Philosophical Foundations of Various Approaches to Medical Ethical Decision Making INTRODUCTION
Seldom if ever is there a case which does not at some point involve a medical ethical decision. One need not look only at exotic cases. Taking a closer look at the decision procedure involves philosophical analysis of the logically possible alternative methods of medical ethical decision making. I am not here arguing for or against any of these alternatives—I have done that elsewhere.1 Here I simply want to state the alternatives and point out the philosophical implications of various basic stances on value. The watershed in ethics and value theory is the subjective-objective controversy, not the naturalistic-nonnaturalistic distinction, the normative-metaethical distinction, or the teleological-deontological distinction. These distinctions, as important as they are, are secondary to the subjective-objective distinction because it determines whether or not value language is even meaningful. That is, are value judgments purely personal private expressions of the opinions and inner subjective feelings of the agent making the judgments, which theoretically are not capable of being either true or false because they do not make epistemological claims, or are value judgments expressions of normative imperatives and moral requirements which are independent of the experience, opinions, and beliefs of the agent and which are theoretically capable of being true * Assistant professor, Department of Family Medicine, Eastern Virginia Medical School, and Department of Philosophy, Old Dominion University, Norfolk. 1 For a detailed philosophical analysis of the alternative positions, see Self (1973). The Journal of Medicine and Philosophy, 1979, vol. 4, no. 1 © 1979 by the Society for Health and Human Values. 0360-5310/79/0401-0002$01.16 20
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DONNIE J. SELF*
Donnie J. Self
THE CASE Mr. John Graham, a thirty-four-year-old male Caucasian with a fourteen-month history of intermittent headaches, was admitted to the hospital March 18. He had been a telephone company lineman until confusion, nausea, and generalized weakness associated with increased frequency and intensity of the headaches resulted in his transfer to a desk job. At first the headaches were relieved with aspirin, but a worsening of the patient's condition required him to seek medical help. He was referred to the medical center by his family physician. Upon examination the patient was alert, cooperative, and welloriented but with some deficiency of recent memory and a slight decrease in higher mental function. He was not dysarthritic, had normal visual acuity, and no papilledema. There was diminished palatal sensation on the right, and the palate moved slightly to the left with phonation. The patient's chemistry was generally unremarkable with blood cell count, electrolytes, urinalysis, SGOT (serum gultamin oxaloacetic transaminase), SGPT (serum glutamic pyruvic transaminase), and BUN (blood urea nitrogen) tests all within normal limits. Creatinine was 1.5 mg%, calcium 11.7 mg%, and phosphorus 4.4 mg%. Lumbar puncture produced CSF (cerebrospinal fluid) with 7 white blood cells, numerous large tumor cells, and a protein content of 93 mg%. A pneumonencephalogram demonstrated dilitation of the lateral and third ventricles, while skull radiography showed a large space-occupying lesion deep in the midbrain which was diagnosed as a glioma. The family history revealed that the patient was lower middle class, of moderate income, married with two children, heavily indebted, and 21
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or false in the epistemological claim they make due to the structure of reality and the existence of a moral order in it? The subjective-objective controversy actually involves three positions (for a brief description, see Self [1976]). On one extreme is pure or complete subjectivism. The opposite extreme is pure or complete objectivism. Between these two positions is a combination of partial subjectivism and partial objectivism. Concrete examples of these positions will be considered shortly, but these are the three logically possible alternatives upon which one's methodology for medical ethical decision making is based. Wittingly or unwittingly one's ethical decisions, including those of a medical nature, rest upon these philosophical foundations. Perhaps an analysis of a paradigm of each alternative will be helpful when considering the practical decision making of the case. Existentalism will be considered as a paradigm of pure subjectivism, utilitarianism as a paradigm of partial subjectivism-partial objectivism-, and value realism as a paradigm of pure objectivism. But first consider the details of the case.
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had no will. The patient's wife and parents were quite anxious and wanted something done for him. The wife's account was consistent with the earlier description of the onset of headaches, etc. ANALYSIS
2
For the context of the remark and an elaboration of the existentialist position, see Sartre (1947), pp. 14-15. 22
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Now with these facts at hand, how does one go about deciding the value question involved, namely, whether or not one ought to do neurosurgery in this case? That is, would it be good in this case to carry out physical intervention in the brain, or should one follow conservative therapy? Consider a specific example of each of the alternative methodologies identified earlier. The description of each paradigm is grossly oversimplified in an effort to focus sharply on a thoroughly consistent example of the particular positions. It was noted that existentialism is a paradigm of pure subjectivism. A brief description of the position may prove helpful in analyzing the decision procedure of the value subjectivist. Existentialism has been one of the most popular ethical theories in the twentieth century. It has enjoyed an immense popularity in both philosophical and nonphilosophical circles. But due to its vagueness it is difficult to define accurately. The term 'existentialism' is so loosely used now that it has become practically meaningless. This is the case partly because of the popularization of the term resulting from its frequent nontechnical use. Jean-Paul Sartre points out that "most people who use the word would be rather embarrassed if they had to explain it. . . . It is intended strictly for specialists and philosophers."2 But part of its popularization is due to the fact that existentialism is not so much a philosophical theory as an attitude or approach to life which has attracted or repelled large masses of people who have no technical knowledge of its philosophical basis. It is more or less a mood, posture, basic orientation, or life-style. Existentialism takes as its basic emphases freedom, authenticity, responsibility, anguish, and subjectivity. It is often summarized by the phrase "existence precedes essence.' Man is free to choose what he pleases. Yet the choice must be authentic in order for it to be what he pleases. And inevitably he is responsible for the outcome of it all. Within this framework it is the aim of existentialism to free people from an illusion of constraint or to establish freedom. In attempting to accomplish its aim existentialism resists the Greek view that man has a certain function for which he is designed and that it is best for one to find his function and fulfill it well. But man continues to categorize himself and things such that they fit
