Chapter II: On the Ethics of Physicians
Fenigsen, Richard, Fenigsen, Ryszard, Issues in Law & Medicine
Attempts to incorporate medical ethics in a universally valid ethical system are certainly justified, but have not been entirely successful. When considering contemporary ethical systems, many physicians do not find the reflection of their own ethical experience, of the emotionally tense, strongly interactive ethical process in which they are involved while practicing medicine.
Renouncing that, the traditionally educated physician might agree with one of the religious systems of ethics, in particular with the Judaic or Christian ethical heritage. He shares with them the belief that human life is inviolable, and the conviction that the lives of all people are of equal and of inestimable value; the commitment to the individual, and to the weakest and most vulnerable among us. However, religious ethics are linked to assumptions that not all doctors are prepared to make.
Much deeper disagreement exists with the ethical systems said to be based on reason, of which utilitarianism is the main representative. (20) Starting from rational and apparently humane assumptions, and driven by impeccable logic, the utilitarian ethics would ultimately lead the physician to do everything he has traditionally, intuitively, and rationally rejected: finding some lives less valuable than others, deciding who should die, siding with the majority of healthy persons against those who are weak and vulnerable, and with societal interests against the individual.
To What Extent Can Ethics Be Formulated. Ludwig Wittgenstein wrote that ethics should not and could not be expressed in words. (21) Quite a few physicians might subscribe to this statement. Oversimplification seems inherent to written ethical rules. Moreover, purged as they are of emotional content, written rules lack that human quality that would make them humane. And no written rule explains, or has the power to command, the devotion or the creative efforts of dedicated physicians.
I and Thou. The debate on medical ethics has seldom discussed how, in reality, physicians of the traditional school attain their ethical views. Their basic ethical attitude, like that of most young men and women, has already been formed in their childhood and youth. As young physicians, they embark on their journey with a few ethical aphorisms, usually conveyed to them by a master. These maxims represent the shared experience and wisdom of the profession.
Then, the bedside closeness to the patient, and an interactive "I and Thou" emotionally charged ethical process play a crucial role in shaping the conduct of a physician. It is this process that enables the physician to grasp in full the complexity and the dynamics of the patient's situation, the richness of his life and spirit, even when nearing the end, and the horror that deliberate destruction of such life would be.
The interaction is not limited to verbal exchange. The traditional physician will stand in awe before the patient who cannot communicate, respecting in the newborn his potential and promise, and in the protractedly unconscious all that he has been, that he perhaps still is, and cherishing whatever hope there is that he might recover.
Distance from the patient imposed by a new technical and overly organized medicine is dangerous because it creates an empty ethical and emotional space.
On the Ethics of Physicians. The coronary care nurses in Den Bosch besieged me with demands to prescribe large doses of Valium to a very anxious patient. A tall, trim, very handsome man of 46, who "had never been sick," was admitted with a particularly bad myocardial infarction. The very high blood levels of creatine phosphokinase, in the thousands, witnessed of a tremendous loss of heart muscle. The dismally low blood pressure and the quickly increasing congestion of the lungs indicated that the pump function of the heart was severely compromised. On the first day the patient's condition improved slightly; but he confessed to the nurses how much he was afraid of dying. …