Medicine is a Moral Activity: But Whose Morals Rule?
John Patrick, MB, BS, MRCP, (Lond, UK)
Introduction
You must not impose your values on anyone else
particularly a patient. This principle is so ingrained in medical
school that virtually no one questions it, yet it is more of a piece
with the bizarre world that Alice entered through the looking glass
than with ours. It is a world where "words mean what I choose them
to
mean neither more nor less." Only a very brief consideration is
necessary to uncover the fatal logical faults contained in this modern
dogma. If everyone is as entitled to his values as everyone else,
only when consensus is reached can anything be done. Sadists and
masochists can go ahead with their pleasures, abusive relationships
must be as honoured as loving ones, attempting to prevent suicide is
intrusive, only individual choice matters. Nothing can be declared
inadmissible if the participants are content. This is absurd; in fact,
it is an inexhaustible mine of absurdity.
The Devastating Question
Only one question is necessary to expose the
shallowness of the intellectual position of those who demand moral
neutrality in the practice of medicine. The question is why? Why
should I practice medicine in this way? The answer must take one of
two forms, either they will say that it is good or sensitive to do so,
or they will say that someone might otherwise be upset. In the first
case all that has been accomplished is to change the type of moral
imposition required from that derived from the rich tapestry of more
than 2000 years of philosophical reflection incorporated in medical
traditions to a debased, untested creed, primarily concerned with the
desires of the autonomous self. I am to take the morals of the ruling
elite instead of my own into the consulting room. In the second case,
it is being proposed that my primary professional function is to make
my patients feel good about their lives even if that is not justified.
This latter position has nevertheless to be suspended whenever the
implications of a serious diagnosis must be explained to a patient.
In both cases, an attempt has been made surreptitiously to bypass the
ancient question of what is good? It is my intent to show that moral
neutrality is neither acceptable nor sensible.
Defining the Good
As yet, most of us think that we know that some things
are always right and others wrong but these certitudes are now under
attack. Killing one another, for example, might seem a suitable
candidate for universal disapprobation. However, if the one to be
killed is a widow in some cultures, or an unwanted, unborn infant in ours,
or an ailing
parent in the future, perhaps then, this ancient landmark will be
moved. This leads the exultant modern to the conclusion that all
truth is relative (except that statement!), that we must accept all
these behaviours as ethical within their cultural context. But all
truth is not relative; some things can be and are truly known. The
categories of truth and lies define the limits of our moral universe
in one plane of experience, justice and injustice in another, honour
and dishonour in another, love and hatred in yet another. We know
these great categories in part, through a glass darkly, but we have
all experienced them truly. What is relative is the way we translate
these categories into the details of living. It may be honourable to
respond to a business failure by committing suicide in Japan, but in
the West, it used to be honourable to wind up efficiently and pay as
many debts as possible, nowadays, it appears to be honourable to hire
a clever lawyer to avoid paying as many debts as possible; nevertheless,
I believe that a debased idea of honour persists. If it is to be preserved
within medicine, we shall need to be much more
insistent on thorough discussion of changing modes of expression.
Words are dangerous, they change the cultural ethos. Evacuating the
products of pregnancy seems a much smaller event than abortion.
How Did We Come to be so Committed to Moral Relativism?
Claims to know are often arrogant and overbearing,
especially in the area of ideas about good and evil, and in disputes
between religious groups. The wars of religion bear eloquent and sad
witness to the dangers associated with moral and religious dogmatism.
The exclusion of religious debate from practical politics was one way to
contain these tensions.
Furthermore, in the glow of post-enlightenment discoveries, it seemed that
science offered certain knowledge that was based on systematic doubt, and
the use of provisional hypotheses, to
be cast aside when defeated by "facts." Facts changed their meaning
to
be applied only to what can be appreciated by the senses, (with a few
notable examples, like evolution, which are not discussed). Moral
knowledge was personal, private, and subjective by comparison.
Scientists could settle their disputes whilst theologians could not.
