Medicine's Intrinsic Good
What is good medicine? Who counts as a good doctor? These are very large questions that cannot be fully addressed here. I want to focus on a basic aspect of these two questions and on the ethical idea of "the good." The term "good medicine," as I have just used it, is not intended to be contrasted with "bad medicine." Rather it is meant to bring to the fore that medicine is something good in itself, a worthwhile and honorable human activity, a "profession" with a specific object of activity, a human good, to which so many men and women devote their lives; an endeavor full of value and capable of fulfilling a person's life with interest, effort and achievement. Medicine is something noble and laudable; both a good and an excellence. This good of medicine is what medicine is about, what it aims at; that which makes medicine to be medicine rather than law, or politics. Let me call this good the medical good.
Ethics is concerned with "the good," described by Plato as "the aim of all endeavour."2 His follower, Aristotle, tells us in his Ethics that "every art and every investigation...aims at some good"--and adds--"since there are many actions, arts and sciences, the aims turn out to be many as well; health is the aim of medicine...."3 Since ancient times the particular good with which the medical endeavor is concerned has been focused on one word, "health." Currently, the traditional goals of medicine concerning health may be formulated as follows:
- To restore the sick patient to health: aiming to cure.
- To alleviate the patient's distressing symptoms--when health cannot be restored--aiming to comfort, to offer palliative care.
- To promote health; to prevent illness.
But we may add that these overall good ends or "good" are concretely realized in the core of medical practice, namely, "the doctor-patient healing-caring relationship." What is involved in the reality of this human relationship is what makes medicine "ethical," a moral activity, a praxis, an activity with its own intrinsic moral worth. In other words, medicine is intrinsically ethical because of the good at which it aims, i.e., its ends or goals. Hence, the moral norms to be followed to attain it, the excellence of character required of its practitioners for its realization, as well as the right activities that accomplish that good, are constitutive of medicine itself.
Ethical aims, norms, principles, excellences of character and activities are the various dimensions of medical practice, and they constitute the subject matter of medical ethics. It is my contention here that we can take the core of medicine to be the "doctor-patient healing-caring relationship," and that in this core (the "medical good") we find the medico-ethical teachings are derivable from the nature of the healing relationship. We cannot understand medicine without its ethic, we cannot understand medical ethics without an appreciation of the nature and meaning of medicine. This is the foundation for my claim that medical ethics is a medicine-based ethic.4
Clearly, this idea of medicine as intrinsically ethical determines the approach to the teaching of medical ethics. In what follows I seek to illustrate that this idea of medicine is Greek in origin and character, as handed down to us by the Hippocratic school, and that it has a transcultural and universal significance. By "Hippocratic medicine" I mean that kind of medicine, which can speak "timelessly" to doctors, and patients of all cultures precisely because its core is the relationship between the doctor and the sick, the one to be healed, the patient, a relationship, which remains basically the same for all places and times. I claim, with the Hippocratic physician, that the meaning of this relationship (as with all true human relationships) is ultimately moral. It embeds a recognition of, and fellow feeling for the other, because he or she is a human being, a morally self-governed and bodily being. It is upon this recognition that medicine as a healing and caring activity is founded and has developed as a professional body bounded by its own professional ethical code.
Approaches to Medicine and to Biomedical Ethics
I am aware that by affirming that medicine is an intrinsically ethical activity, and hence that medical ethics is a medically based ethic, I am going against some current conceptions of medicine, which may be classified under the umbrella of "technocratic medicine." Hence the position outlined here does not accord with the approaches to medical ethics that accompany those conceptions. Let me briefly dwell on this point.
Medicine is currently being regarded by some to be a morally-neutral activity, value free, like science or technology. Doctors, some defend, are primarily scientists rather than healers, equipped with a large body of medical knowledge and technical training. Scientific knowledge and technical skills are said not to have intrinsic moral goals. What counts as a "good use" of medicine is not intrinsic to medical knowledge and techniques themselves, but rather to the "ethics" of the user. A good doctor will know how to use those skills well, like any other technological expert, but his or her ethical outlook and opinions are independent of them. In this view, medicine is regarded as a contractual agreement between doctor and patient on the basis of the doctor's expertise, but whose "ethical" use depends on "external ethical principles." Hence, the use of medical expertise may be seen as divorced from specific moral goals and from the moral character of those involved, which may be matters considered "private" and personal. In this view, the external ethical principles governing the good use of medicine are regarded as being derived from religious codes,5 socially determined customs,6 the law,7 the opinions of the doctor, and/or the wishes of the patient.8 Conceiving medicine as purely scientific and technical and value-free is consistent with much of our current liberal, legal (and not litigious) cultural milieu. For "the ethical" in our modern world, that is, what is regarded as good or evil, has become something relative, changeable, and very much a matter of individual or cultural opinion and outlook; it is also something private, or for some, an intangible non-scientific dimension added to the objective facts or scientific data and evidence; it is something independent of history and tradition; something "pluralistic" since there are so many varied ethical outlooks; and something that must be "rationally" validated, and argumentatively justified, according to a pre-determined standard of reason. In other words, medicine within this outlook is considered to be amoral, scientific, a skill or know-how, a-historical, and hence ethically pluralistic.
Within the current liberal perspective, the external ethical principle which makes the "neutral" use of medicine something medically "good" is the idea of individual freedom, "the right to choose," freedom to do and implement one's own preferences. This is the primary ethical principle in our culture, commonly invoked as "autonomy." In this social context medicine has become a "service" governed by market forces, which gives the patient--now called a "client"--what he or she wants. The doctor is there to serve the autonomy of the patient.9 And when this autonomy cannot be exercised, then he or she has to carry out what is the most compassionate or benevolent thing to do in the best interests of the patient, this could include mercifully killing him or her.
