Koch, Tom

Simon Fraser University Institutional Repository

BMC News and Views (2001) 2:3 http://www.biomedcentral.com/1471-8219/2/3BMC News and Views (2001) 2:3LetterListening to the critics: a response to "Clinical ethics revisited"Tom KochAddress:  Adjunct professor of gerontology, Simon Fraser University, Vancouver, BC. Canada. Research associate in bioethics, The Hospital for Sick Children, Toronto, ON, CanadaE-mail: tokoch@attglobal.netThe signal value of Singer, Siegler, and Pellagrino's arti-cle, "Clinical ethics revisited," [1;  [http://www.biomed-central.com/1472-6939/2/1] ] appears to lie in itsrecognition of the subdiscipline as the authors define it.Certainly, a series of critiques posted with the article [2]question the article's central thrust, that while clinicalethics remains a developing field of medicine that itsgeneral tenants are sound. Most damning, perhaps, isthe original author's admission that, "if the goal of clini-cal ethics is to improve patient care and outcomes, thereis scant evidence this has been achieved." If that is true -and it is a point upon which both critics and authorsagree - then arguing as do Singer et al. for increasedfunding, more research, and a stronger educational pos-ture is at best premature.As Virginia Sharpe notes [2], the clinical ethic espousedby the authors is limited and perhaps incomplete fromthe start. Singer et al. insist that "clinical ethics is notfounded in philosophy, law, or theology but, instead, is asub-discipline of medicine, centering upon the doctor-patient relationship" [1, 2]. This assumes that only thedoctor-patient relationship is important. The authorsthus exclude - critically and I believe incorrectly - notonly other professional "healing relationships" (withnurses, for example) but also those involving family car-egivers and the institutional context in which care is pro-vided for patients and through those caregivers.And yet these often affect not only patient care and well-being, but also clinical decision making. The needs andperspectives of patient surrogates effect, for example,questions of how patients with chronic progressive con-ditions should be treated (ALS, MS, etc.), and of course,the issues of continuance for those in a coma or a persist-ent vegetative state. A clinical ethics defined as involvingonly doctor-patient relationships is thus necessarily in-complete and limited from the start.The assumption that clinical ethics is easily divorcedfrom either philosophical or legal issues is similarlyproblematic. This "clinical-not philosophical, social, orlegal" approach may explain the limits of the approachthe original authors advance. The social perspectives ar-gued in general bioethical appraochs, the social restric-tions presented in law and the general views ofhumanness and personhood advanced by theologians(and philosophically trained ethicists) all directly affectclinical medicine and the ethics of its practice. Proce-dures ranging from therapeutic or elective abortion, topalliative care or treat modalities for patients withchronic progressive conditions (MS, ALS, etc.) are atonce clinical, philosophical, legal and theoretical prob-lems requiring broader rather than narrower address.Indeed, it is precisely because of the interplay betweenclinical decision making and social concerns that bioeth-ics first was created. In the 1960s, for example, a purelyclinical ethic was incapable of addressing the rationing ofdialysis facilities among the many patients then under-going dialysis in the USA. It was this debate that intro-duced moral philosophers as clinical commentators tothe greater public [3]. Things haven't changed overmuchPublished: 6 July 2001BMC News and Views 2001, 2:3This article is available from: http://www.biomedcentral.com/1471-8219/2/3BMC News and Views (2001) 2:3 http://www.biomedcentral.com/1471-8219/2/3in the intervening two decades. If appropriate outcomesare unclear socially or counter-indicated by law, thentheir clinical implementation will be problematic [4].There is in the original article - but not in the critiques of-fered to date - a general refusal to acknowledge the im-portance of the social context in which medical decisionmaking occurs. Here, Benetar's comments [5] are espe-cially damning, and worth quoting: "The growth ofbioethics has taken place in an era when medicine, par-ticularly in the USA, has been transformed into a busi-ness, and health care has been commodified andbureaucratised." This may explain why, there has been a"loss of trust in health care professionals." Why trustthose whose relation to the patient is in fact defined bycommercial relations rather than historical associationsof care and caring? And it may be that the commodifica-tion of health that has affected clinical outcomes by af-fecting treatment decisions. It almost certainly hasaffected patient-health professional relationships.Contemporary medical ethics is redolent with cases inwhich the needs of the patient are opposed by the oftencommercially defined practice guidelines of hospitalsand funding agencies. In his critique Daar cites the Gels-inger case, "in which a teenager died while undergoinggene therapy in the hands of researchers who allegedlyhad conflicts of interest and failed to report to the au-thorities important previous research data that may havecontributed to the fatal outcome [6]".Another