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into their proper place or fulfill their role. Existentialism rejects this categorization because it leads to (or is) hypocrisy. It points out that man by bad faith or self-deceit tries to become a thing and thus avoid ultimate responsibility. Man seeks to escape his terrible responsibility for the values he lives by, by attributing them to a necessary, cosmic, or supernatural source. Existentialism attempts to rid man of all his superstitions and make him totally free and entirely self-dependent. Freedom resulting from complete subjectivism is the basis of the whole enterprise. The existentialist feels that one must live a life of absolute freedom. With no essence or nature one has no determinants. One should not seek or accept any justification for any act other than that justification imposed upon the act by virtue of its being a free choice. To accept justification of acts or categorization of man is to live unauthentically. One must realize one's possibilities as an individual, alone, isolated, and independent. In the authentic life one must be prepared to take full responsibility for it. One ought not to seek to escape from this responsibility which results from complete freedom, although it causes one anxiety and despair. With the lack of an essence man is free to mold or fashion his life however he desires. This being empty and devoid of essence is what the existentialist calls the human condition. The familiar stereotypes which are traditionally attributed to man are considered inappropriate. This natureless nature is what Sartre meant when he said of man that existence preceded essence. First man merely exists and then determines his own nature or essence by what he chooses to do. Due to this initial lack of essence man is free to choose whatever nature he prefers. Freedom is then not just experienced but a quality of being. It is the condition of man. Freedom is the key concept in existentialism. There are other important concepts in existentialism, such as responsibility and anguish, but they are dependent upon the notion of freedom and cannot be treated in detail here. Now specifically with respect to the case under consideration, consider how the existentialist physician, in light of the philosophical position just described, would decide whether or not he should do the neurosurgery. Since complete freedom is his ultimate ethical principle, the decision becomes purely a matter of personal preference on the part of the physician. Indeed it becomes arbitrary. Value considerations of what would be better or worse are not cognitively meaningful for a consistent subjectivist and so should not enter into the deliberation. For him value judgments are simply an expression of volition or attitude. What decision is reached is not important. What is important is how it is reached—that is, it must be freely chosen without any influence or constraint from any traditional or exterior value structure. The
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3
For a concise elaboration of the utilitarian position and a good general introduction to ethics, see Frankena (1968), p. 29. 24
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thoroughly existentialist physician needs give no reason for his choice in matters of value other than it is what he authentically prefers. This illustrates the need for physicians to study and understand the philosophical implications of their positions in matters of value. Needless to say, many physicians who are inclined to identify with an existentialist ethics would not think that this would or should have serious consequences or influence in a decision in their medical practice—such as whether or not to do a given operation. But if one is to be consistent, intellectual integrity requires that knowledge beliefs carry over between disciplines. In the case of Mr. Graham the existentialist physician might decide to do the neurosurgery. He could figure that the patient came to him expecting treatment, that the family wanted something done, and that the surgeon stands to gain both financially and in experience while the outcome of the case will likely be about the same regardless of the course of action taken. And after all there is a surplus of neurosurgeons; they have to make a living somehow; they are trained to operate, so go ahead. Of course, on the other hand, that the existentialist physician might decide not to do the surgery is an equally likely and viable option. His basic ethical principle does not place constraints, one way or the other, on the particular outcome of any given ethical dilemma. Second, consider the partial subjective-partial objective alternative. It was noted earlier that utilitarianism is a paradigm of this position. It is objective with respect to value language, that is, value judgments are cognitive, epistemologically meaningful, and subject to confirmation as true or false since they are about value experience. But it is subjective with respect to value experience, that is, value experience has no semantic content per se, is not epistemologically meaningful, and can be exhaustively described or translated into nonvalue language. Utilitarianism is a teleological theory of obligation with the greatest good being the end toward which all actions are aimed. It establishes a decision procedure by employing the principle of utility. The teleological nature of utilitarianism is emphasized by its claim that the lightness of actions is to be judged solely by their consequences. The decision procedure is set out quite clearly by W. K. Frankena in saying of utilitarianism: "[It is] the view which says that the sole ultimate standard of right, wrong, and obligation is the principle of utility . . . which says quite strictly that the moral end to be sought in all that we do is the greatest possible balance of good over evil." 3 For the utilitarian, the basis of the decision procedure in moral choice is always simply the principle of utility. An act is obliga-
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tory if and only if it is conductive of the greatest possible balance of good over evil. But immediately there arises the problem of whose greatest good or most useful for whom. Is it to be a monistic or pluralistic utilitarianism? That is, is the utility of an act to be based solely on the interests of the single agent performing the act? If not the agent, yet still monistically, then which individual, perhaps the patient, and how does one determine that? Or is the utility of an act to be based broadly on the interests of one's family, one's community, society, or mankind as a whole? Here an interesting conflict arises between philosophy and medicine. Historically it has been the tradition of philosophy to interpret utilitarianism pluralistically in the manner of Jeremy Bentham and John Stuart Mill as expressed in the popular phrase "the greatest good for the greatest number." Yet in the tradition of medicine, particularly evidenced in the evolvement of the patient-physician relationship, utilitarian concerns have been interpreted monistically solely in terms of what is best for the patient. And this has been codified in the canons of medical tradition and accepted as common law. This, nevertheless, raises some interesting possibilities when the patient's interests conflict with the interests of society or of mankind in general and with the interests of the physician in particular. Of course ideally the interests of the patient and physician would coincide. But this is sometimes not the case. An example of this utilitarian conflict comes over the prescribing of oral contraceptives. Monistically, on a one-to-one basis of the best interest of the patient a physician might not recommend oral contraceptives because of possible side effects or unknown long-term risks, but pluralistically on a broader view basis he might prescribe oral contraceptives because of a recognition of the need to control population, etc. From this arises the problem of who is the patient. A physician cannot isolate himself to a patient. He is always also in a moral relationship to the family and others, as well as to the community, society, and mankind as a whole. The physician is more than just a physician and functions in more than one role simultaneously. He cannot completely segregate these functions and have each act independently of the other. To do so would be to become schizophrenic, for frequently the different roles compete and conflict. The physician is also a researcher, civic leader, hospital director, citizen, and taxpayer—at least, often one or more of these. But again, specifically with respect to the case of Mr. Graham, consider how the utilitarian physician would decide whether or not he should do the neurosurgery. Since the principle of utility is his ultimate ethical principle, the decision is reduced solely to determining which alternative presents the greatest possible balance of good over evil. Such determinations are difficult, and no ready calculus is available for weighing conflicting interests. Conflicts of interest were seen to be the source of the
