Ethics of Living and Dying - Essay Example

?Iatrogenesis is a term from the medical literature that refers to an unintentional unfavorable effect or complication that arises from medical treatment given by therapists, psychologists, pharmacists, nurses, dentists, and medical doctors (Sharpe and Faden). A complication that arises because of a surgical procedure is a clear instance of iatrogenesis, but instances can also be difficult to identify, such as drug interactions that affect complex organ systems. In conditions for which there is no readily identifiable cause, the cause may be iatrogenetic, due to the complexity of modern drug and procedural interactions in medicine. Iatrogenesis is often caused by medical error or negligence, instrument design, social control (in cases of psychotherapy), medical anxiety, and negative interactions between medications. Evidence points to iatrogenesis as a significant attribute of between 44,000 and 98,000 deaths in the United States per year, according to some estimates (Weingart, Ship and Aronson). Given the large-scale incidence of iatrogenesis and the threat to life it poses for so many people, there are clear ethical implications for understanding the phenomenon. In bioethics, there are a number of normative frameworks from which thinkers may approach complex moral questions. In the case of iatrogenesis, it is often assumed that like other issues in medical ethics, iatrogenesis is grounded in the duty (or implicit contract) that healthcare givers allegedly have toward the patients receiving their care. However, an emerging (and ultimately more productive) perspective on the issue is emerging from virtue ethicists, who point to various characteristics of healthcare givers as either helpful or harmful in the incidence of iatrogenesis. The normative approach one takes in this case reduces to a more fundamental debate about which moral theory is more applicable to general sorts of cases, although iatrogenesis is a special bioethical issue. The purpose of this paper is to examine the implications of shifting away from a duty perspective to a virtue perspective in bioethics by examining the issue of iatrogenesis in particular. The moral concept of duty emerges strongly in 18th century German philosophy, especially with Immanuel Kant, whose three seminar works in moral philosophy laid the groundwork for an understanding of a so-called “rational” knowledge of ethics. Kant’s concept of morality is famous for describing the “categorical imperative,” which is a principle that is intrinsically valid, or good in itself. This is strongly connected to a notion of duty: that, for instance, a person has a duty to another intrinsically (or, performing the duty is good in itself). Because duties arise from categorical imperatives, they apply to all situations, and the consequences of our actions are morally irrelevant. In addition, they apply to all people, including members of the psychology, medical, and nursing professions. In their work, as well as in the personal lives, these individuals are morally bound, according to deontological theories, to the commitments naturally arising from the categorical imperative. The moral concept of virtue emerges centuries before Kantian deontology, most prominently with the works of Aristotle and his Nicomachean Ethics. Aristotle begins by setting forth the function of a human life, which is the achievement of excellence in one’s soul (or being). A human being who achieves the virtues (or excellences) will also be a fulfilled human being, which is taken to be a profoundly moral achievement. In addition, these excellences are not merely a pattern of action for the moral agent, but a series of habits (or a natural way of acting, aside from conscious deliberation). Ethical prescriptions, then, are not duties that one has to others (or to oneself), but rather the kinds of characteristics and habits that one should embody. The distinction at play between these two cases is that moral knowledge for Kant is descriptive (or capable of being laid out in written sentences as a list of rules, like steps in baking a cake), while moral knowledge for Aristotle is procedural (or only capable of being expressed in action, like the indescribable steps that it takes to correctly ride a bicycle). This distinction between the two views is philosophically significant from the get-go, and they are particularly important for understanding the differences in perspectives that an ethicist could take with respect to iatrogenesis. In medicine, to say that a healthcare giver has a duty to his or her recipients means that the giver has an unconditional obligation to provide something good in itself to that recipient (Sharpe and Faden 168). A duty to do minimal harm, for instance, dictates that a healthcare giver has an unconditional obligation not to jeopardize the life and safety of a healthcare recipient, since the life and safety of a recipient is a good in itself. Today, medical professionals are morally culpable for the harms associated with the care that they provide. Accordingly, the principle is increasingly tied to an individual’s moral being—irrespective of the context in which that person is acting (accidentally killing someone in one’s personal life is the same, morally, as doing so in a medical context). The duty to “minimize total harm” is determined through a “proportional calculus of the pain and suffering associated with both disease and treatment” (Sharpe and Faden 11). Each healthcare giver is bound to this duty by the nature of morality, its universality and the categorical imperative. Virtue ethics offers a different interpretation of iatrogenesis and its bioethical implications. For nurses, in particular, the revised Code of Ethics for Nurses says, “Virtues are habits of character that predispose persons to meet their moral obligations; that is to do what is right. Excellences are habits of character that predispose a person to do a particular job or task well” (White). Explicitly basis a code of ethics on a code of virtues indicates the importance that a virtue ethics perspective can have in the context of looking at unsafe practices in providing individuals with care. In addition, Robert S. Pepper has looked at the effect that the vice (the opposite of virtue) of omnipotence has on causing iatrogenesis in the context of healthcare treatment for patients (Pepper). Having laid the conceptual foundation for discussion, it should now be made clear that deontology is an inadequate answer to the question of iatrogenesis and the moral problems it proposes. First, it is germane to ask what, if anything, changes