What makes an issue an ethics issue?
The answer, when known, is really very simple. But for some health career students and laypersons, responses to the question are elusive.
Standing before a group of medical students, Henry S. Perkins, MD, associate professor of medicine and interim director of the Center for Ethics and the Humanities in Health Care at the Health Science Center, asks the question again: "What makes an issue an ethics issue?" By now, the students realize that the question is not rhetorical—the lecturer is waiting for a response.
Their silence ends when several of them mention the word "values." "What about values?" queries Dr. Perkins. Following a few more exchanges of ideas and sensing the students are on the right track, the bioethicist shares the answer: an issue becomes an ethics issue when there are conflicts of values about what to do.
As burgeoning technology offers patients and health care providers more treatment options, questions are being raised about whom, when and how to treat. And, with the recent advent of mammal cloning, a myriad of new ethics issues is being debated.
"Some branches of ethics are purely rational and some are not," explained Dr. Perkins. "We can't expect nice, Hollywood solutions for all ethical questions. We've had remarkable success in replacing hearts, hips and other body parts under the machine model of medicine. But I see real danger in considering human beings like machines. Replacing or fixing the broken-down parts isn't all there is to medicine. "The truth is that heart and hip failure have different implications for different people," added the ethics expert. As an example, Dr. Perkins explained, an office worker with a hip replacement can return to work, but an athlete with that surgery (like football and baseball great Bo Jackson) may be forced to retire.
Director of the "Introduction to Ethics and Humanities" class for fourth-year medical students, Dr. Perkins also lectures third-year medical students and coordinates lectures and events for the ethics center. "Over the years my teaching methods have changed," stated Dr. Perkins. "Previously, I taught exclusively formulas for decision making. Now I also teach 'virtue ethics,' which these days don't get talked about much in America."
As an example, Dr Perkins recalled a class during which he asked students to consider the courage required of a mother of three children, whose husband had left her, and who had just been told she had AIDS. "Rather than tell them they need to act in a responsible, trustworthy manner, I tell them a story that encourages certain attitudes, like admiration or respect, toward the patient," Dr. Perkins said.
The general understanding of ethics today, explained Dr. Perkins, is skewed toward principles and actions—people are looking for a formula to tell them how to act. "The formula does not force one to examine oneself critically and perhaps to change oneself. The actor is intimately affected by the action. There is an equal need to talk about general attitudes we ought to have toward each other and life. Virtues don't just happen. They have to be cultivated," he said.
Recalling another patient's case, Dr. Perkins said a group of residents could not understand why it would be important to get an official, legal authorization to treat a person, possibly demented, who arrives in the emergency room. "Why don't we just treat him? Boom! Save his life! Treat him the way we think he ought to be treated!" exclaimed Dr. Perkins.
"Well, there are a number of reasons why it's important to go through the legal hoops," he explained. "I think the most important has to do with our attitudes about the people who present themselves to us. They don't present themselves to us and then we take over and run their lives or, at least, run their bodies for them. That's not our role; that can't be our role. Another reason is, it's important to acknowledge that we practice medicine in a social, cultural environment that includes all sorts of laws about who may make and who may not make decisions for incapacitated patients," he added.
The physician, Dr. Perkins continued, must respect a patient's autonomy by acknowledging well-informed, voluntary decisions by patients who have the capability of making those decisions and making sure there's a proper surrogate decision maker for people who lack that ability.
The bioethicist also cautions his students to carefully consider the limits of human knowledge. Questions such as: "Is there some sense to pain?" are posed to his classes. Dr. Perkins said, "I cannot let myself believe pain is meaningless, and physicians need to be there during the quandaries and confusion. With students, we need to address the important question of simple human existence: Why are we here? What have I done with my life? What things should I be doing?"
Whatever the human dilemma or ethical issue, Dr. Perkins' message to physicians is to make the experience positive, be there for the patient during the hard times, and carefully consider successes for which they can and cannot take credit. "We can arrange organs and connect them in a new body. But, what makes these organs function in a different person? Some of what we do is a total mystery. We need to acknowledge and celebrate that," he said.
A flurry of media interest in ethics-related questions, debates and condemnations surfaced when the sheep was cloned in Scotland. "I knew it was going to cause a furor,"said Dr. Perkins, "and I wasn't really sure that the furor would be sustained in the light of day, actually. Some of that initial negative response is now dying down."
Viewing mammal cloning as an exciting development and an opportunity to begin to look further at issues of "nature vs. nurture," Dr. Perkins indicated such research will help scientists determine how differences in environment may or may not affect differences in personality and physiology. "This cloning advance will help us define what makes a person—will push us to define what makes a person more precisely than we've ever had to define before. Is it just the 46 chromosomes or is it something more than just the genetics?" he continued.
"I think many people look at clones as physically identical robots, but I'm not sure that's the case. It could be that a human being clone is as much sensate and thoughtful as the original, maybe more so. Would it have a soul? I have no idea. I'm not sure that any of us can know. Would I have to assume that the clone would have a soul? I suppose it would be a good idea to go about the practical business of living with that appropriately conservative assumption. I certainly would hate to be wrong by assuming the clone doesn't have a soul, when indeed he does," added Dr. Perkins.
While acknowledging many people view cloning as a Frankenstein-type technology that will run ahead of man's ability to control it, Dr. Perkins recalled past technological discoveries, such as atomic energy and weapons of chemical warfare, which had both disadvantages and advantages. "I guess I have a faith, as I look back, that life and technological progress are by and large good. There will be some problems; the problems will sometimes be new ones. But fear of problems unknown, I don't think, should keep us from developing the technology," added Dr. Perkins.
"I think we ought to ask the question of why it is that we're fearful of cloning humans. One reason might be that parenthood might come into question. Could people be cloned only with the permission of the DNA donor, and, if so, does that mean that the DNA donor would assume certain parental responsibilities? What would inheritance laws be like under those circumstances?" continued Dr. Perkins.
Commenting on the sheep cloning news, President Bill Clinton stated that every human being is unique. "Well, that may have been true in the past, at least genetically," Dr. Perkins said. "But does it necessarily have to be true in the future? I'm not sure why it does. Cloning may be the answer to the shortage of organs for donation—the shortage of blood for transfusion."
Channeling cloning research for the right purposes, while conducting the research openly and reporting it to the public, is Dr. Perkins' recommendation. Declaring a moratorium on mammal and human cloning, he added, would be impossible. "I see that the goodness or the evil that flows from technology is not necessarily connected to the technology, but to the uses for which it is put. I'm willing to wait and see what the benefits are and what the potential advantages are and then have us deal with the disadvantages as we see them materialize" said Dr. Perkins.
"I sometimes wonder if our ability to consider points of view other than our own has been stunted recently," said Dr. Perkins. Citing the abortion issue as an example, "I think the so called pro-life and so called pro-choice people have minds completely closed to the other point of view," he added. "They no longer talk with each other, they yell at each other."
Therefore, said the ethicist, vigorous, thoughtful, open and recurring debate about the specific uses of technologies, like cloning, and our attitudes and virtues is necessary. "People who come to the debate," explained Dr. Perkins, "should come with the spirit of inquiry—that is the spirit that says, 'I can have these views already, but I'm willing to listen, to consider other points of view and to revise my own views in light of reasonable contrary arguments.'"