The Bioethical Mandala
A Reflection on the Moral Structure of Health Care (part 6)
The Intuitive Approach (Deontological Ethics)
Ancient moral teachings, perhaps by the weight of tradition, have been deemed to be eternal truths given by God, or, in the case of the Vedas of India, held to be integral realities of the universe, intuitively comprehended by direct communication with the infinite. Critical examination of their inconsistencies has lead many to believe the supposed basis of such codes in divine revelation to be flawed and that "revealed" codes should be discarded altogether. Hence the search for a more rational position, such as the utilitarian.
Deontologists nevertheless hold that there are natural rights and duties to which rational beings are beholden, no matter what the cost. Kantians base the ethic in abstract standards of value; rational beings must be perceived as an ends-in-themselves, or moral absolutes. Ends-in-themselves may not be used in any purely instrumental sense by others, for such usage degrades the essential dignity of rational beings. Kant declares, in his Metaphysic of Morals (1785), that moral absolutes are categorical imperatives; known intuitively, bearing no connection with any such instrumental calculations as those postulated by utilitarians. This ethic prescribes a formal obligation to duty: respect for a higher law than calculations of happiness, political expediency, or bowing to the interests of the majority.
Modern deontologists concern themselves with human rights. We have the right to life; the right to choose; the right to refuse treatment; the right to receive treatment; the right to have children; the right to abort them; the right to monopolise the doctor's time with trivial complaints; the right to compensation; the right to "free" (taxpayer funded) medical attention; the right to receive other people's organs, or the organs of unfortunate animals and so on. The list is interminable and growing with every new "discovery". Moreover, many of the so-called rights are really unjust demands for special consideration that put genuinely ill people in real need at a considerable disadvantage.
Take for example the foolish provision of a "free" health service that allows any malingerer, hypochondriac or neurotic individual with a trivial complaint to choke up the health system at no charge to themselves and at substantial inconvenience to the rest of us. (What really are the ethics of giving someone an operation, or a drug, just because they want one? Whose interests are served?)
Moreover, and this concerns the epistemological issue, free or subsidised treatment tends to encourage the growth of unnecessary concentration on the latest technological wizardry, which, were it not for the bottomless purse of the taxpayer, would be unavailable for consideration, thus diverting both funds and attention away from the use of inexpensive, more environmentally sound methods of treatment that will actually work. The focus on glamorous technological therapies, whether mechanical or drug-related, carries another moral burden: the enormous numbers of laboratory animals that are tortured to death every year in the name of "research", along with the large numbers of "iatrogenic" maimings and deaths through the use and misuse of these therapies in which we display such a touching faith.
Neither purely deontological, nor purely utilitarian positions provide satisfactory solutions to ethical dilemmas, but taking elements of the two older systems and combining them in a more holistic fashion may make some sense.
The Ethics of Relevant Interest
An appeal to formal legality, or principles of moral right, may not produce an ethically satisfying conclusion should rights and obligations of medical practitioners or their clients be framed in such a way as to reflect unjustly the interests of a particular group, especially should the interests of others be overridden. Yet, at the same time, most of us feel there must be some objective, eternal standards of what is right and what is wrong, irrespective of breakdowns in its application.
Utilitarian ethics fail to achieve the best possible result when conflicts arise over the appropriate assignment of weights; even under Rule Utilitarianism, conflicts may still arise should the relevant circumstances not fit the established pattern, or should the practitioner upon examination of the set of guides, draw up his own sheet and decide that the balance has not been appropriately pinpointed. However, they point to a solution of the problem, so long as we are prepared to admit the possibility of happiness being expressed in terms of the fulfilment of needs or interests, rather than desires, preferences, or maximising the balance of pleasure over pain.
The multifaceted role of the medical practitioner, healer, bodymechanic, consoler, bureaucrat and social pillar, drug prescriber, counsellor and priest, is fraught with difficulties. Ethical decisions, based in a sense of a basic human right to health and wellbeing balanced against the competing interests of institutions and the distribution of scarce resources and the interests of the professional in his or her own right are made under fragmentary and often confused conditions that derive from an uncertain ethical basis. This uncertainty derives both from a lack of moral intent and an epistemological confusion regarding the true nature of health care which stems from the atomistic reductionism of orthodox medicine. Clearly the medical ethic must be concerned with promoting the interests of its clients, as well as the practitioners and their support staff. The problem lies in determining where these interests truly lie and how they may be best served.
Eudaimonia, or Harmony and Wellbeing
The relevant interests of any being are best conceived as those items which generate or lead to the optimal satisfaction of its needs. Interests are best served in seeking the condition of wellbeing, which Aristotle calls eudaimonia, that dynamic state of the Good, which permits an organism to thrive and prosper (Aristotle, incidentally, considers the highest good to be contemplation).
Without denying that there may be any number of other worthwhile objectives, he moves to argue that the most obvious and widely accepted aim and goal, the supreme Good of human life, is to achieve an optimal state of flourishing. Flourishing, maintaining the best possible mode of living, consists in the attainment of an enduring condition of eudaimonia, or wellbeing, for both the individual and the broader community. Wellbeing is that condition in which our interests and the interests of the community are fulfilled, to the best possible degree. Aristotle notes that a study of the supreme Good, the subject of political science, reveals that the wellbeing of the community comprises, of the two, the more desirable and sublime aim. Human nature, being inherently social, is thus best fulfilled within a group comprising a set of reasonably fulfilled human beings going about the business of becoming increasingly happy and fulfilled.
The mandala of the ancients has returned to haunt us in the first decade of the twenty-first century. The hierarchies of the initiates have been displaced in the popular consciousness by the hierarchies of science and medicine. An increasing demand for personal control and fulfilment may yet displace these modern hierarchies through the discovery that our interests are best served in awareness of a deep truth: that we comprise an intimate continuum with our environment and that this profound relationship with nature must be preserved and comprehended for the people to continue to flourish on the earth.
This concludes the article.
Return to the beginning of the Bioethical Mandala