What emerged a good and defensible desire for religious tolerance and a
particular
respect for anything with the title scientific. The way this would
lead to moral relativism was not appreciated and still is not in some
quarters, but once moral truth was replaced by subjective moral
opinions, relativism was inevitable. The reversal of this error
demands a critique of the anthropological arguments for moral relativity.
Ethical Relativity and Anthropology
One of the most common supposed facts, upon which
arguments for ethical relativity and hence for the denial of objective
moral truth is based, is the existence of dramatically different
ethical codes found around the world. These are undeniable phenomena
extremely well documented by anthropologists. But the essential
question is what are these different codes attempting to achieve? I
wish to argue that in every case the behaviours deemed ethical are
attempts at Honour, Truth or Justice, or some other major category.
The appropriate response then is not to declare all ethical opinions
relative, but to decide which most closely achieves conformity with
the fundamental principles. Over some issues we respond intuitively,
reflecting our own cultural history and with quite remarkable
forcefulness for so called multiculturalists. For example, in parts
of the Sahel, girls are subjected, by older women, to extensive and
painful circumcision to signal their passage into womanhood and to
preserve their and their family's honour. When they migrate to
Canada, they wish to continue this practice, but we call this practice
child abuse and it is forbidden. In other words, over this issue, we
are prepared to say that our understanding of how the concept of
honour should be translated into the ethics of everyday life is better
than that of the Sahelians. What we have done is to say that the
power of our cultural story to give meaning and honour to female
puberty is greater than the Sahelian one Multicultural sensitivity
accepts that the intent of the Sahelians was good, but denies the
appropriateness of the practice. For this practice virtually everyone
agrees, but we need criteria for making such judgments in less
intuitively obvious cases.
How Can We Judge?
Historically, all cultures are forced to judge, and the success or failure
of cultures is probably more dependent upon these judgments than on economics
or politics. Perhaps, the most noble
description of what an ethical society would be like is contained in
the law of Moses. Sadly, no society has ever come remotely close to
such standards. The authority of the Mosaic law is rooted in its
claim to be spoken by God, a claim derisively dismissed by modernity.
Were the claim accepted, then the logical response of the Jews, namely
the attempt at obedience, would be rationally mandatory for all.
An alternative approach is to attempt to reason one's way to what is good.
The Greeks attempted this, and subsequently their efforts were synthesized
with the gospel by the great thinkers
of the middle ages to provide a basis for Christendom. It is fashionable
to decry those efforts, but as we sink into a sea of relativism, the medieval
belief in an objective natural law which held
sway over all things begins to look like a highly desirable one.
The modern approach, based on individualism where feelings are given as
much weight as careful thought, is exceedingly shallow by comparison. It
lacks any consistency or means to achieve
consensus and must ultimately depend upon power, even though at present
that power is exercised only through intimidation. Lewis expressed our dilemma
with characteristic elegance:
"For the wise men of old, the cardinal problem of human life was how
to conform the soul to objective reality (God) and the solution was wisdom,
self-discipline and virtue. For the modern
mind the cardinal problem is how to subdue reality to the wishes of
men and the solution is a technique. The pursuit of happiness in the
modern sense is therefore self indulgent. Man's conquest of nature
must always become man's conquest of other men using nature as the
means. But these powerful people no longer think of God and God's laws as
objective reality so they are controlled not by God's supernatural ideals
but by the natural forces of their own heredity
and environment. Thus man's conquest of nature turns out to be nature's
conquest of man." (1.)
This scenario is being played out in medicine at present as competence is
displaced from first place by various forms of affirmative action. Whenever
a cultural elite uses connotation words like male, or white, or Caucasian
to justify their attempt to enforce quotas or speech codes, they invariably
talk about victimization. We should resist derisively pointing out that
it is particular people who are victimized, not groups, and therefore, it
is always human rights that need consideration, not sex, race, or class
in a group sense. They talk of paternalistic demeaning of groups, and then
inconsistently demean a whole group by proposing to "empower"
them. Ask those who have triumphed over great odds what they feel about
affirmative action and quotas. Why should any person's subjectivity dominate
another's without objective justification?
