March/April 2006

Catechism and medical science

By MARC RINGEL, MD

In November I sat in on a fascinating meeting of the Bioethics Committee at North Colorado Medical Center in Greeley. A nursing home patient—sometimes competent, sometimes not, afflicted by multiple severe illnesses that he denied were about to kill him, and often refusing to cooperate in his care—was causing consternation among staff, physicians and his own family members. The committee did a wonderful job of delineating the critical issues and presenting the nursing home staff with options for caring for this very, very difficult man.

I cut my ethical teeth on that committee, where I served a fascinating seven years before I left Greeley to practice in Brush. In order to sit on the Bioethics Committee I had to take a tutorial in medical ethics taught by Richard Blanke, a philosophy professor at the University of Northern Colorado, who still chairs the group. I would like to share with you the principles I learned from Richard; they’ve served me well in the ensuing decade-and-a-half of practice.

Those principles of ethical reasoning form the basis of the medical ethics system most used in the United States these days. Wryly dubbed the “Georgetown Catechism,” this system was codified in the early 1980s by ethicists, of course, from Georgetown University. The Catechism consists of four principles: non-maleficence, beneficence, autonomy and justice. I’ll describe them one at a time, then present cases that illustrate how these principles might be applied.

Non-maleficence is a primary principle of medical care. Primum non nocere, which means “First do no harm,” has been harped at medical trainees since Hippocrates first pronounced those Latin words in the fourth century B.C.E. It seems obvious. You never do a procedure where the likelihood of harm to a patient outweighs the likelihood of good. If the situation is desperate, then you may be justified in trying something very dangerous because the possible good of saving a life, no matter how unlikely, may still be less harmful than doing nothing. On the other hand, to experiment on one person in order to benefit another, even to benefit a whole class of people, is not permissible. Think of the Nazi doctors.

The second principle, beneficence, is sort of the mirror image of non-maleficence. It says you are obligated to do good. As a doctor I’m obligated not only to not harm my patients, but also to do what’s best for them. Of course, that’s begging the question about what’s best. It doesn’t necessarily mean saving a life if that life is nothing but suffering. More about that later.

Autonomy, the third principle, is especially dear to us individualistic Americans. A competent person’s own wishes should be honored whenever possible, which means that an adult is free to make bad decisions. A doctor is obligated to follow the direction of a young Jehovah’s Witness, mother of four, with brisk bleeding and faltering blood pressure who refuses a life-saving transfusion. The only thing a physician who is uncomfortable with the situation can do is to hand off care of the patient to someone whose conscience allows him to follow the woman’s explicit instructions. A doctor does have a right, indeed an obligation, to order a transfusion for that woman’s non-autonomous young child, should he need it.

The fourth principle, justice, means being fair about who gets what. In the United States, where we tolerate a system that leaves more than 40 million citizens without any form of health insurance, justice clearly takes a back seat to autonomy. Health care is not a basic human right in this, the only industrialized society that does not assure care for all its citizens. Ethical questions that hinge around the principle of justice read something like, “If I can do a coronary bypass on one adult or deliver prenatal care to 20 impoverished mothers, how do I decide what to spend the money on? What if the patient is a Nobel Prize winner? What if he can pay for the procedure himself? How about if he’s a prison inmate?”

As I mentioned, different cultures weigh the four principles differently, based on values. Values are to culture as postulates are to geometry, an unproven starting point. Except in the face of overwhelming counter-arguments, culture and the values it posits are considered givens. Female genital cutting is one example; though the custom is deeply entrenched in the value system of a subgroup of pious Muslims, ethical principles such as non-maleficence and autonomy (the procedure is performed on children) can be called on to trump a cultural value.

On the other hand, I would likely respect the wishes of a Japanese family that, due to an extreme cultural regard for non-maleficence, expects the doctor not to reveal grandmother’s diagnosis to her because they believe knowing she has a terminal illness would do her more harm than good. Never mind that in America, based on autonomy (also called “respect for the individual”), the default position is always to share bad medical news with a competent adult so she can decide for herself just what treatment she does and does not want.

The real interesting stuff happens when different ethical principles, consistently applied, give conflicting answers to the same question. Autonomy versus beneficence is one of the most common pairs of colliding principles that arises out of sticky medical situations.

Here’s an example. Grandpa, a patriarch adored by his children and grandchildren, once said he didn’t want to be kept alive by artificial means. Then he gets pneumonia and, as a result of the infection, becomes delirious (that is, incompetent). The doctor tells the family that it’s a serious illness but one that, with aggressive antibiotic therapy, he has even odds to beat. The dilemma is that Grandpa is so sick that, on his way to recovery, he might require a several day stay in the intensive care unit with a tube in his trachea and a respirator doing the breathing for him.

The principle of autonomy dictates that we are obligated to follow Grandpa’s clearly stated wish never to be kept alive by a breathing machine. However, his son knows that Grandpa made that statement about respirators after he’d watched how Grandma died. After years of gradual decline into severe Alzheimer’s dementia, her body was kept alive for a few extra weeks by a machine that breathed for her. Junior believes that, given a fifty-fifty shot at surviving intact, Grandpa would probably accede to a few days on a respirator. That is beneficence speaking: Junior wanting to do what’s best for Grandpa.

You could argue, and you’d also be correct, that it’s actually autonomy at work here, that the son’s surmising what his father would want if he really knew the facts of the situation is a subtle interpretation of autonomy. Nobody can anticipate everything that might happen to him and so, based on an individual’s values (there’s that word again), someone who knows the patient very well and desires what’s best for him may make a decision that doesn’t quite jive with the exact words he said before he was too sick to express himself. There is the danger, though, that deciding to allow a treatment in the face of explicit refusal of that therapy has led past beneficence to a disempowering paternalism, doing a thing “for Grandpa’s own good” instead of respecting his wishes.

Then there’s the whole question about what makes a person competent. There are degrees of competency. This was the crux issue in the discussion we had at that Bioethics Committee meeting. Though a patient may not have been competent to choose to live in his own apartment, he was still with it enough to decide for himself whether or not to accede to lifesaving treatment. Even the wish of a completely coherent and logical but depressed person to forgo lifesaving treatment may sometimes be over-ridden long enough to treat the depression and then see if he still wants to die.

The potential cases and the ethical issues they raise are infinite. Unlike high school geometry, which I have loved for how neatly axioms flow from postulates, definitive answers do not drop off the end of a chain of ethical arguments based on the Georgetown Catechism. Words like “values” keep on popping up. The particulars of the people involved and of their culture and beliefs are all-important. That’s what I like about medical ethics. The cases to consider are so variable, so nuanced, so unclear—so very human.

Marc Ringel, MD, is a family practitioner and writer based in Greeley, Colorado.