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monistic-pluralistic distinction in utilitarianism. Of course, sometimes, even frequently, the two interpretations would arrive at the same end decision since the common good and the good of the individual sometimes coincide. But such is not necessarily the case. As a result, consider the case of Mr. Graham from both perspectives. Assuming that the interest of the patient is the sole consideration of the monistic utilitarian physician, conflicts of interest will then not be taken into consideration. As a result, in the case of Mr. Graham a monistic utilitarian physician would quite likely decide not to do the neurosurgery since due to the deep location of the tumor it would leave a speech deficit, partial paralysis, and generally poor quality of life without significantly altering the ultimate resolution of the case. In essence it would involve sacrificing quality without gaining quantity, that is, it would leave the patient in worse shape than he was found in initially. As a result, the consistent monistic utilitarian physician would conclude that solely on the basis of the interest of the patient the tumor was inoperable but that cobalt therapy should be initiated in order to give the patient at least a thread of hope and the feeling that something was being done. On the other hand, a pluralistic utilitarian physician would take many other broader considerations into account. The interest of all relevant parties would be taken into consideration. This raises the additional problems of determining who counts as a relevant party as well as how to resolve the inevitable conflicts of interest. But on the whole the decision chosen must be the one which presents collectively the greatest amount of good, that is usefulness, for all concerned. This differs drastically from the monistic utilitarian position. As a result, in the case of Mr. Graham a pluralistic utilitarian physician would quite likely decide to do the neurosurgery since to a certain extent in terms of total utility more stood to be gained than lost. The reasoning would likely run as follows. Due to the deep location of the tumor and the inevitable resolution of the case, little stood to be lost, even with respect to the patient—at most, only a few months of speech and certain voluntary muscle movement, which is only a fraction of one percent of his total life span and which would have become of progressively poorer quality anyway. Yet considerable utility stood to be gained from many aspects. First, the patient, who came expecting treatment, would gain the feeling that everything possible was being done. And the family would gain the sense of satisfaction of knowing that they had unquestionably provided the maximum support of their loved one even to the extent of sacrificing thousands of dollars for extreme and last-resort therapy. Also, they would be spared the agony of waiting for their loved one to die with a feeling of helplessness and hopelessness that nothing could be done. Then the physician would gain financially, a consideration perhaps not too significant for a sensitive and compassionate physician but one, nevertheless, too frequently taken into consideration.
Donnie J. Self
4
For a detailed description of this position, see Self (1975a). For the foundations of the empiricist epistemology, see Hall (1952, 1961) and Adams (1960). 5
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Also the economics of the hospital favor keeping a high patient census. For an 800-bed hospital the overhead operating expense is about the same for 500 patients as it is for 800 patients. Furthermore, the case occurred at a teaching hospital which would gain valuable teaching material if the surgery took place, both in terms of experience for trainees and in terms of materials and accumulated data. Similarly, research laboratories would gain from the availability of scarce human tumor tissue with which to do theoretical work, as would the practical clinical research of the cooperative brain tumor study group. When viewed from broader considerations, it seems that more utility would be gained from doing the surgery. Third, consider the purely objective alternative. It was noted earlier that the position known as value realism is a paradigm of this alternative.4 Value realism is a subclass of realism. Basically, realism is the position that an object of knowledge is independent of the knowing of it. This is what makes it an objective position. A realistic or objective theory of value holds that value judgments are of and about an external, independent reality and that normative value requirements exist regardless of whether or not they are acknowledged. It does not incorporate or endorse an ultimate ethical principle as its foundation, such as utilitarianism does with the principle of utility or existentialism does with the principle of freedom. Value realism contends that value experience is knowledge yielding and that value judgments make truth claims about the world which in some sense obtain of the world. This means that there are imperative features and normative requirements in reality. It holds that both value language and value experience are objective and that what is grasped or known by value experience is not grasped or known by any other mode of experience, that is, value language is uniquely groundable through value experience to the structure of reality and cannot be reduced to language grounded through any other mode of experience. All this permits the central contention that statements about value and obligation are empirically verifiable descriptions of reality. But this involves the formation of a nonnaturalistic position of value realism with a somewhat novel twist. The novelty comes from the fact that generally value realism has been considered to hold a rationalistic, as opposed to empiricistic, epistemology, whereas this version of value realism advocates a thoroughgoing empiricistic epistemology.5 This empiricistic epistemology serves as the foundation for the empirical basis of ethics. Briefly, this version of value realism is the position that: (1) Value experience is epistemic in character, and (2) value experience is ontologically significant. A corollary of this is that value experience is supervenient upon
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6
For the details of the arguments alluded to, see Self (1973, 1974, 19756). These claims are crucial to the establishment of the value realist position. For the details of the arguments, see Self (1974). 8 This point is established in Self (19756). 7