Ethics and Subjectivity
The assumption that all ethics are subjective expresses itself in such phrases
as "good for you" or "wrong for you." Subjective ethics
would make it impossible to demonstrate that
anything was always right or always wrong, independent of what a given
individual thinks. In practice we all live as though objective right
and wrong exists. If you do not believe me, stamp on the toe on a
subjectivist. The University myth of the student's essay on relativism makes
the point neatly. The student had worked hard, organized a lot of material,
written well and clearly understood much
of the material but had failed to grasp the implications of subjectivism
adequately. The professor, to instruct the student, gave an F. The student,
incensed, returned to argue. After listening for a
while the professor said, "Ah, but you don't understand, I hate blue
folders." The student took the point and was given a more appropriate
grade. For "Justice," which the student demanded, to exist something
beyond individual preferences is necessary. Professor Leff, from Yale law
school, expressed the dilemma eloquently:"I want to believe - and so
do you- in a complete, transcendent, and immanent set of propositions about
right and wrong, findable rules that authoritatively and unambiguously direct
us how to live righteously. I also want to believe - and so do you - in
no such
thing but rather that we are wholly free, not only to choose for
ourselves what we ought to do, but to decide for ourselves, individually
and as a species, what we ought to be. What we want, Heaven help us, is
simultaneously to be perfectly ruled and perfectly
free, that is, at the same time to discover the right and the good and to
create it." (2.)
Leff recognized that moral freedom of that sort would lead to anarchy, but
he could not solve the conundrum. He knew that if all opinions were equal
justice was an illusion but couldn't bring himself to accept the inevitable
consequences of objective moral truth.
Are All Ethical Opinions Equal?
Only a moment of serious consideration is necessary to answer this question.
To equate the ethical sophistication of the Greeks with the now extinct
Ik is nonsense. The Ik were a nomadic tribe caught in a terrible predicament
where their traditional way of life was threatened. Their responses were
selfish and far from noble, and led to their extinction. (3.) Similar foolish
choices, such as the
current adoption of crass egalitarianism, are destroying the
University, because recognition of real scholarship and erudition is
necessarily hierarchical. Grade inflation, also part of this process,
is intrinsically unjust to the most talented.
The conclusion of Leff's essay dramatically illustrates our dilemma.
"All I can say is this.- it looks as though we are all we have. Give
what we know about ourselves and about each other that is an extraordinarily
unappetizing prospect,- looking around the
world, it appears that if all men are brothers the ruling model is
Cain and Abel. Neither reason, nor love nor even terror, seems able
to make us good, and worse than that there is no reason why anything
should. Only if ethics is something unspeakable by us could law be
unnatural and therefore unchallengeable. As things stand now
everything is up for grabs. Nevertheless napalming babies is bad,
starving the poor is wicked, buying and selling each other is
depraved. There is in this world such a thing as evil."
Sadly, having demonstrated that his premise did not
lead to a morally consistent conclusion, Leff did not re-examine his
premise, and, as Johnson wrote in his essay, Leff spent the rest of
his life on the minutiae of the law and never returned to the
weightier issues.
Tolerance
So far, we have seen that moral neutrality presupposes the absence of metaphysical
truth, that it espouses a moral subjectivity which is easily shown to be
unacceptable and
unworkable, that it necessarily accepts the equal validity of every-
one's moral choices, but nevertheless, passes legislation outlawing
some cultural choices. The primary driving force of the morally
neutral is a fear of intolerance and a love of individual liberty,
which verges on libertarianism. The question is: can a society be
built on the basis of tolerance and untrammeled individual liberty?
Tolerance and Freedom are not Supreme Virtues
No one likes to be called intolerant, but it can be demonstrated that intolerance
in certain things is critical to the stability of society Consider the following
scenario. There is a
society in North America with the declared aim of legalizing sexual
activity between adult males and pre-pubertal boys. "Eight is too
late" is their slogan. Now imagine yourselves as parents of an eight-
year-old boy who find themselves with one of these men as a houseguest
for two weeks. He is charming, witty, intelligent and full of fun,
but he does have this quirk. Will you allow him unopposed opportunity
to use his charm and sophistication to persuade your eight-year-old
that he is being deprived of the rightful experiences of every eight-
year-old? I have asked this question of several audiences. No one has
said yes. There are activities which all of us will not tolerate, and
we feel no shame in displaying our intolerance.
