Textbook of Healthcare Ethics

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Textbook of Healthcare Ethics

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Introduction to the Second Edition

Textbook of Healthcare Ethics

2nd Edition

Erich H. Loewy, M.D.

University of California, Davis School of Medicine

Sacramento, California

Roberta Springer Loewy, Ph.D.

University of California, Davis School of Medicine

Sacramento, California

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This book is dedicated to our students past, present and future

And to

Dr. Thomas Frühwald of Vienna, Austria for his unflagging interest and support

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Acknowledgments

There are many people we need to thank. Of course we stand, puny as we may be, on the shoulders of giants. But above all, and perhaps more importantly, we stand on the shoulders of our contemporaries: colleagues, students and laypersons who ask “naïve”

questions which, hard as it is to admit, are often right on target and are the very questions which need to be asked and which we in our “conceptual ghetto” (as the late Danner Clouser used to speak of it) have failed to see.

First of all we want to thank the University of California, Davis and especially its Dean, Dr. Joe Silva, who have done all they could to support this project. It is impossible to name all of the people who by advice, criticism, “the lifted eyebrow,”

etc., have shown their interest, pointed us to pertinent literature and deflected us from the wrong avenue of approach. Without Dr. Faith Fitzgerald again and again making major contributions by criticism, suggestions and disagreements (and above all by asking questions), this revision would not have been possible. Likewise, thanks go to our former Dean, Dr. Hibbard Williams (who is still very active in our department), for his continued and ongoing support. Our colleagues in the Division of General Medicine have uniformly given us encouragement and asked questions that helped propel the work forward. Equally, our thanks go to Dr. Tim Grennan of Kaiser Permanente for his encouragement, help and often highly incisive suggestions.

In our Bioethics Program thanks go first of all to my immediate colleagues, Dr.

Ben A. Rich, and to my co-author, Dr. Roberta Loewy. Formally and informally they have helped to shape the book, its style and its basic briefness of discussion. Like- wise, thanks go to our associate faculty, who are often the first to raise troubling questions. Special thanks must likewise go to Dr. Thomas Frühwald of Vienna, Austria, a geriatrician and one highly knowledgeable and interested in Bioethics. Speaking and corresponding with him has been most helpful in researching certain areas and gain- ing certain insights. His role has indeed been a critical one. Dr. Joachim Widder at the University of Vienna, by making suggestions and asking penetrating questions has, likewise, helped us explore regions that might otherwise have been left unexplored.

My assistant, Ms. Cynthia Gomez, did much that was essential to help the work

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being protective of our time, and putting up with the sometimes not altogether pleas- ant personality of the senior author. In addition, her comments about the work in progress have added a lot to this edition. We owe her a great debt of gratitude. With- out her it would not have been possible. Most of the revisions of this book were done in a tiny hamlet in the Haute Savoie whose proprietors (Monsieur and Madame Busson) deserve special thanks—as does, for that matter, the whole village and its people.

Last but not least we want to thank our editors Anne Ultee and Nellie Harrewijn together with Mariclaire Cloutier who shepherded this book to its conclusion. Their suggestions were invariably well taken and helpful.

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Introduction to the Second Edition

The new edition of the original Textbook of Healthcare Ethics last published in 1997 has been greatly changed. In this short period of time many former questions have changed and many new approaches have been articulated. We have deleted some material which no longer forms a great deal of controversy (such as whether physicians are or are not obligated to treat AIDs patients) and have added chapters on ge- netics and the influences that new scientific and other knowledge have on the way we conceive and deal with ethical issues. We have tried to bring some of the previous controversies up to date. The senior author has also asked Roberta Springer Loewy to be co-author, write some of the chapters and oversee the whole way in which the book flows. Her philosophical contributions to the first edition were substantial—those to this edition are indispensable. Such a move also enables us to establish some sort of continuity for the future.

Just as when the first edition came out, our main and increasingly serious prob- lem in health care ethics is one we are wont to shove under the rug: an increasing number of people in the United States are uninsured and most of the rest of us who are supposedly fully insured, in fact, are not. What is mainly discussed is what we have called “rich man’s ethics”—the problems only those of us who can afford medical care in the first place encounter. Those of us who lack access do not worry much about the finer points of informed consent or advance directives but, rather, worry about getting our pneumonia treated or children immunized. We live with comfort- able fictions: Medicaid does cover some (by no means all!) of the poor—but fewer and fewer health care organizations accept Medicaid patients. Medicare (which is supposed to “cover” those over 65) in fact allows a limited length of hospital stay after a significant out of pocket contribution. Patients who want outpatient, labora- tory or x-ray coverage will have to buy part B out of their own limited funds—and part B is becoming hair-raisingly expensive and out of reach for many. Even those fortunate enough to have part B have no coverage for medications and are, therefore, in the lovely position to receive advice (in the form of the prescription) that they are often financially unable to follow. Those who are allegedly “fully insured” have co-

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of that insurance—the choice is often between physician visits, lab work, x-ray and other procedures or food for the family or education for the children. The whole system (though, in fact, it is not a system but a hodge-podge of competing ones) is one of callousness, disingenuousness and hypocrisy.

