When you have an ethical problem, you have invariably a number of options, almost all of which are unpalatable.
One of the functions of the bioethicist, in my view, is to piss people off ...
...we give children no health care. We are not a life-affirming society.
It's impossible to practice ethical medicine in an unethical system.
Photography by Debbie Aldridge |
Moral MedicineBy Ralph Brave
Austrian-born, Loewy (pronounced LOO-vee) fled his country at age 11 and lost much of his family to the Holocaust. In his philosophy and bioethics work, he continually circles back to the social contexts in which ethical questions arise and the nature of the social bond. In addition to his teaching, writing and bioethics consultations, Loewy is directing the creation of master's and doctor's programs in bioethics, with an expected launch date sometime in 1998. UC Davis Magazine sat down with Loewy for a wide-ranging discussion of his views on the increasingly complex and difficult ethical considerations emerging from the shifting structure of health care and the deployment of new medical technologies. In the following excerpts from that conversation, Loewy fully lives up to his reputation as a provocative thinker with a keen eye for paradox and a passion for social justice. Q: This interview is occurring at a time when we've just had the successful cloning of a sheep in Scotland, the Human Genome Project is advancing rapidly, there's growing disparity in access to health care in the United States, managed care has become a dominant force in medicine in the United States, the Supreme Court has ruled on a case on physician-assisted suicide, and everyone now seems to be turning to bioethicists for answers and opinions. How does it seem to you from the inside? A: All of these things, except perhaps for sheep cloning--which I think is not much of an issue--are critical problems. I think there are two issues really that have to be separated, though they are not separate, and you alluded to them in the whole melange. One of the social issues is justice in health-care--managed care, access to health care, that sort of thing. And the other is the relationship of physician and patient, which includes things like physician-assisted suicide, abortion, maybe the Genome Project, which falls somewhere in between. They're all ethical problems. Now I want to be very clear about one thing: Ethicists have no more answers than anybody else. In point of fact, I don't think there is such a thing as an answer writ large. When you have an ethical problem, you have invariably a number of options, almost all of which or all of which, in fact, are unpalatable. Certainly, helping a patient to die at the end of life or euthanizing him is not in and of itself a good thing to do. Killing people is not nice. It may, however, under some circumstances, be a less evil thing than the alternatives you're confronted with. Doing an abortion is, under no circumstances, a good thing. It is merely that under many circumstances it may be a better thing than the alternative. So that's one of the problems with ethics. People want answers, but they're not to be had. One of the things that I think ethicists are compelled to do is to articulate questions: to articulate the question, make clear distinctions, try to point out particular values and try to analyze where the suggested means would serve to get to these values. Otherwise you would distort the values themselves. In other words, what ethicists do is to use philosophical tools to analyze questions of "right" and questions of "wrong." Once you give up on a notion of absolute truth, where does an ethicist find the ground from which to conduct these explorations toward values? Somehow we have to find something that unites us. And I think we can. And I think the uniting thing is common basic human experiences--capacities and experiences that we all share--together with a so-called primitive sense of compassion with which humans and other higher animals are born. Otherwise we wouldn't care about ethics. So these existential a prioris consist of things like: We all know that we want to exist. We all know that we have biological needs. We all know that there are social needs--as different as they may be in different cultures and among different species, we need each other. We have a desire not to suffer. We have a common logic--basic logic. And we have a desire to live freely. Now the libertarians claim that the only thing that we know about each other is that we want to live freely. But notice that you can't live freely unless you exist, unless our biological needs are met, unless our social needs are met, etc. Otherwise a claim to freedom becomes cynicism. You place a very high priority on a notion of solidarity, on a notion of community, which has been very much against the trend in the United States toward a more narrowly libertarian view of individual rights as the ultimate value. How has it been for you to be arguing your position in a society where you are so much against the overwhelming direction of thought? A friend of mine--I was then about 20--said that when I die he expects seriously to find my body floating upstream in a river. But it's worthwhile floating upstream, because we make what to me is a bogus distinction between individual rights and communal needs. I cannot have individual rights absent a community that supports them. And a community cannot continue to endure absent developing individual interests and rights. The two are not in opposition to each other. They need each other to have a common goal. How do you work with the disparity of access to health care and health insurance in the day-to-day setting of the medical center? You know, it is one of my more frustrating