What sorts of behaviours do we legitimately attempt to suppress? I would
suggest a starting list of four - unloving, unjust, untruthful, dishonourable
behaviour.
Love, truth, justice and honour cannot even share a sentence with the verb
to tolerate. You do not tolerate love, you embrace it, you seek it; you
do not tolerate truth or justice, you
demand them and honour is admired not tolerated. Tolerance and
compromise are not the stuff from which great societies, great
stories, or even great professions are made.
But tolerance is important. It is the oil which lubricates so many human
interactions; but often its strength is to overlook error or wrong-doing,
to have compassion in the human
frailties which beset us all. Unlike truth, love and justice which
brook no rivals, the proper use of tolerance involves wise judgment.
To lack the necessary skills of prudent judgment will lead the defective
into either bigoted narrow-mindedness or libertarian excess.
The Necessity for Appropriate Tolerance
Neutral values do not exist, but we do need the tolerance they would seek
to protect to adjudicate the conflicts which arise in our attempts to translate
the unchanging but only imperfectly
known truth into the working ethics of daily living. Human judgments
on how this should be done are very culturally dependent, as even a
brief list of practices considered ethical in different parts of the
world in the last century clearly illustrates. Such a list would
include: widow burning, ritual prostitution, infanticide, slavery,
abortion, and euthanasia. Changes in what is considered ethical occur
very slowly, but they are dependent on dogma for their foundation.
Christians, for example, affirmed that all were one in Christ Jesus,
that there was neither Jew nor Greek, neither male nor female, neither
slave nor free from the time of Paul. But this doctrine did not
translate into the practical condemnation of slavery for 18 centuries,
and the war of the sexes is still continuing!
What is desired, and rightly so, is tolerance as a normal virtue in our
human interactions, but it is clear that the espousal of neutral values
is not the way to create the appropriately
tolerant society. Neither is the refusal to accept every opinion as
equally valid truly intolerant; rather those who would demand such
things are intolerant of logic. It is becoming apparent that the
atheistic secularist has no adequate basis for tolerance because if
this life is all we get, and there are no individual moral consequences,
it is logical to use power to achieve your own ends. The Christian, on the
other hand, believes in both his own fallenness
and the ultimate unknowableness of God in His entirety, and therefore,
has good reason to be humble in the face of contrary opinions.
The Hidden Premise
Those who want a neutral value policy usually say something like "you
keep your opinions on morals private and I will do the same, and in that
way we will both be happy." This slick piece of
sophistry is neither true nor honest. The hidden implication is that
there is no objective truth at stake - but, as we have already seen, in
order to have justice objective truth is necessary. We have to have means
to judge. But, I believe the real motivation behind the "I have my
values you have yours" argument is the objective of a libertarian
society and this follows by default without the risk of rigorous
debate, if we accept their argument. It is the old hatred of our
creatureliness in modern dress. Pascal expressed it most eloquently:
"It is the nature of self-esteem and of the human self to love only
oneself and to consider oneself alone. But what can a man do? He wants to
be great and finds that he is small,- he wants to be
happy and finds that he is unhappy,- he wants to be perfect and finds
that he is riddled with imperfections; he wants to be the object of
men's affection and esteem and sees that his faults deserve only their
dislike and contempt. The embarrassing position in which he finds
himself produces in him the most unjust and criminal passion that can
possibly be imagined; he conceives a mortal hatred of the truth which
brings him down to earth and convinces him of his faults. He
would like to be able to annihilate it, and, not being able to destroy
it in himself, he destroys it in the minds of other people. That is
to say, he concentrates all his efforts on concealing his faults both
from others and from himself and cannot stand being made to see them
or their being seen by other people. (4.)