Needless to say the law has become the best ally to sustain this technocratic conception and practice of medicine. For traditional medical ethics and medical practice have been changed by the continuous chain of judicial rulings and court cases in the USA, Europe (including Ireland), and Australia. That is, with this new outlook, doctors are handing over their ethical self-governance (it seems that they have accepted that it does not belong to them), while "society" and "the law" are taking full control of the medico-ethical domain.10
With the acceptance of state medical services, doctors' governing bodies may have failed to remind their members and the State that doctors' professional duty is subject to their own professional commitment as a body. In view of this commitment, doctors cannot be asked by the State--or any one else--to carry out "health policies" which would contravene their duty to cure and care, to benefit and not to harm their patients. Clearly, the law and lawyers of this new legal climate often ask doctors to do so. Thus, the new norms become medico-ethical requirements. If there are doctors, or patients, who do not agree with these new judicial requirements, a "conscience-clause" is to be invoked, and sometimes granted.
This overtaking of the medico-ethical domain by the law, in many contexts through its lawyers and lawmakers, is depriving the medical profession of its rightful ethical self-governance--partly with its consent, whether implicit or explicit. This amounts, in my view, to a disintegration of medical goals, demanding increasing "conscience clauses" to cover those physicians who cannot professionally agree with the new legal rulings. This makes the practice of medicine more and more difficult for them, while it creates two strands of medicine, a conscience-governed medicine, and a law-governed medicine, whereby the truly ethical self-governed medicine has disintegrated. The legalistic trend in medicine is also, in my view, a direct attack on the right use of practical wisdom, of true medical distraction, of that prudent judgment of the doctor on the spot, which medical practice requires. Moral wisdom is "legalistically" destroyed, for the legalistic trend is entering and changing genuine moral thinking, genuine moral governance, and genuine moral acting. I share my concern with those who conceive our cultural task as a response to our cultural crisis, which is "intellectual, moral and spiritual."11 So in view of this crisis, what practical approach may be suggested in the teaching of medical ethics?
In attempting to answer this question we can turn our eyes to the original idea of medicine. It is summarily presented in many of the medico-ethical codes, which ultimately find their roots in the Hippocratic Oath, as it has been handed down to us over two thousand years.12 Looking back to ancient Greece for an understanding of medicine and its timeless universal nature is not to have an undue devotion to tradition or history, nor to disregard the new scientific and technological era in medicine. It is only to recognize that the idea and meaning of medicine is a legacy that we have received, not something that has been newly invented. By looking at its origins in history we can better understand and gain a deeper insight into its meaning. We should allow the Hippocratic writing to speak for itself. Then we may ponder the inspirational impact it has laid on the medical profession for about two thousand years. But even if we leave this remarkable historical fact aside, we may be able to recognize the writing as an articulation of that understanding of human nature and of medicine that captures its centre, its essence, its core. This is what I have called "the medical good," which makes the meaning of medicine timeless and universal.
The fundamental reason why Hippocratic medicine can speak timelessly and relevantly to us today is because our embodied humanity is the same now as it was in ancient Greece. Hence, the activity of healing and caring for the sick is essentially the same; it cannot change, nor can the desire of the sick to get well. The basic understanding of our being healthy, as a natural condition of our embodied selves working-well, is also the same. Clearly human beings have not invented animal or human health. Whatever our difficulties in understanding people of other times, other languages and other cultures, "we are all products of similar natural processes and we all live out our lives under the same skies and this gives us at least enough in common to recognize each other's humanity... [I know] that honey tasted as sweet to Achilles as it does to me."13 Medicine as a dedication to healing and caring is founded upon our embodied and moral nature, that is, on our human nature.
1 Adapted from Teresa Iglesias, The Dignity of the Individual: Issues of Bioethics and Law, Pleroma Press, Dublin, 2001, pp.20-25.
2Republic VII, 505e.
3Nichomachean Ethics, 1094a-8.
4 See (1) above, p. 226.
5 Cf. A.G. Johnson, Pathways in Medical Ethics, Edward Arnold, London, 1990, ch. 5.
6 Cf. D. B. Black, "Iconoclastic Ethics," Journal of Medical Ethics 10:179, 1984, p.82; there a "relativist" view of medical ethics is portrayed.
7 Cf. R. Gillon, also for a treatment of (5) and (6), in Philosophical Medical Ethics, Wiley, 1986.
8 An exponent of the idea that medicine serves the autonomy of the patient can be found in M. Charlesworth, Bioethics in a Liberal Society, CUP, 1993.
9 This is the main thesis defended by M. Charlesworth in (8) above.
10 In an article in The Lancet vol. 345 (June 3, 1995), p. 1423, "Cultural Lag and the Hippocratic Oath" by Eugene D. Robin and Robert F. MacCauly, in which the medico-ethical value of the Oath is dismissed, the authors explicitly state that "it is not physicians but society or women themselves" who have to decide the fundamental moral issue of abortion.
11 Cf. Leon Kass, The Hungry Soul: Eating and the Perfecting of Our Nature, The Free Press, Macmillan, New York, 1994, pp. 1-16.
12 See version of the Oath as translated by L. Edelstein, in Ancient Medicine: Selected Papers of Ludwig Edelstein, Oswei Temkin and C. Lillian Temkin (eds.), Baltimore, The Johns Hopkins Press, 1967, pp. 3-63; version adapted by L. Kass and discussed by him in (1) above, pp.224-46.
13 C. Rhodes, The Necessity for Love, Constable, London, 1972, p. 234.