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cognizance of facts. These contentions are the heart of value realism. The details of arguments for these contentions have been given elsewhere.6 It is crucial for value realism to determine whether an emotion may be said to be correct and justified or incorrect and unjustified over and above the correctness of the agent's factual beliefs about the circumstances which mediate the emotions. Value realism contends that an emotion can be unjustified even though the agent correctly discerns the factual circumstances because he mistakes the value requiredness involved in the facts. If emotions are subject to such rational appraisal in their own right, they can be regarded as cognitive, for cognitions are subject to the epistemic concepts of rational appraisal. It is generally recognized that value language involves the language of emotion, attitude, volition, etc. In view of this the nature of this mode of experience becomes central in any claim of moral knowledge. If one accepts the scientific descriptive-explanatory account with the sensory mode of experience as the only way to obtain legitimate, valid knowledge, one automatically rules out the very possibility of value knowledge. In other words the possibility of value knowledge turns upon an epistemological analysis of emotive and volitional experience. In another place I have argued in detail that several considerations support the claim that value experience is epistemic in character and ontologically significant.7 A corollary to the claim that value experience is both knowledge yielding and ontologically significant is that value experience is supervenient upon cognizance of facts. This also has been argued in detail elsewhere and need not be repeated here.8 Suffice it to say that values have a status parallel to facts, but they are integrally tied to the presence of the facts that obtain in the situation. Change the factual reality and the corresponding value involved is changed. With this explication of value, value is parallel to fact as a category of reality. Value may be supervenient or dependent upon facts, but it is a separate entity from facts and cannot be reduced to facts. Only the fact that an act has other specific properties makes it an obligatory act. One does not abstractly perceive goodness and Tightness. Rather, one discerns the goodness or Tightness of a situation as a result of perceiving the nature of the situation through the characteristics it possesses. It is the ascertainment of the factual properties on which the normative relationships depend which determines when a value concept is properly applied, even if the value concept cannot be reduced to nonethical or merely factual properties. That is, one cannot simply assert 'x is good' without being prepared upon request to provide some reasons which
Donnie J. Self
9
This decision procedure for medical ethical problems is elaborated in Self (1974). 29
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support the claim as being justified by some particular facts. For the realist it is the facts plus the requirements grounded in them that serve as the basis of evaluations. All this emphasizes how factual curcumstances play a formative part in value judgments. For value realism value judgments are grounded in experience. It is the characteristics in the factual circumstances which determine the value and not just the attitude of the agent. This is why the agent can make mistakes and misinterpretations of the value in the situation. Mistakes can only be made if there is something to take incorrectly. This is part of what is meant by value experience being objective. It is corrigible. And it is this corrigibility of being subject to rational assessment and appraisal that makes something locatable in the world or ontologically significant. Again, specifically with regard to the case of Mr. Graham, consider how the value-realist physician would decide whether or not he should do the neurosurgery. He has no ultimate ethical principle upon which to base his decision. So he must develop another means. In another place I have advocated a specific decision procedure for medical ethical problems.9 It is based upon the above theoretical explication of the empirical basis of ethics. Briefly it involves the following. First, identify the moral issue in the situation. Second, gather all the relevant data, that is, the facts of the circumstances. And third, place an interpretation on the data with the best interpretation being the one most coherent with everything else known about the issue. Of course, in the final analysis this involves an immediate and direct intuitionistic grasp of the moral requiredness—a notion which is currently in disfavor but which when properly understood need not be. First, the central moral issue in this case is whether or not one ought to carry out physical intervention in the brain for this kind of deep-situated tumor. Second, the main relevant facts of the situation are that the patient has a malignant brain tumor, that the tumor is located deep in a preferentially inaccessible region, that surgery will leave the patient with a speech deficit and hemiparesis, that without surgery the patient will probably live three to four months, that with surgery the patient will probably live four or five months, one of which will be a hospitalization, that the patient does not have a will or his financial affairs in order, that the patient is seeking help, and that the family is supportive of the patient and wants something done. Facts of the situation which are not relevant in this decision are the economics of a high patient census, the financial status of the surgeon, and the facts that it is a teaching hospital and that the data and human tissue
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REFERENCES Adams, E. M. Ethical Naturalism and the Modern World-View. Chapel Hill: University of North Carolina Press, 1960. Frankena, William K. Ethics. Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1968. Hall, Everett W. What Is Value? New York: Humanities Press, 1952. Hall, Everett W. Our Knowledge of Fact and Value. Chapel Hill: University of North Carolina Press, 1961. Sartre, Jean-Paul. Existentialism. Translated by Bernard Frechtman. New York: Philosophical Library, Inc., 1947. Self, Donnie J. "Value Language and Objectivity: An Analysis in Philosophical Ethics." Ph.D. dissertation, University of North Carolina, 1973. Self, Donnie J. "Methodological Considerations for Medical Ethics." Science, Medicine and Man 1 (1974): 195-202. 30
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would support both theoretical and clinical research. To consider these without patient participation in the deliberations would be to dehumanize the patient, for it would be to treat the patient as a thing and not a person. It would violate the Kantian imperative to act always only so as to treat a person as an end in itself and never as a means. Third, the interpretation of the above data which fits most coherently with other things known about the situation, such as that the man needs a clear mind and speech to get his affairs in order and that no clearly established malignant glioma has ever been cured, surgically or otherwise, etc., is that the neurosurgery should not be done. That the surgery should not be done is seen directly from the facts of the situation and does not involve any mystical or infallible revelation. In fact, fallibility is what makes this position viable—it can get value questions right, and it can get them wrong. Intuition simply means direct and unmediated. The intuitionistic grasp of the moral requiredness in this case comes directly from the facts of the situation and is not mediated by some ultimate ethical principle. This alternative allows one to use common sense and experienced clinical judgment and to balance conflicting interests in a humanistic way which does not degrade patients to the status of a thing. It permits taking utility factors into consideration along with all the rest but simply does not overweight or exclusify them. At the same time, it maintains the autonomy of the physician and freedom of decision on an individual case basis. In conclusion, it might be noted that what is most likely the case is that we are guilty of sometimes operating from within one alternative methodology and sometimes from another, which is to say that we are not very consistent. And philosophically, this is a cardinal sin which can be avoided by becoming aware of and paying attention to our underlying value position.
Donnie J. Self Self, Donnie J. "An Alternative Explication of the Empirical Basis of Medical Ethics." Ethics in Science and Medicine 2 (December 1975): 151-66. (a) Self, Donnie J. "Objectivity and Value Superveniency in Medical Ethical Decision-Making." Ethics in Science and Medicine 2 (December 1975): 145-50. (b) Self, Donnie J. "Inconsistent Presuppositions of Dewey's Pragmatism." Journal of Educational Thought 10 (August 1976): 101-9.
