Ethics in Medicine should be fairly obvious, don’t you think? Primum non nocere – variably translated as something like: ‘Most importantly, do no harm’- pretty well sums it up. And yet even that can be difficult..
Although there have been several formulations of various ethical tenets throughout the years, there seem to be four main principles involved: Nonmaleficence –as I have already suggested above; Beneficence- acting in the best interests of the patient; Autonomy -allowing the patient herself to act in her own best interests; and finally, Justice –acting in a fair and equitable fashion to all.
I’m not an ethicist, merely a practitioner trying to navigate the labyrinth of ethical considerations that obtain in my sometimes lengthy sojourns with patients. I do not pretend to have mastered them, nor do I consciously run through them like a checklist at the end of each visit. But they are there, unstated, like the unseen concrete in a wall. And like the wall, there can be hidden flaws that test its strength.
Trust is one of these. Much of the effectiveness of Medicine throughout the ages has been rooted in Trust as much as in Hope. Without trust, there would be no dialogue; without trust, there would be no hope. And trust, unlike the four ethical principles, is not something that can be taught. It is rooted in ethics to be sure, but not confined to it, or by it. It is a feeling shared, an aura that permeates a room; it is non-verbal.
And yet even trust can be betrayed. That is where Ethics enters like the big sister who listens and watches unseen in the corner. I would like to contextualize her importance in everyday encounters in a medical practice.
Perhaps Justice -the fourth principle in my list, is a good place to start. While it is not often emphasized as much as the others in ethical discussions, it certainly does make the headlines in today’s climate of fiscal restraint. The seemingly inequitable apportioning of scarce and expensive medical resources is frequently brought to our attention as a way of castigating a particular political ideology, or highlighting our slow but inevitable descent into moral depravity. It is the elephant in the room: we realize that something needs to be done, expectations modified, and yet it is difficult to confront without seeming callous and uncaring. As a society, it is to our advantage to be seen as attempting to be just for all, and yet excuses are equally advantageous. And distracting.
Prejudices, often hidden and unstated, can modify responses. Street people are frequent beneficiaries of this penalty, especially if they have had the temerity to step outside the pattern. Drugs are illegal, so any problems they engender are self-inflicted, voluntary… Resources must be sustained, conserved; allocation should be prescriptive and privileged. They are the benefits that accrue to normal behaviour. If exceptions to the equality of largesse must occur, if our resources really are limited, should those who have chosen to depart from the established societal conventions be the first to be rationed? Should that be one of the consequences meted out to those who won’t comply? Won’t play by our rules? One would have to be hard-hearted indeed to subscribe to that, and yet the punishment is insidious and often invisible -or ignored. Rationalized. Like any illness, it is easier for the Well, to pass by on the opposite side of the street rather than dealing with it. Only when they are ill and need the compassion entailed in obtaining a slice of those resources does it enter their lives with any clarity or meaning. Hence the need for Justice in our dealings with everybody -and especially the less fortunate among us who, sometimes through no fault of their own, cannot access medical help. I suspect that most of us don’t intend to be insensitive to others in need, and yet it is easy to forget what we do not experience. It is easy to be unduly influenced by Media hyperbole. Unexamined claims play to our confirmation biases: there is no pressing need to critically analyse what we have always felt to be true…
But these bold and often unsubstantiated allegations are abstruse and usually peripheral distractions in everyday medical encounters. They engender fear and apprehension in some perhaps, but are almost always secondary to the problems at hand. They are usually forgivable.
Take for example the occasional need to juggle the order of surgical waiting lists to accommodate unforeseen emergencies or more truly urgent cases. The usual marketplace First come, first served is clearly inapplicable in these circumstances; most of us recognize this and hope that we too would be treated the same way if the need arose. The juxtaposition may be inconvenient, even poorly received, and yet it is understandable. Condonable: Justice perceived.
Some are more trivial: the appointment that has to be cancelled, or more probably moved to another time because of an emergency, the arrival at the office later than expected for the same reason… All somewhat minor, perhaps, and pallid in comparison to the larger Health agendas that are so compelling and momentous, and yet in their own fashion, equally exemplary of Justice applied.
And yet there are more serious concerns that arise in practice as well: Justice has many faces. In any system, resources are limited: there are only so many hospital beds available at any given time; only so many operating theatres that can accommodate unanticipated needs. Choices have to be made, some with foreseeable albeit unavoidable consequences. These are obviously trying times and decisions contextual. Blame can explode like fire long after it has died down; embers are never inconsequential. Justice is not meant to be relative, malleable or adjustable and yet in retrospect it often seems so -maybe because it is still an evolving concept. It was once seen merely as an ideal to be striven for: a goal not yet attained or even possible. We now -correctly, I think- view it as a right. Or more: a necessity to treat all with compassion and fairness regardless of their status in the hierarchy. And yet, we can only work with the tools we are given; we can only try -then try again…
As Shakespeare’s Iago said: What wound did ever heal, but by degrees? We can hope.