 19th century utilitarianism to an extent that is uncomfortable for U.S. philosophers and medical professionals alike.
U.S. health care policy is shaped by applications of the 18th century values of personal liberty and responsibility that also inform the U.S. legal system.
Some contemporary philosophers have achieved public notice as commentators on health care policy, more so in the U.K. than the U.S.
Commenting is of course far from shaping; commentators tend to be successful not because they originate new policy directions but rather because they elucidate or ornament prevailing policy.
Recently, many people in the US have been debating over the individual mandate, i.e. whether it is constitutional for the government to require you to buy medical insurance or pay a penalty. What do you think about this issue?
The U.S. Supreme Court now has declared the individual mandate constitutional by conceptualizing this element of the Affordable Care Act as a tax, such as is required to support the existing Social Security system. As long as U.S. health care mainly is financed through corporate insurers rather than through a single public payer state program, insurance companies will apply their political clout to acquire protection against adverse selection (as the individual mandate does).
Otherwise, insurance corporations fear, only citizens in need of medical services, and not those healthy ones whose premiums can contribute to services for others who are ill, will purchase insurance.
So the so-called individual mandate is part of the price paid for maintaining private rather than state-supported health care safety nets. But single payer public systems also constrain individual liberty in various ways. So extending access to health care to more people seems to mean shrinking the scope of personal choice, which creates a difficult challenge for health care justice.
What are you currently researching or planning to research?
My research touches on several topics that have an underlying unifying theme. I’m interested in how decisions are made about pre-term fragile neonates, about which lives to support and which to let die.
Physicians’ decisions are influenced by predictions that such children will be disabled, but a closer look reveals their basis for prediction often does not meet reliability standards.
I’m also deeply interested in reshaping the concepts, and thereby the policies and practices, which direct health care professionals’ responses to chronic illness and old age. And I’m a strong advocate of the use of so-called enhancement technologies, both mechanical and biological, though I’m no fan of the hyperbole about multi-century life spans and super-server type memory and such like that too often is trotted out to make funding enhancement seem glamorous. These interests all emerge from my research on the misuse of “normality” as a standard in medicine.
This month Oxford University Press is publishing the second edition of Medicine and Social Justice, on which I collaborated with Rosamond Rhodes and Margaret Battin. So much has changed in the world since the first edition in 2002 that this volume is about 100 pp. longer than the first (but seems to cost only $10 more). Sensitivity to health care injustices has grown in the past decade, but the political will to rectify or guard against them has not kept pace.
How do you see the future of medical ethics progressing?
Some medical ethicists want to make medical ethics into a clinical field, so as to acquire the prestige and place acceded to credentialed specialists by the health care system. This is a worrisome direction, I think, because moral medical practice benefits best from perspectives that are not constrained by professionals’ prevailing presumptions and prejudices.
Where can readers find more information?
They can find more information at:-
About Professor Anita Silvers
Anita Silvers is Professor and Head of the Philosophy Department at San Francisco State University. She has been awarded the Quinn Prize for contributions to philosophy by the American Philosophical Association and was an appointee of the President of the United States to the National Council on the Humanities.
Silvers has written extensively about medical ethics for the past two decades; for more than a decade she has served on the medical ethics committee at San Francisco General Hospital. A polio survivor and wheelchair user, she also has pioneered philosophical and legal research on disability justice theory.