At White Coat Underground, PalMD ponders what to make of members of the same professional community with divergent views of the ethical principles that ought to guide them:
As I thought a bit more about the doctor who wrote the letter to the editor we discussed yesterday, I wondered how two similarly-trained doctors (he and I) could come to such different conclusions about ethical behavior.
The generally agreed upon set of medical ethics we work with has developed over centuries. Patient confidentiality, for example, was demanded by Hippocrates of Kos. But many of the medical ethics we work with are fairly modern developments that reflect the thinking of our surrounding society. The changing weight of patient dignity and autonomy vs. physician paternalism is such an example.
The very fact that our views (individually and collectively) or what is or is not ethical change over time is important to notice. The folks who believe there are “moral facts” in the world for us to discover might account for this in terms of improvements in our ability to perceive such moral facts (or maybe an improvement in our willingness to look for them). Myself, I’m not sure you need to be committed to the existence of objective moral facts to grant that the project of sharing a world with others may change in important and interesting ways as our societies do. And, I don’t think we can rule out the possibility that in some respects, earlier generations may have been jerks, and that we can do better ethically, or at least try to.
“Justice” makes its official entry into the list of essential ethical principles that need to guide research with human subjects (whether biomedical or not) in the Belmont Report, which was convened to respond to the Tuskegee syphilis experiment. That 30 year long study was notable for how unequally risks of the research and the benefits from the knowledge it produced were distributed, and the public outcry when the study was exposed in the newspapers (while it was still ongoing) made it clear that the behavior of the researchers was ethically abhorrent in the eyes of a significant segment of the American public.
In Belmont, it’s worth noting, justice is one of three guiding principles (the other two being beneficence and respect for persons). The authors of Belmont acknowledge that the tensions that sometimes arise between these three principles can make it difficult to work out the best thing (ethically speaking) to do. However, attention to these three principles can help us rule certain courses of action right out (because they wouldn’t fit with any of the principles, or only kind of fit with one while violating the other two, etc.). It’s not a matter of throwing one of the three principles overboard when the tensions arise, but rather of finding a way to do the best you ca by each of them.
On the matter of someone who might say, “I don’t believe justice is an essential ethical principle, so I’m going to opt out of being guided by it,” here’s my take on things:
Ethics do not begin and end with our personal commitments. Ethics are all about sharing a world with other people whose interests and needs may be quite different from our own. Ethical principles are meant to help up remember that other people’s interests and needs have value, too, and that we can’t just trash them because it’s inconvenient for us to take those interests and needs seriously. In other words, in ethics IT IS NEVER ALL ABOUT YOU.
This is not to say that there aren’t struggles (especially in a pluralistic society) about the extent of our ethical obligations to others. But you can’t opt out without opting out of that society.
And here’s where we get to the researcher or physician (my expertise is in the ethical standards guiding communities of researchers, but PalMD notes that the current position of medical ethics now embraces justice as a guiding principle). He’s free to say, “I’ll have no truck with justice,” if he is prepared as well to opt out of membership in that professional community. Alternatively, he can stay and try to make a persuasive case to his professional community that justice ought not to be one of the community’s shared ethical values; if he changes enough minds, so goes the community. (This could have implications for how willing the broader society is to tolerate this professional community, but that’s a separable issue.*)
But, he cannot claim to be part of the community while simultaneously making a unilateral decision that one of the community’s explicitly stated shared values does not apply to him.
I think Pal nicely captures why physicians (among others) should take the community standards seriously:
Why should physician’s adhere to any code of ethics? Can’t we just each rely on ourselves as individuals to do what’s right?
As doctors we are given extraordinary privileges and responsibilities. Physicians have always recognized that this demands high standards of behavior. The way we act professionally must take into account not just what we each believe, but what our patients and our society believes. Ethics are easy if we all have the same values. Ethics get hard when we don’t share beliefs. And when we don’t share beliefs, we must at the very least remember our core principles, those of helping our patients, and not causing them harm; of granting them autonomy and privacy; of treating them with basic human dignity.
Even physicians have to share a world with the rest of us. Our ethics, whether as members of professional communities or or society at large, are a framework to help us share that world. Maybe you can make a case for opting out of an ethical principle you don’t care for if you are the supreme leader of your world, or have a world of your very own with no world-mates. Otherwise, it behooves you to figure out how to play well with others, even if sometimes that’s hard..
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*While it’s a separable issue, it’s worth noting, as I have before, that the codes of conduct, ethical principles, and such adopted by professional communities exist in part to reassure the broader public that these professional communities mean the public well and don’t plan to prey on them.
Thanks for the discussion, Janet. In hospital medicine, it’s easy to focus on the problem-solving ethical discussion and avoid some of the broader issues.
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Janet — You seem to be assuming that “justice” has a consensual meaning, and that its meaning conveniently coincides with your own left-wing politics.
To the contrary, the question “What is justice?” is one of the oldest in all of philosophy.
It is not at all obvious to me that endorsing left-wing social programs, of the sort referenced in PalMD’s post, constitute the only possible way of enacting “justice.”
Similarly, it is not obvious to me that a doctor who rejects such programs is dispensing with any consideration of justice or is outside any ethical standards. Rather, one might note that he is consistent with the empirical evidence that the “War on Poverty” has failed over the last 45 years .
If there are no “moral facts” nor “moral opinions” what are we left with?