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31
Seldom if ever is there a case which does not at some point involve a medical ethical decision. One need not look only at exotic cases. Taking a closer look at the decision procedure involves philosophical analysis of the logically possible alternative methods of medical ethical decision making. I am not here arguing for or against any of these alternatives—I have done that elsewhere.1 Here I simply want to state the alternatives and point out the philosophical implications of various basic stances on value. The watershed in ethics and value theory is the subjective-objective controversy, not the naturalistic-nonnaturalistic distinction, the normative-metaethical distinction, or the teleological-deontological distinction. These distinctions, as important as they are, are secondary to the subjective-objective distinction because it determines whether or not value language is even meaningful. That is, are value judgments purely personal private expressions of the opinions and inner subjective feelings of the agent making the judgments, which theoretically are not capable of being either true or false because they do not make epistemological claims, or are value judgments expressions of normative imperatives and moral requirements which are independent of the experience, opinions, and beliefs of the agent and which are theoretically capable of being true * Assistant professor, Department of Family Medicine, Eastern Virginia Medical School, and Department of Philosophy, Old Dominion University, Norfolk. 1 For a detailed philosophical analysis of the alternative positions, see Self (1973). The Journal of Medicine and Philosophy, 1979, vol. 4, no. 1 © 1979 by the Society for Health and Human Values. 0360-5310/79/0401-0002$01.16 20
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DONNIE J. SELF*
Donnie J. Self
THE CASE Mr. John Graham, a thirty-four-year-old male Caucasian with a fourteen-month history of intermittent headaches, was admitted to the hospital March 18. He had been a telephone company lineman until confusion, nausea, and generalized weakness associated with increased frequency and intensity of the headaches resulted in his transfer to a desk job. At first the headaches were relieved with aspirin, but a worsening of the patient's condition required him to seek medical help. He was referred to the medical center by his family physician. Upon examination the patient was alert, cooperative, and welloriented but with some deficiency of recent memory and a slight decrease in higher mental function. He was not dysarthritic, had normal visual acuity, and no papilledema. There was diminished palatal sensation on the right, and the palate moved slightly to the left with phonation. The patient's chemistry was generally unremarkable with blood cell count, electrolytes, urinalysis, SGOT (serum gultamin oxaloacetic transaminase), SGPT (serum glutamic pyruvic transaminase), and BUN (blood urea nitrogen) tests all within normal limits. Creatinine was 1.5 mg%, calcium 11.7 mg%, and phosphorus 4.4 mg%. Lumbar puncture produced CSF (cerebrospinal fluid) with 7 white blood cells, numerous large tumor cells, and a protein content of 93 mg%. A pneumonencephalogram demonstrated dilitation of the lateral and third ventricles, while skull radiography showed a large space-occupying lesion deep in the midbrain which was diagnosed as a glioma. The family history revealed that the patient was lower middle class, of moderate income, married with two children, heavily indebted, and 21
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or false in the epistemological claim they make due to the structure of reality and the existence of a moral order in it? The subjective-objective controversy actually involves three positions (for a brief description, see Self [1976]). On one extreme is pure or complete subjectivism. The opposite extreme is pure or complete objectivism. Between these two positions is a combination of partial subjectivism and partial objectivism. Concrete examples of these positions will be considered shortly, but these are the three logically possible alternatives upon which one's methodology for medical ethical decision making is based. Wittingly or unwittingly one's ethical decisions, including those of a medical nature, rest upon these philosophical foundations. Perhaps an analysis of a paradigm of each alternative will be helpful when considering the practical decision making of the case. Existentalism will be considered as a paradigm of pure subjectivism, utilitarianism as a paradigm of partial subjectivism-partial objectivism-, and value realism as a paradigm of pure objectivism. But first consider the details of the case.
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had no will. The patient's wife and parents were quite anxious and wanted something done for him. The wife's account was consistent with the earlier description of the onset of headaches, etc. ANALYSIS
2
For the context of the remark and an elaboration of the existentialist position, see Sartre (1947), pp. 14-15. 22
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Now with these facts at hand, how does one go about deciding the value question involved, namely, whether or not one ought to do neurosurgery in this case? That is, would it be good in this case to carry out physical intervention in the brain, or should one follow conservative therapy? Consider a specific example of each of the alternative methodologies identified earlier. The description of each paradigm is grossly oversimplified in an effort to focus sharply on a thoroughly consistent example of the particular positions. It was noted that existentialism is a paradigm of pure subjectivism. A brief description of the position may prove helpful in analyzing the decision procedure of the value subjectivist. Existentialism has been one of the most popular ethical theories in the twentieth century. It has enjoyed an immense popularity in both philosophical and nonphilosophical circles. But due to its vagueness it is difficult to define accurately. The term 'existentialism' is so loosely used now that it has become practically meaningless. This is the case partly because of the popularization of the term resulting from its frequent nontechnical use. Jean-Paul Sartre points out that "most people who use the word would be rather embarrassed if they had to explain it. . . . It is intended strictly for specialists and philosophers."2 But part of its popularization is due to the fact that existentialism is not so much a philosophical theory as an attitude or approach to life which has attracted or repelled large masses of people who have no technical knowledge of its philosophical basis. It is more or less a mood, posture, basic orientation, or life-style. Existentialism takes as its basic emphases freedom, authenticity, responsibility, anguish, and subjectivity. It is often summarized by the phrase "existence precedes essence.' Man is free to choose what he pleases. Yet the choice must be authentic in order for it to be what he pleases. And inevitably he is responsible for the outcome of it all. Within this framework it is the aim of existentialism to free people from an illusion of constraint or to establish freedom. In attempting to accomplish its aim existentialism resists the Greek view that man has a certain function for which he is designed and that it is best for one to find his function and fulfill it well. But man continues to categorize himself and things such that they fit