things. We teach medical students, when it comes to dealing with their patients, that "you've got to get to know your patients, you've got to talk to them more, you've got to understand and appreciate their values, you've got to be more of an equal in partnership." Then they get out in the real world; they are told "you've got 14 minutes for a new patient." That's ridiculous. With managed care, the joke is that The only good thing I can say about managed care--I think it's so bad--is that it will destroy itself and it will lead to a decent, equitable health-care system-- whatever that may be. Could you give us an example of a failure of the ethics process? Well, I think one of the breakdowns is not at this institution but is nationally--not doing anything about our social problems. We as an ethics community have, in my view, failed to address the issue of poverty. We have failed to address the issue of lack of education. Not even to mention we have failed to address meaningfully the lack of health care. No one is taking an actual stand as a bioethics community. Why is the bioethics community ethically failing on that front? They are going to say--and this is so analogous to what the German academics did--"OK, we sit in this ivory tower. This is not our function, to get our feet wet. We can teach, we can speak, but we ought to refrain from taking any particular stand on any particular issue." That's the general policy. I totally disagree with that. I think it's socially irresponsible. And it's very often done because [taking a stand] isn't the popular thing to do. One of the functions of the bioethicist, in my view, is to piss people off--not sufficiently to turn their hearing aids off but sufficiently to get them thinking and to get them out of the comfort of their thinking. The moment a guy becomes absolutely popular and everybody just loves him and he does what everybody wants, he has failed. He's got to raise questions that people would really rather not have raised. Can you give me a specific example of an experience of a failure of ethical considerations in a health-care institution? It depends on what you mean by fail. Failing means not living up to a particular expectation, and very often the expectation of people in the health-care setting is that we're going to call in the ethicist and he's going to point to a good way to go. And, again, the ethicist says, "You know, there is no good solution here; let's look at what the bad solutions are and pick out the most tolerable or least intolerable of those." And, of course, then people are going to say, "That's a failure. It really doesn't solve my problem." People look at ethics as a predominately prescriptive enterprise: Here are the 10 things you ought to do, and here are the 12 things you ought not to do; now go out and do them. Well, that's not the issue. It's about getting people, first of all, to develop some ethical sensitivity. If you don't have that, you don't even see the problems. To me the most frightening thing is when I ask a doctor, "What ethical problems do you have in your practice right now," and he says, "I don't have any." That I find frightening. Is that something that's common? Yes, because ethical problems are painful. We try to avoid pain. But I also have the sense that, almost for survival, doctors and nurses will define themselves according to a professional code of prescriptive action and divorce themselves from paradox, dilemma--the kinds of things by necessity entailed in ethical considerations. Of course. In the daily problem this works as well as algorithms do anywhere. The problem is you have got to examine your algorithms occasionally, number one, and number two they fail miserably in a context in which they are not appropriate and in complicated problems. Of course, it's often a mechanism of [emotional] pain control [for the health professional]. When I make rounds with residents I find that it is exactly that--it's pain control. And I find that they are more than eager to ventilate their problems once it is legitimate to do so. Because there is, of course, this macho feeling that I shouldn't be suffering pain. How do you see the current status of the abortion debate? Insoluble--on an either yes or no basis. The point is to make a clear distinction between my personal morality, which may say I find abortion reprehensible and I cannot do it--that's one thing--and saying, therefore, abortion is wrong. I think, personally, killing animals is wrong. I'm a vegetarian and that means eating meat is morally reprehensible. But I don't think you're a bad person because you eat meat. And I do not have a passion for making the eating of meat illegal. Yet in your book you really seem to push for a position of being supportive of abortion based on a difference between potentiality and actuality. If you frame the question as "does it make abortion right?" it doesn't. If you frame the question "given the alternatives, is it better to do one than the other?" realizing that both are bad ways to go, then that may help. I find abortion to be ethically a bad thing. I just find that there are some situations, unfortunately, mainly since we use birth control so slovenly, in which abortion is a more acceptable alternative. That doesn't make it good. I don't think you can launch a philosophical argument that has any hands or feet--at least it's never been done--that totally opposes abortion. You'd have to make some argument of why oak trees are the same as acorns, which they're not. Or why a third-year medical student in surgery should be considered equivalent to a boarded surgeon. That doesn't mean that they're without value; it doesn't mean that acorns are not valuable or that medical students are not valuable. But they are not