by approaching iatrogenesis from a virtue perspective as opposed to a duty perspective. Most clearly and most importantly, one’s standard for what is wrong and what is right changes drastically. Instead of starting from a list of duties and rules, and justifying one’s prescriptive claims from that a priori list, one begins from a list of characteristics and habits that lead to one fulfilling the proper function of a doctor, psychotherapist, or whatever field one belongs to. Figuring out what the purpose of one’s job as a healthcare provider need not be a priori, however: it can be derived from one’s own personal experience of what it means to be a good doctor, psychotherapist, and so on. In addition, a change in perspective signifies a shift in the moral blame (and the nature of the legal crime, if applicable) ascribed to a healthcare provider in the case that his or her actions caused iatrogenic disease. From deontology, one blames the wrongdoer for not living up to his or her duty through wrong action; from virtue, one blames the wrongdoer at a more fundamental level: at the level of personality traits and personal habits. In medicine and psychotherapy, it is important to be virtuous: arguably more so than committed to moral duties. Because no two cases in these fields are exactly alike in every way, it requires professionals to apply their knowledge and skills to new situations. Virtues enable people to act appropriately in all situations, regardless of their familiarity with them. Analogously, a football player who is given a list of instructions of what to do in every situation possible on a football field will not be a successful player, because it is cognitively impossible to remember an infinitely long list. A virtuous football player, however, has developed the skills and habits required to succeed in all of those contingent circumstances. Extending this to healthcare givers, the same principle applies: the moral consequences of one’s actions will not always be reflected in a list of a priori rules, but is more predictably anticipated by the development of good behaviors and habits in approaching problems when they arise. Another component of this is acting in response to virtues (or personal characteristics) as opposed to consequences. An example of a negative consequence in the medical field is the death of the patient, which will invoke a disciplinary response from the institution. Undoubtedly, it is best to evaluate healthcare givers based on their personal characteristics, rather than the consequences of their actions (proactively after, for example, their negligence caused a fatal iatrogenic disease). On a deontological framework, decisions about the ethics of particular healthcare givers would be based on their ability to meet their duties to the recipients of care. However, like understanding the consequences of actions and responding to them, this approach can only be employed after an immoral event has occurred and thus is not a good framework to use in dictating healthcare policy. An additional argument to consider against a deontological perspective on iatrogenesis is the conflict between duties in the healthcare profession. At times, physicians have both a duty to respect privacy of their patients and a duty to protect society against individuals with venereal diseases like HIV/AIDS. Requirements to post notices of an individual’s infection with HIV are a duty that conflicts the duty to respecting privacy (Sharpe and Faden 125). The problem here is that duties often conflict in the diverse range of circumstances that healthcare professionals are faced with. This may require the ranking of duties, so that resolution to conflicts among them may result. However, this conflicts with the notion of a categorical imperative (and thus the definition of duty) as something that is good in itself and absolutely binding for all individuals, regardless of context. Consider also the claim made by an expert on duty ethics earlier, which was that the duty to “minimize total harm” is determined through a “proportional calculus of the pain and suffering associated with both disease and treatment” (Sharpe and Faden 11). In this case, the ethicist is using pain and suffering (which belong to utilitarianism normative frameworks as the standard of value for ethical and unethical action) as a criterion for determining the content of one’s duties to his or her healthcare recipients. At this point, the distinction between deontology and utilitarianism is breaking down—namely, with respect to the fact that utilitarianism presents a similar sort of moral “duty” to produce the greatest pleasure and reduce the pain of patients. The fact that one can substitute and interchange these two moral perspectives so easily is troubling, leading one to look for an alternative mode of explanation such as the one provided by virtue ethics and an understanding of ethics as based on habituation. Iatrogenesis and iatrogenic disease are large problems for modern medicine, in terms of the complexity of the treatments (pharmacological and otherwise) being given to patients without properly considering the potentials for bad effects. The high incidence of iatrogenesis today means that a moral discussion of the phenomenon is necessary, and a decision on the perspective to take on iatrogenesis is relevant. Ultimately, virtue ethics provides a sounder normative framework from which to address the issue because it takes into account the inherent complexity and nature of healthcare work. Deontology and categorical imperatives provide a weaker account of the moral standards society ought to be holding healthcare professionals to, because it depends on a moral theory disconnected from the complexity and nature of the professional environment. Looking at new trends, such as the new nursing code of ethics, which is based on an explicitly virtue ethical theory, it seems that medicine and psychotherapy are moving in this direction, which is a welcome and necessary change. Works Cited Pepper, Robert S. "The omnipotent clinician: A potential source of iatrogenesis." Journal of Contemporary Psychotherapy 26(3) (1996): 287-294. Sharpe, Virginia Ashby and Alan I. Faden. Medical Harm: Historical, Conceptual and Ethical Dimensions of Iatrogenic Illness. 1st. New York: Cambridge University Press, 1998. Weingart, Saul N., Amy N. Ship and Mark D. Aronson. "Confidential Clinician-reported Surveillance of Adverse Events Among Medical Inpatients." Journal of General Internal Medicine 15(7) (2000): 470-477. White, Gladys B. Patient safety: an ethical imperative. August 2002. 19 October 2011 . Read More