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into their proper place or fulfill their role. Existentialism rejects this categorization because it leads to (or is) hypocrisy. It points out that man by bad faith or self-deceit tries to become a thing and thus avoid ultimate responsibility. Man seeks to escape his terrible responsibility for the values he lives by, by attributing them to a necessary, cosmic, or supernatural source. Existentialism attempts to rid man of all his superstitions and make him totally free and entirely self-dependent. Freedom resulting from complete subjectivism is the basis of the whole enterprise. The existentialist feels that one must live a life of absolute freedom. With no essence or nature one has no determinants. One should not seek or accept any justification for any act other than that justification imposed upon the act by virtue of its being a free choice. To accept justification of acts or categorization of man is to live unauthentically. One must realize one's possibilities as an individual, alone, isolated, and independent. In the authentic life one must be prepared to take full responsibility for it. One ought not to seek to escape from this responsibility which results from complete freedom, although it causes one anxiety and despair. With the lack of an essence man is free to mold or fashion his life however he desires. This being empty and devoid of essence is what the existentialist calls the human condition. The familiar stereotypes which are traditionally attributed to man are considered inappropriate. This natureless nature is what Sartre meant when he said of man that existence preceded essence. First man merely exists and then determines his own nature or essence by what he chooses to do. Due to this initial lack of essence man is free to choose whatever nature he prefers. Freedom is then not just experienced but a quality of being. It is the condition of man. Freedom is the key concept in existentialism. There are other important concepts in existentialism, such as responsibility and anguish, but they are dependent upon the notion of freedom and cannot be treated in detail here. Now specifically with respect to the case under consideration, consider how the existentialist physician, in light of the philosophical position just described, would decide whether or not he should do the neurosurgery. Since complete freedom is his ultimate ethical principle, the decision becomes purely a matter of personal preference on the part of the physician. Indeed it becomes arbitrary. Value considerations of what would be better or worse are not cognitively meaningful for a consistent subjectivist and so should not enter into the deliberation. For him value judgments are simply an expression of volition or attitude. What decision is reached is not important. What is important is how it is reached—that is, it must be freely chosen without any influence or constraint from any traditional or exterior value structure. The
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For a concise elaboration of the utilitarian position and a good general introduction to ethics, see Frankena (1968), p. 29. 24
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thoroughly existentialist physician needs give no reason for his choice in matters of value other than it is what he authentically prefers. This illustrates the need for physicians to study and understand the philosophical implications of their positions in matters of value. Needless to say, many physicians who are inclined to identify with an existentialist ethics would not think that this would or should have serious consequences or influence in a decision in their medical practice—such as whether or not to do a given operation. But if one is to be consistent, intellectual integrity requires that knowledge beliefs carry over between disciplines. In the case of Mr. Graham the existentialist physician might decide to do the neurosurgery. He could figure that the patient came to him expecting treatment, that the family wanted something done, and that the surgeon stands to gain both financially and in experience while the outcome of the case will likely be about the same regardless of the course of action taken. And after all there is a surplus of neurosurgeons; they have to make a living somehow; they are trained to operate, so go ahead. Of course, on the other hand, that the existentialist physician might decide not to do the surgery is an equally likely and viable option. His basic ethical principle does not place constraints, one way or the other, on the particular outcome of any given ethical dilemma. Second, consider the partial subjective-partial objective alternative. It was noted earlier that utilitarianism is a paradigm of this position. It is objective with respect to value language, that is, value judgments are cognitive, epistemologically meaningful, and subject to confirmation as true or false since they are about value experience. But it is subjective with respect to value experience, that is, value experience has no semantic content per se, is not epistemologically meaningful, and can be exhaustively described or translated into nonvalue language. Utilitarianism is a teleological theory of obligation with the greatest good being the end toward which all actions are aimed. It establishes a decision procedure by employing the principle of utility. The teleological nature of utilitarianism is emphasized by its claim that the lightness of actions is to be judged solely by their consequences. The decision procedure is set out quite clearly by W. K. Frankena in saying of utilitarianism: "[It is] the view which says that the sole ultimate standard of right, wrong, and obligation is the principle of utility . . . which says quite strictly that the moral end to be sought in all that we do is the greatest possible balance of good over evil." 3 For the utilitarian, the basis of the decision procedure in moral choice is always simply the principle of utility. An act is obliga-
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tory if and only if it is conductive of the greatest possible balance of good over evil. But immediately there arises the problem of whose greatest good or most useful for whom. Is it to be a monistic or pluralistic utilitarianism? That is, is the utility of an act to be based solely on the interests of the single agent performing the act? If not the agent, yet still monistically, then which individual, perhaps the patient, and how does one determine that? Or is the utility of an act to be based broadly on the interests of one's family, one's community, society, or mankind as a whole? Here an interesting conflict arises between philosophy and medicine. Historically it has been the tradition of philosophy to interpret utilitarianism pluralistically in the manner of Jeremy Bentham and John Stuart Mill as expressed in the popular phrase "the greatest good for the greatest number." Yet in the tradition of medicine, particularly evidenced in the evolvement of the patient-physician relationship, utilitarian concerns have been interpreted monistically solely in terms of what is best for the patient. And this has been codified in the canons of medical tradition and accepted as common law. This, nevertheless, raises some interesting possibilities when the patient's interests conflict with the interests of society or of mankind in general and with the interests of the physician in particular. Of course ideally the interests of the patient and physician would coincide. But this is sometimes not the case. An example of this utilitarian conflict comes over the prescribing of oral contraceptives. Monistically, on a one-to-one basis of the best interest of the patient a physician might not recommend oral contraceptives because of possible side effects or unknown long-term risks, but pluralistically on a broader view basis he might prescribe oral contraceptives because of a recognition of the need to control population, etc. From this arises the problem of who is the patient. A physician cannot isolate himself to a patient. He is always also in a moral relationship to the family and others, as well as to the community, society, and mankind as a whole. The physician is more than just a physician and functions in more than one role simultaneously. He cannot completely segregate these functions and have each act independently of the other. To do so would be to become schizophrenic, for frequently the different roles compete and conflict. The physician is also a researcher, civic leader, hospital director, citizen, and taxpayer—at least, often one or more of these. But again, specifically with respect to the case of Mr. Graham, consider how the utilitarian physician would decide whether or not he should do the neurosurgery. Since the principle of utility is his ultimate ethical principle, the decision is reduced solely to determining which alternative presents the greatest possible balance of good over evil. Such determinations are difficult, and no ready calculus is available for weighing conflicting interests. Conflicts of interest were seen to be the source of the