case in which the primacy of patient careseemed to have been suborned by commercial issuesdrives home the point. At the Hospital for Sick Children,in Toronto, Canada, the Olivieri case saw a physician os-tracized and condemned for publicly announcing thedangers of a disease she was testing among juvenile pa-tients with Thalassemia Major [7]. Dr. Olivieri arguedthat as a physician her primary duty was to her patients,not the drug company that funded her work or the hospi-tal that employed her [8]. For this she was suspendedfrom her work by the hospital.Singer et al. lament the failure of public engagement byclinical ethicists. But the truth is that too often those in-volved in clinical policy do not wish public dialog at all.This was underscored when the Cleveland Clinic Foun-dation's sought to implement a non-beating heart proto-col - commonly known as the Pittsburgh Protocol - in the1990s. It was done without public input, or apparently,legal review. The program was terminated after an inves-tigation by the local prosecutor's office became a nationalissue. The use of specific drugs to facilitate organ extrac-tion from respiring patients was seen as potentially ac-tionable under state homicide statutes.A CCF bioethicist, arguing the clinical efficacy of theplan, later described this as the imposition of unwantedand unnecessary public and legal attention to a funda-mentally clinical issue. If clinically sound protocols wereso treated, CCF ethicist George Aggich argued, "The fu-ture of bioethics may be not in the media spotlight, but inshadows where the quality of everyday patient care is en-hanced [9]." What Aggich ignored was both the socialand legal climate in which medical protocols exist. AsAnkney notes, public perception has a real effect on do-nation [10, for example. The problem was not, in the end,with public exposure but with the institution's failure toinvolve interested parties - local citizenry and their rep-resentatives - in a dialog over policy [11] with profoundclinical and social implications.It would seem from this and the other critiques offeredby readers of the original paper that a methodologicallybased clinical ethics is a failure. It has served the needs ofprofessionals but not the patients, or their carers. It thusin too many cases ignores the social context in whichmedicine is practiced and in which patients receive or aredenied care. It ignores, in the original authors' formula-tion, the broad complex of healing relationships thatcontribute greatly to a patient's condition, and often hisor her medical outcome. If clinical ethics is, in fact, a sub-discipline of medicine, it is one that necessarily must in-volve social, legal, and sometimes theological percep-tions.In the end, clinical ethics needs to be redefined in a man-ner that acknowledges that medicine is more than meth-odology, that patient outcomes result from a complex offactors extending beyond the "doctor-patient relation-ship." Before the subdiscipline can evolve into an effec-tive perspective it therefore must engage the complex ofeconomic and social factors influencing patient healthand well-being.References1. Singer P, Siegler M, Pellegrino E: Clinical ethics revisited. BMCMedical Ethics 2001, 2:1 [http://www.biomedcentral.com/1472-6939/2/1/] 2. Benatar S, Bhutta Z, Daar A, Tony Hope, MacRae S, Weiss RobertsL, Sharpe V: Clinical ethics revisited: Responses. BMC MedicalEthics 2001, 2:2 [http://www.biomedcentral.com/1472-6939/2/2] 3. Alexander S: Thirty years ago. In, Albert R. Jonsen, Ed. The Birth ofBioethics (Special Supplement). Hastings Center Report 1993, 23:S54. Koch T: Living VS Dying 'with Dignity' A new perspective onthe euthanasia Debate. Cambridge Quarterly on Healthcare Ethics1996, 5:50-605. Solomon R Benatar: Promoting national and international jus-tice through bioethics. BMC Medical Ethics 2001, 2:16. Daar AS: Failure of clinical ethics to deliver on its promise.Clinical ethics revisited: Responses. BMC Medical Ethics 2001, 2:2 [http://www.biomedcentral.com/1472-6939/2/2] 7. Mandel M: Nancy and Goliath/Sick Kids' Doctors Battle withDrug Giant is Anything but Black and Whit. Ottawa (Ont.) Sun1998, 8:8. Oliveri NF, Brittenham GM, Mclaren CE, et al: Long-term Safetyand Effectiveness of Iron-Chelation Therapy with De-BMC News and Views (2001) 2:3 http://www.biomedcentral.com/1471-8219/2/3feriprone for Thalassemia Major. New England Journal of Medicine1998, 339:417-4239. Aggich G:  From Pittsburgh to Cleveland: NHBD Controver-sies and Bioethics. Cambridge Quarterly of Healthcare Ethics 1999,8:269-27410. Ankeny , Rachel A: Recasting the Debate on Multiple Listing forTransplantation Through Consideration of Both Principlesand Practice. Cambridge Quarterly of Healthcare Ethics 1999, 4:330-339Publish with BioMedcentral and every scientist can read your work free of charge"BioMedcentral will be the most significant development for disseminating the results of biomedical research in our lifetime."Paul Nurse, Director-General, Imperial Cancer Research FundPublish with BMC and your research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours - you keep the copyrighteditorial@biomedcentral.comSubmit your manuscript here:http://www.biomedcentral.com/manuscript/BioMedcentral.com

Listening to the Critics: a Response to "Clinical Ethics Revisited"

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