Social ethics—which after all plays a critical role in health care ethics and of which health care ethics is a part—is likewise increasingly worse. The gap between the grindingly poor and those who are opulently rich has grown—indeed it is greater here than in any of the industrialized countries. About 25% of children (33% of black children) go hungry a good part of the time and persons may work a forty-hour week on a minimum salary and still remain beneath the unrealistically low poverty level.

Our social conditions—reflected in the state of our medical care—are a national shame.

This by no means makes the problems of what we have called “rich man’s ethics”

unimportant but, by forcing us to look at the reality of access to medical care, it puts them into a proper context and—we shall argue—imposes on health-professionals more than merely the duty to do the best for the individual patient lucky enough to be sitting in front of them. Beyond imposing this obligation on health care professionals, however, we would argue even more forcefully that those of us who pretend to do health care ethics are obligated to do all we can to rectify the conditions which today have at best limited the scope of ethical practice and have often made it impossible. It is the shame of health care ethicists and of our organizations that we have generally refused to play an active part in pushing for more justice within our health care system. Like the Nazi academics who saw, heard and spoke no evil and who, therefore, made themselves a part of that very evil, organized health care—including, and most shamefully, organized health care ethics—in this country has chosen to place itself in the same position.

Education has suffered. People are, as one of us [RSL] emphasizes, not taught how to think but what to think—or to think only within very narrow confines. Medi- cal education has suffered as faculty are more and more forced to see more patients, earn more money for the University and receive more grant money for research. Since time is not unlimited and physicians, after all, are also people this means not only that less teaching will occur, but also that the quality of what teaching that does occur may suffer.

All of this makes teaching ethics frustrating: we teach people to do what we know they cannot do, viz., get to know their patients, their values, their circumstances, etc.

When a physician is only allowed fifteen minutes to see a patient this, of course, goes out the window as, indeed, does careful medical care which is predicated on a thor- ough history and physical in the light of an understanding of basic sciences. We will be spending considerable time articulating these problems, their geneses and their possible resolutions.

As we have been rewriting the book, the relevance of ongoing studies about the participation of the medical profession and the role of so-called bystanders in the holocaust has become more and more evident. A study of the events leading up to this tragedy and the role played by various individuals within it are highly pertinent to our problems today. We ignore them at our peril. Social injustice covers a whole spec-

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trum of evils—the discrimination against Blacks or women is in the same continuum as is the attempt to destroy Jewry in the Holocaust. The similarities among those who would tolerate the fact that 52 million of our fellow citizens have only capricious access to health care (so long as they themselves do have access) and those who would stand by and watch Jews forbidden to enter Parks, forbidden to engage in any but menial work and ultimately beaten or shipped to Auschwitz are frightening. The most insidi- ous forms of social evil and injustice starts in small steps and each time we accept one the likelihood of accepting the next (which is after all only a bit worse) looms large. The fact, furthermore, that so many highly trained physicians blithely partici- pated in the holocaust (as they did in Tuskegee) is a sobering thought.

Ethicists are not, in our opinion, here to give answers. They certainly are enti- tled to say that some contemplated course of action would be ethically problematic and to give their reasons for such a statement. Ethicists are no more “moral” than anyone else—they are simply people who by training and daily activity are more skillful at sorting out questions and examining assumptions. Indeed, the main role of the ethicist is to examine presuppositions, inquire into precise definitions, scrutinize the logic used and, above all, to ask questions. We are all moral agents and responsi- ble for what we do or refrain from doing.

This new edition, we hope, brings some of the issues in bioethics up to date. Given the rapidity with which new knowledge operates, they will never be totally up to date—

but at least we must try. If there is one message we would like to leave with health care professionals it is that practicing “good” technical medicine with particular patients does not exhaust the duty one has: it is almost impossible to practice ethical medicine in an unethical institutional setting and it is unlikely that an unjust society will build a just institution. Thus, it is also our duty as health care professionals—

whether doctors, nurses, ethicists or others—to do all we can to help improve our society and our institution.

Textbook of Healthcare Ethics

Textbook of Healthcare Ethics

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Textbook of Healthcare Ethics

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Contents

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Acknowledgments

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Introduction to the Second Edition

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