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monistic-pluralistic distinction in utilitarianism. Of course, sometimes, even frequently, the two interpretations would arrive at the same end decision since the common good and the good of the individual sometimes coincide. But such is not necessarily the case. As a result, consider the case of Mr. Graham from both perspectives. Assuming that the interest of the patient is the sole consideration of the monistic utilitarian physician, conflicts of interest will then not be taken into consideration. As a result, in the case of Mr. Graham a monistic utilitarian physician would quite likely decide not to do the neurosurgery since due to the deep location of the tumor it would leave a speech deficit, partial paralysis, and generally poor quality of life without significantly altering the ultimate resolution of the case. In essence it would involve sacrificing quality without gaining quantity, that is, it would leave the patient in worse shape than he was found in initially. As a result, the consistent monistic utilitarian physician would conclude that solely on the basis of the interest of the patient the tumor was inoperable but that cobalt therapy should be initiated in order to give the patient at least a thread of hope and the feeling that something was being done. On the other hand, a pluralistic utilitarian physician would take many other broader considerations into account. The interest of all relevant parties would be taken into consideration. This raises the additional problems of determining who counts as a relevant party as well as how to resolve the inevitable conflicts of interest. But on the whole the decision chosen must be the one which presents collectively the greatest amount of good, that is usefulness, for all concerned. This differs drastically from the monistic utilitarian position. As a result, in the case of Mr. Graham a pluralistic utilitarian physician would quite likely decide to do the neurosurgery since to a certain extent in terms of total utility more stood to be gained than lost. The reasoning would likely run as follows. Due to the deep location of the tumor and the inevitable resolution of the case, little stood to be lost, even with respect to the patient—at most, only a few months of speech and certain voluntary muscle movement, which is only a fraction of one percent of his total life span and which would have become of progressively poorer quality anyway. Yet considerable utility stood to be gained from many aspects. First, the patient, who came expecting treatment, would gain the feeling that everything possible was being done. And the family would gain the sense of satisfaction of knowing that they had unquestionably provided the maximum support of their loved one even to the extent of sacrificing thousands of dollars for extreme and last-resort therapy. Also, they would be spared the agony of waiting for their loved one to die with a feeling of helplessness and hopelessness that nothing could be done. Then the physician would gain financially, a consideration perhaps not too significant for a sensitive and compassionate physician but one, nevertheless, too frequently taken into consideration.
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For a detailed description of this position, see Self (1975a). For the foundations of the empiricist epistemology, see Hall (1952, 1961) and Adams (1960). 5
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Also the economics of the hospital favor keeping a high patient census. For an 800-bed hospital the overhead operating expense is about the same for 500 patients as it is for 800 patients. Furthermore, the case occurred at a teaching hospital which would gain valuable teaching material if the surgery took place, both in terms of experience for trainees and in terms of materials and accumulated data. Similarly, research laboratories would gain from the availability of scarce human tumor tissue with which to do theoretical work, as would the practical clinical research of the cooperative brain tumor study group. When viewed from broader considerations, it seems that more utility would be gained from doing the surgery. Third, consider the purely objective alternative. It was noted earlier that the position known as value realism is a paradigm of this alternative.4 Value realism is a subclass of realism. Basically, realism is the position that an object of knowledge is independent of the knowing of it. This is what makes it an objective position. A realistic or objective theory of value holds that value judgments are of and about an external, independent reality and that normative value requirements exist regardless of whether or not they are acknowledged. It does not incorporate or endorse an ultimate ethical principle as its foundation, such as utilitarianism does with the principle of utility or existentialism does with the principle of freedom. Value realism contends that value experience is knowledge yielding and that value judgments make truth claims about the world which in some sense obtain of the world. This means that there are imperative features and normative requirements in reality. It holds that both value language and value experience are objective and that what is grasped or known by value experience is not grasped or known by any other mode of experience, that is, value language is uniquely groundable through value experience to the structure of reality and cannot be reduced to language grounded through any other mode of experience. All this permits the central contention that statements about value and obligation are empirically verifiable descriptions of reality. But this involves the formation of a nonnaturalistic position of value realism with a somewhat novel twist. The novelty comes from the fact that generally value realism has been considered to hold a rationalistic, as opposed to empiricistic, epistemology, whereas this version of value realism advocates a thoroughgoing empiricistic epistemology.5 This empiricistic epistemology serves as the foundation for the empirical basis of ethics. Briefly, this version of value realism is the position that: (1) Value experience is epistemic in character, and (2) value experience is ontologically significant. A corollary of this is that value experience is supervenient upon
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For the details of the arguments alluded to, see Self (1973, 1974, 19756). These claims are crucial to the establishment of the value realist position. For the details of the arguments, see Self (1974). 8 This point is established in Self (19756). 7
