Sunday, December 12, 2010

Medical Ethics: President Obama Makes the Right Call


I have always felt that issues should be judged by the context of their times. For some issues, however, context provides no justification. Thankfully, the field of medical ethics has evolved into a robust discipline, and there is an enormous need for it. I have read defenses of prior ethical lapses, and even some recent ones, suggesting that context matters. If a 3 month placebo-controlled study is conducted in the developing world testing a medicine that was highly effective against a serious illness, are the ethical dimensions considered and respected? Were the pharm companies choosing this study locale as a cheap test run for their drug, which will ultimately be marketed in the west? Is it ethically problematic not to provide additional medications to ill subjects after the 3 month trial ends? Can we be assured that a rigorous informed consent process was followed? Sadly, outrageous practices have been reported in the very recent past.

Our president and secretary of state recently and rightfully apologized to Guatemala for American experiments performed there in the 1940s when patients were intentionally infected with syphilis. These patients were mentally ill. While I can concoct a distorted and tortured rationale that would justify this reprehensible practice, such reasoning passes no threshold of decency. Some behaviors and practices are always wrong, in any context.

How can decent folks behave indecently? We have seen in the Holocaust how ordinary folks can tolerate, and even perform, evil during the week, and then attend religious services on Sunday. Many of these dark acts were committed by physicians, who are sworn to heal and to comfort. Here’s a perspective on this issue from a man who is known as the conscience of the world.

These are frightening notions. First, they suggest that we may not have innate inclinations to do good, despite our belief that we are all equipped with powerful superegos. If we were all good by nature, then we wouldn’t need such an expansive criminal justice system and thousands of laws telling us what not to do. The reason that the bible is replete with ‘Thou shalt nots’, is because human behavior is often ‘I shalt’. Secondly, these repeated ethical lapses and catastrophes point out that all of us are vulnerable to do wrong, even when we know what the right choice would be. While we might like to think we would push back against a black tide, it is less certain what we would truly do in that situation. Would we risk a job, for example, to take a righteous stand for another person?

I recognize that medical ethics addresses tough issues, where one person’s rights are weighed against another. The resolution of ethical issues yields winners and losers. Yet, despite these controversies, we need a firewall separating what we must do from what we must never do. The argument that the ends justify the means must be resisted. What American scientists did in Guatemala nearly seventy years ago was appalling and morally indefensible. It was wrong then, it is wrong today and it will be wrong tomorrow. The president has just ordered a review of all research involving human subjects being funded by the federal government to assure that medical ethics are being properly practiced. Recent history demonstrates that oversight is necessary. Third world citizens deserve first class ethics.

7 comments:

Elaine Schattner, M.D. said...

Michael,
This is interesting. Although much of what you say might or should be morally obvious, the reality is that many people, including doctors ("we"), don't always do the right thing.

A. Bailey said...

The Hippocratic Oath is as relevant today as it was 2500 years ago. We don't need to reinvent the wheel so much as to return to our roots.

Unfortunately the Oath is anathema to Democrat politicians, Obama being first and foremost.

Dr. Kingsberg said...

Happy Holidays!

Nicholas Fogelson, MD said...

These types of experiments were as ethically reprehensible then as they are now, not just because of today's ethics, but of the ethics of the time as well. This episode has clear parallels with the Tusgkeegee experiments performed on our own people. At its core, racism is what allows this to happen - a belief that another person has less value than one's self.

I am struck by this all, as it is think it is little simplistic to label actions pure black and pure white. I think you have to look at ethics of past events not though today's ethics, but through the ethics of the time. "good" people brought up to believe things we consider 'bad' now are unfairly labeled as 'bad', when really they were just typical for that time. It seems unrealistic and unfair to expect some person in the past to have a 100 year advanced view of medical ethics, when such precepts had not been conceived of at that time. The sad thing about this particular case, is that I think the medical ethics of that time still would have proscribed this behavior, making it completely unethical even in that time.

I just finished reading Huck Finn for the first time, and am struck by the banality of the racism throughout the book - and I don't mean racism of the book itself, just the racism of the time described. Tom and Huck were clearly raised to see black people as inferior humans, and in fact they did see Tom that way, and acted accordingly. Yet underlying they had a certain ethics as well, and were not sociopathically evil in any way. Over the course of the book, of course, Huck finds errors in his initial views of slavery, which is perhaps a central theme.

The Hippocratic Oath is a description of the precepts of medical ethics in the time of Hippocrates, and like many documents written a great number of years ago, has some elements that no longer fit current practice, and in some cases current medical ethics. For example, abortion is considered ethical by the majority of the country, despite its proscription in the original Oath.

Michael Kirsch, M.D. said...

Thanks for your thoughts, Nick. As you know, Huck Finn has been in the news lately. Do you think it was proper to change Twains' wording?

Nicholas Fogelson, MD said...

No I don't. Huck Finn was a profoundly racist boy, as he was taught to be so by his upbringing. That said, his use of the N-word is not part of that racism. That was just the language of his time.

The racism of Huck and Tom was in everything they did, and yet they also were good in many ways. They saw Tom both as a person but also as a sub-person, as we see in their joy at contriving his rescue attempt for their own entertainment rather than maximizing Jim's benefit through a simple and effective rescue. They continually believed that no matter how much they put Jim through for their entertainment, their rescue him was boon enough that Jim would have no right to complain.

The book gives us a good understanding of how people felt and acted at that time, at least in the eyes of Mark Twain. If there is racism in the book itself, it was in the portraying of Jim as so dull-witted, almost to the level of being mentally retarded. Clearly a slave in that time would have had little education, but Jim was portrayed as not just uneducated, but also lacking reason and thought as well, which to me read as a racist portrayal. I have many patients who speak not unlike Jim did, or in a 120 year old evolution of how Jim spoke, but under that language and in some cases lack of education, most are still quite bright and articulate people, like people of other races.

Nicholas Fogelson, MD said...

I think that for the standard of the time, Mark Twain was very non-racist. The very fact that the main theme of Huck Finn is Huck's realization of the wrongness of slavery speaks to that. I think that Clemens' depiction of Jim did demonstrate some prejudiced ideas within him (Clemens), but that overall he was probably very progressive for his time.

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