full-blown whatevers, and we, therefore, don't assign the same rights to them. We say the right of the board-certified surgeon is a different right than the right of the medical student in surgery. I don't say he has no rights. His rights are different and lesser. I think you can make an impeccably good argument against abortion only within a particular belief system. Ethics is a matter of authority. Particular belief systems ground their arguments by an appeal to an authority other belief systems cannot accept. If we are going to communicate across these belief systems, the only appeal to authority is what I started out with, our existential framework and logic. Another issue that you address in your book is the issue of care of the terminally ill and, as it's become defined, the question of physician-assisted suicide. How do you frame your response to those dilemmas? I think there are some very great analogies to the abortion issue. I think the better birth control the less you will need abortion. The better we manage end-of-life issues, the better we orchestrate the end of life, the less call for euthanasia. There will still be some cases. Do you believe in physician-assisted suicide or believe that it is a legitimate practice? Those are different questions. The first question is, is it ever legitimate to kill a human being? If the answer is no, then we can go home. What's your answer? Of course, we do it. We mine coal, we, God forbid, execute people, we wage war and make heroes. I mean, empirically, we give children no health care. We are not a life-affirming society. Number two, the question is, is there something in the concept of health-care professionals that should prevent them from participating in this? And the third question which you allude to, is it wise to legalize it? Or is it wiser to have it go on, which it does anyway, undercover and uncontrolled? We don't know. It's a cultural question. What do you mean you don't know? You're the bioethicist; you're supposed to know. I don't know. I see a not unreasonable fear of disabled persons and of the poor being disadvantaged. I see that everything comes from a bottom-line cost issue, and I fear it. On the other hand I see poor Mr. Smith dying of prostate cancer and saying, "For God's sake, do something." Would you under certain circumstances like to be able to turn to your physician and say, "Help me die"? Yes. Of course. And have I as a physician, when asked, done so? Yes. You've done so as a physician? Yes. Painful as it is. But that does not mean I would make it social--it does not mean anything as far as legalizing it goes. I don't know what would happen. I did quite a few ethics consultations and found that a large number of them for end-of-life, terminating care came when the insurance expired. I had one doctor wanting to justify his do-not-resuscitate [order] by the excuse that the lady was on welfare. When I have experiences of this sort, I have problems. I think we over-emphasize the euthanasia question. I think the one thing that physician-assisted suicide can teach us is that we need to orchestrate the end of life better. What does "orchestrate the end of life better" mean? I happen to love music. And as far as I'm concerned it's the same method as directing a symphony orchestra. The conductor generally and for the most part is the physician. The players are a whole array of people. They are physicians and other specialists in that community, they are pain-control specialists, they are nurses, they are social workers, they are clergy, they are family. It is the job of a physician not to play the instrument but to direct the orchestra, so at appropriate times the appropriate instruments can play. It is the job of the audience, i.e., the patient and the family, to pick the music. If the orchestra plays well, very few people want to walk out, but a few may. You're going to reduce the call for euthanasia significantly. That means make it just as legitimate in the training of physicians to teach them about palliative care as to teach them about some new-found cancer. We need to get them over the linguistic hurdle, and it is a linguistic hurdle, of saying "there is nothing left to do" when somebody no longer has a chance of being positively affected in terms of longevity or cure by, let's say, chemotherapy or some other modality. That locks you linguistically into whether doing something is foolish and wasteful. There's a lot left to do, and it's orchestrating the end of life. Part of the argument around palliative care involves the use of drugs, of pain-reducing drugs. The medical marijuana debate is a subset of that. Do you perceive the United States to be puritanical in its attitude toward the use of drugs for palliative care? I don't know if it's puritanical. In palliative care I think we have learned that if you have cancer and you have severe pain you will probably [be given] decent pain relief. However, if you have some other disease equally painful, you will not, which is irrational because what you are treating is pain. And our method of pain control in people who have severe rheumatoid arthritis or another very painful disease is totally inadequate because we live under the presumption that people are going to get addicted by this--they are not. Not if they're having pain. One of the things coming along technologically that the proponents claim will revolutionize health care is the Human Genome Project: the decoding of the sequence of DNA in the human genome and the identification of the genes and ultimately the arrival of genetic therapy, which will allow for treatment at the genetic source of problems. Are we on the road toward a revolution in health care being brought about by the Genome Project? You have to