Throughout history there have always been those who wish, as they put it,
to be free. But unless we are good, our freedom always deteriorates to license,
and usually to the tyranny of the few
over the many. The bane of human history is the desire to be an
autonomous self, to be beholden to no-one. But such autonomy
is not the truth, ethics is the condition of man (Wittgenstein).
Conscience is real. For those who accept an over-arching reality, it
is a gentle nudge towards truth, and for those who refuse, it is the
guilt trip laid on them by society.
Conscience
The first thing to recognize is that the word itself
shows its origin in the idea that conscience is not a feeling but a
form of knowing. We all have the experience of being inwardly
obligated to do "good" or to eschew "evil." This is
true even when it
is to our own immediate hurt, as with passing up an opportunity to
cheat. This is not a feeling, indeed it fights against our feelings.
This is moral knowledge. In most cases, it offers no evolutionary
benefit to our genes so that the reductionist is left with an
explanatory problem. Whence cometh the moral law within? When one
reads a law, it is normal to ask who is the lawgiver! The objection,
of course, as Leff clearly understood, is that if we accept this view,
we accept our creaturely status. A lawgiver, the legitimacy of whose
laws we cannot deny, demands our obedience.
Conclusion
So, what needs to be done to remove the illusion of relativism from our
teaching guidelines, and replace it with a more sophisticated understanding
of moral truth, including appropriate
tolerance of different ethical judgments? First, those who understand
the process that has led to the logical nonsense of so-called neutral
values must start saying so publicly, and doing what they can to
redress the damage done. This damage is primarily to create an
atmosphere where moral relativism is the norm. We must all examine
our intolerances and decide whether they are bigoted or selfishly
libertarian, and therefore to be decried and removed, or legitimate,
and therefore to be defended. Judgment is hard, but it must be
attempted if we are not to be left with a crude and debased culture.
For tolerance to be properly exercised, it must be held in tension
with all the other virtues. This is what character formation is all
about. It requires the development of wisdom which is quite different
from the acquisition of knowledge, and utterly different from the mere
cataloguing of information which currently passes for education. It
requires a recognition that metaphysical truth exists, even though our
knowledge of it is limited. Sincerity is not enough. As Iris Murdoch
put it, our failure as a society is that we have substituted for the
hard idea of truth, the facile idea of sincerity.
Life requires us to answer the age-old key questions, or else to spend immense
psychological energy in denying their cogency and paying the price for such
denial in the neuroses
characteristic of our society. Where did I come from? Why am I here?
Where am I going? How can I make sense of suffering? How do I come
to terms with mortality? How can I believe in justice? What can I
know? What may I believe? What should I do?
These questions are compulsory. The Jews were told that the critical educational
environment for answering them was the home; the conversations at meals,
on journeys, the practice of
giving thanks to God morning and evening, and of celebrating the
feasts with joy before God. Moses taught the Jews that the reality of
their faith in God must be lived out in the everyday environment. For
work ridden professionals, framing life within these eternal realities
is difficult and needs constant attention, but if our children have
only an education that deals in facts perceived solely with the
senses, with no space for the spiritual, then the future is grim.
Real education is rooted in the telling and retelling of culturally formative
stories which give meaning to ideas of honour, courage, justice, truth,
and love. An education without
these foundations is an education that is not worthy of the name.
References
1. Lewis CS. The Abolition of Man. Macmillan, New York, 1972.
2. Arthur Leff, quoted by Johnson PE. Nihilism and the end of the
Law. First Things 1993;31:20.
3. Turnbull CM. The Mountain People. Simon and Schuster, New York,
1972.
4. Pascal B. Pensees. Penguin Classics, 978.
Dr. Patrick is a Professor of Biochemistiy at the
University of Ottawa in Canada. His address is:
University of Ottawa,
Departments of Biochemistry and Paediatrics,
451 Smyth Road,
Ottawa, Ontario KIH 8M5, Canada.
Disclaimer: Information provided here does not reflect official UA
viewpoints nor gives rise to any claim against the author