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cognizance of facts. These contentions are the heart of value realism. The details of arguments for these contentions have been given elsewhere.6 It is crucial for value realism to determine whether an emotion may be said to be correct and justified or incorrect and unjustified over and above the correctness of the agent's factual beliefs about the circumstances which mediate the emotions. Value realism contends that an emotion can be unjustified even though the agent correctly discerns the factual circumstances because he mistakes the value requiredness involved in the facts. If emotions are subject to such rational appraisal in their own right, they can be regarded as cognitive, for cognitions are subject to the epistemic concepts of rational appraisal. It is generally recognized that value language involves the language of emotion, attitude, volition, etc. In view of this the nature of this mode of experience becomes central in any claim of moral knowledge. If one accepts the scientific descriptive-explanatory account with the sensory mode of experience as the only way to obtain legitimate, valid knowledge, one automatically rules out the very possibility of value knowledge. In other words the possibility of value knowledge turns upon an epistemological analysis of emotive and volitional experience. In another place I have argued in detail that several considerations support the claim that value experience is epistemic in character and ontologically significant.7 A corollary to the claim that value experience is both knowledge yielding and ontologically significant is that value experience is supervenient upon cognizance of facts. This also has been argued in detail elsewhere and need not be repeated here.8 Suffice it to say that values have a status parallel to facts, but they are integrally tied to the presence of the facts that obtain in the situation. Change the factual reality and the corresponding value involved is changed. With this explication of value, value is parallel to fact as a category of reality. Value may be supervenient or dependent upon facts, but it is a separate entity from facts and cannot be reduced to facts. Only the fact that an act has other specific properties makes it an obligatory act. One does not abstractly perceive goodness and Tightness. Rather, one discerns the goodness or Tightness of a situation as a result of perceiving the nature of the situation through the characteristics it possesses. It is the ascertainment of the factual properties on which the normative relationships depend which determines when a value concept is properly applied, even if the value concept cannot be reduced to nonethical or merely factual properties. That is, one cannot simply assert 'x is good' without being prepared upon request to provide some reasons which
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This decision procedure for medical ethical problems is elaborated in Self (1974). 29
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support the claim as being justified by some particular facts. For the realist it is the facts plus the requirements grounded in them that serve as the basis of evaluations. All this emphasizes how factual curcumstances play a formative part in value judgments. For value realism value judgments are grounded in experience. It is the characteristics in the factual circumstances which determine the value and not just the attitude of the agent. This is why the agent can make mistakes and misinterpretations of the value in the situation. Mistakes can only be made if there is something to take incorrectly. This is part of what is meant by value experience being objective. It is corrigible. And it is this corrigibility of being subject to rational assessment and appraisal that makes something locatable in the world or ontologically significant. Again, specifically with regard to the case of Mr. Graham, consider how the value-realist physician would decide whether or not he should do the neurosurgery. He has no ultimate ethical principle upon which to base his decision. So he must develop another means. In another place I have advocated a specific decision procedure for medical ethical problems.9 It is based upon the above theoretical explication of the empirical basis of ethics. Briefly it involves the following. First, identify the moral issue in the situation. Second, gather all the relevant data, that is, the facts of the circumstances. And third, place an interpretation on the data with the best interpretation being the one most coherent with everything else known about the issue. Of course, in the final analysis this involves an immediate and direct intuitionistic grasp of the moral requiredness—a notion which is currently in disfavor but which when properly understood need not be. First, the central moral issue in this case is whether or not one ought to carry out physical intervention in the brain for this kind of deep-situated tumor. Second, the main relevant facts of the situation are that the patient has a malignant brain tumor, that the tumor is located deep in a preferentially inaccessible region, that surgery will leave the patient with a speech deficit and hemiparesis, that without surgery the patient will probably live three to four months, that with surgery the patient will probably live four or five months, one of which will be a hospitalization, that the patient does not have a will or his financial affairs in order, that the patient is seeking help, and that the family is supportive of the patient and wants something done. Facts of the situation which are not relevant in this decision are the economics of a high patient census, the financial status of the surgeon, and the facts that it is a teaching hospital and that the data and human tissue
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REFERENCES Adams, E. M. Ethical Naturalism and the Modern World-View. Chapel Hill: University of North Carolina Press, 1960. Frankena, William K. Ethics. Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1968. Hall, Everett W. What Is Value? New York: Humanities Press, 1952. Hall, Everett W. Our Knowledge of Fact and Value. Chapel Hill: University of North Carolina Press, 1961. Sartre, Jean-Paul. Existentialism. Translated by Bernard Frechtman. New York: Philosophical Library, Inc., 1947. Self, Donnie J. "Value Language and Objectivity: An Analysis in Philosophical Ethics." Ph.D. dissertation, University of North Carolina, 1973. Self, Donnie J. "Methodological Considerations for Medical Ethics." Science, Medicine and Man 1 (1974): 195-202. 30
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would support both theoretical and clinical research. To consider these without patient participation in the deliberations would be to dehumanize the patient, for it would be to treat the patient as a thing and not a person. It would violate the Kantian imperative to act always only so as to treat a person as an end in itself and never as a means. Third, the interpretation of the above data which fits most coherently with other things known about the situation, such as that the man needs a clear mind and speech to get his affairs in order and that no clearly established malignant glioma has ever been cured, surgically or otherwise, etc., is that the neurosurgery should not be done. That the surgery should not be done is seen directly from the facts of the situation and does not involve any mystical or infallible revelation. In fact, fallibility is what makes this position viable—it can get value questions right, and it can get them wrong. Intuition simply means direct and unmediated. The intuitionistic grasp of the moral requiredness in this case comes directly from the facts of the situation and is not mediated by some ultimate ethical principle. This alternative allows one to use common sense and experienced clinical judgment and to balance conflicting interests in a humanistic way which does not degrade patients to the status of a thing. It permits taking utility factors into consideration along with all the rest but simply does not overweight or exclusify them. At the same time, it maintains the autonomy of the physician and freedom of decision on an individual case basis. In conclusion, it might be noted that what is most likely the case is that we are guilty of sometimes operating from within one alternative methodology and sometimes from another, which is to say that we are not very consistent. And philosophically, this is a cardinal sin which can be avoided by becoming aware of and paying attention to our underlying value position.
Donnie J. Self Self, Donnie J. "An Alternative Explication of the Empirical Basis of Medical Ethics." Ethics in Science and Medicine 2 (December 1975): 151-66. (a) Self, Donnie J. "Objectivity and Value Superveniency in Medical Ethical Decision-Making." Ethics in Science and Medicine 2 (December 1975): 145-50. (b) Self, Donnie J. "Inconsistent Presuppositions of Dewey's Pragmatism." Journal of Educational Thought 10 (August 1976): 101-9.
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