split the question up. There is a critical difference between the genetic manipulation that changes phenotype--i.e., it changes you as an individual, but it has no effect on your children--and something that changes genotype that may or may not change you but is going to affect subsequent generations. This is a grave difference. The next distinction we have to make is between something that affects genotype in order to create blue-eyed, blond, sturdy Aryans and something that affects genotype and eliminates, let us say, sickle-cell anemia. Now the problem with that, which seems obvious, is that what we label disease is a social construct, and that's dangerous. It may surprise you, but lots of diseases have been named crimes or insanity or sin. Look at homosexuality. In the last century in this country, masturbation was an illness that was debated in the surgical literature with surgical procedures of cure. And it was a legitimate cause of death on death certificates. In the Soviet Union, not agreeing with the regime made you psychiatrically ill. In Germany, Jews were classified as disease organisms. So [the issue is] not quite that simple because you can simply redefine it. As with any other bit of knowledge, we have to know it. The danger is when we translate the knowledge into doing something about it. And the only hedge against this, and I'm afraid I'm coming back to where I started, is a well-functioning democratic community. What is your view on the meaning and implications of the successful cloning of a sheep? I am intrigued by the attention it has gotten. And I think the attention has a number of roots: first of all, our irrational quest for immortality. I do not believe if you took a few cells from my colon and made another me out of it that it would be another me. I mean, it might have the same genetic endowment, granted, but it is not going to have the same experiences. It's going to have quite different memories. It's a quite different human being. I believe that people are worried about where the soul comes from in the cloned person. We don't have enough sheep? I mean, I don't really think we ought to go out and clone humans, first of all because I think we ought to reduce the number of humans that we produce and not increase them. And secondly, why? There is utterly no proof that if we produce another Einstein genetically that it's going to give you another Einstein functionally. One of the things that I most deeply appreciate about your work is your continued emphasis that ethics does not begin at the clinic door nor does it end there, that it is part and parcel of the everyday society in which we live, and we're not going to have something inside the medical system that's dramatically different than what's outside. And yet simultaneously there is this increasing specialization, compartmentalization, technocratizing of health-care treatment and health-care understanding. The health-care system exists within the social nexus. Physicians and nurses cannot really be much better than the society in which they have to operate. It's impossible to practice ethical medicine in an unethical system. It is extremely difficult to produce a just system or a just institution outside the framework of a just society. It gets back to the basic problem of creating a functioning democratic society. Physicians, I think, especially with this managed-care thing, which robs them of time--and time is a commodity we don't talk enough about--become technocrats because they see that they have little other choice. Now they always have tended to be technocrats. But the impetus now comes from a different direction. When you've got x number of patients assigned that you must see in a day, you've got to become technically very slick to accomplish it, and the rest tends to go by the board. That's one of the problems. I think that on the whole physicians have been and perhaps will continue to be, in terms of various professional occupational groups, a cut above the average--which is not surprising, because physicians are confronted with the immediate results of what they do. They are daily confronted with human misery and, unless it dulls a sense of compassion, are going to be constantly reminded of this. This does not make angels of them nor does it mean that there is not an unseemly number of Imagination being that which allows you to expose yourself to the others who may not be in the room with you? What I'm working on currently is the role of curiosity and imagination in ethics and science. And to me curiosity comes far prior to reason or compassion. When I perceive something moving over there, alive, whatever, it is curiosity that impels me to look. Without this I can neither begin to reason nor can I begin to be compassionate. I don't know what it is. So imagination suggests to me a number of hypotheses of what it might be. And reason allows me to falsify or verify the hypothesis. And is imagination something that needs to be reinstilled in the training, the deliberative process? Look at the waiting room of a pediatrician: 2- and 3-year-olds--curious, imaginative children, engaging the whole world in their gaze. Look at the waiting room of an internist: dull, uncommunicative adults. Something terrible has happened in between. Ralph Brave is a free-lance writer on science and technology issues. |
ith the arrival of Erich H. Loewy at the UC Davis Medical Center in January 1996, the university immediately achieved front-rank status as a focal point for bioethical discussion. Loewy, the author of several philosophical works as well as a now-standard text on health-care ethics, is among the world's foremost bioethicists. He joined the UC Davis School of Medicine as holder of its endowed chair in bioethics.