Medicine's Intrinsic Good1
The Center for Bioethics and
Human Dignity
9 September, 2003
Reproduced with permission
What is good medicine? Who counts as a good
doctor? These are very large questions that cannot
be fully addressed here. I want to focus on a basic
aspect of these two questions and on the ethical
idea of "the good." The term "good medicine," as I
have just used it, is not intended to be contrasted
with "bad medicine." Rather it is meant to bring to
the fore that medicine is something good in itself,
a worthwhile and honorable human activity, a
"profession" with a specific object of activity, a
human good, to which so many men and women devote
their lives; an endeavor full of value and capable
of fulfilling a person's life with interest, effort
and achievement. Medicine is something noble and
laudable; both a good and an excellence. This good
of medicine is what medicine is about, what it aims
at; that which makes medicine to be medicine rather
than law, or politics. Let me call this good the
medical good.
Ethics is concerned with "the good," described by
Plato as "the aim of all endeavour."2
His follower, Aristotle, tells us in his Ethics that "every art and every
investigation…aims at some good"-and adds-"since
there are many actions, arts and sciences, the aims
turn out to be many as well; health is the aim of
medicine…."3
Since ancient times the particular good with which
the medical endeavor is concerned has been focused
on one word, "health." Currently, the traditional
goals of medicine concerning health may be
formulated as follows:
- To restore the
sick patient to health: aiming to cure.
- To alleviate the
patient's distressing symptoms-when health
cannot be restored-aiming to comfort, to offer
palliative care.
- To promote health;
to prevent illness.
But we may add that these overall good ends or
"good" are concretely realized in the core of
medical practice, namely, "the doctor-patient
healing-caring relationship." What is involved
in the reality of this human relationship is what
makes medicine "ethical," a moral activity, a praxis, an activity with its own intrinsic
moral worth. In other words, medicine is
intrinsically ethical because of the good at which
it aims, i.e., its ends or goals. Hence, the moral
norms to be followed to attain it, the excellence of
character required of its practitioners for its
realization, as well as the right activities that
accomplish that good, are constitutive of medicine
itself.
Ethical aims, norms, principles, excellences of
character and activities are the various dimensions
of medical practice, and they constitute the subject
matter of medical ethics. It is my contention here
that we can take the core of medicine to be the
"doctor-patient healing-caring relationship," and
that in this core (the "medical good") we find the
medico-ethical teachings are derivable from the
nature of the healing relationship. We cannot
understand medicine without its ethic, we cannot
understand medical ethics without an appreciation of
the nature and meaning of medicine. This is the
foundation for my claim that medical ethics is a medicine-based ethic.4
Clearly, this idea of medicine as intrinsically
ethical determines the approach to the teaching of
medical ethics. In what follows I seek to illustrate
that this idea of medicine is Greek in origin and
character, as handed down to us by the Hippocratic
school, and that it has a transcultural and
universal significance. By "Hippocratic medicine" I
mean that kind of medicine, which can speak
"timelessly" to doctors, and patients of all
cultures precisely because its core is the
relationship between the doctor and the sick, the
one to be healed, the patient, a relationship, which
remains basically the same for all places and times.
I claim, with the Hippocratic physician, that the
meaning of this relationship (as with all true human
relationships) is ultimately moral. It embeds a
recognition of, and fellow feeling for the other,
because he or she is a human being, a morally
self-governed and bodily being. It is upon this
recognition that medicine as a
healing and
caring activity is founded and has
developed as a professional body bounded by its own
professional ethical code.
Approaches to Medicine
and to Biomedical Ethics
I am aware that by affirming that medicine is an
intrinsically ethical activity, and hence that
medical ethics is a medically based ethic, I am
going against some current conceptions of medicine,
which may be classified under the umbrella of
"technocratic medicine." Hence the position outlined
here does not accord with the approaches to medical
ethics that accompany those conceptions. Let me
briefly dwell on this point.
Medicine is currently
being regarded by some to be a morally-neutral
activity, value free, like science or
technology. Doctors, some defend, are primarily
scientists rather than healers, equipped with a
large body of medical knowledge and technical
training. Scientific knowledge and technical skills
are said not to have intrinsic moral goals. What
counts as a "good use" of medicine is not intrinsic
to medical knowledge and techniques themselves, but
rather to the "ethics" of the user. A good doctor
will know how to use those skills well, like any
other technological expert, but his or her ethical
outlook and opinions are independent of them. In
this view, medicine is regarded as a contractual
agreement between doctor and patient on the basis of
the doctor's expertise, but whose "ethical" use
depends on "external ethical principles." Hence, the
use of medical expertise may be seen as divorced
from specific moral goals and from the moral
character of those involved, which may be matters
considered "private" and personal. In this view, the
external ethical principles governing the good
use of medicine are regarded as being derived
from religious codes,5
socially determined customs,6
the law,7
the opinions of the doctor, and/or the wishes of the
patient.8
Conceiving medicine as purely scientific and
technical and value-free is consistent with
much of our current liberal, legal (and not
litigious) cultural milieu. For "the ethical" in our
modern world, that is, what is regarded as good or
evil, has become something relative, changeable, and
very much a matter of individual or cultural opinion
and outlook; it is also something private, or for
some, an intangible non-scientific dimension added
to the objective facts or scientific data and
evidence; it is something independent of history and
tradition; something "pluralistic" since there are
so many varied ethical outlooks; and something that
must be "rationally" validated, and argumentatively
justified, according to a pre-determined standard of
reason. In other words, medicine within this outlook
is considered to be amoral, scientific, a skill or
know-how, a-historical, and hence ethically
pluralistic.
Within the current liberal perspective, the external ethical principle which makes the
"neutral" use of medicine something medically "good"
is the idea of individual freedom, "the right to
choose," freedom to do and implement one's own
preferences. This is the primary ethical principle
in our culture, commonly invoked as "autonomy." In
this social context medicine has become a "service"
governed by market forces, which gives the
patient-now called a "client"-what he or she wants.
The doctor is there to serve the autonomy
of the patient.9
And when this autonomy cannot be exercised, then he
or she has to carry out what is the most
compassionate or benevolent thing to do in
the best interests of the patient, this could
include mercifully killing him or her.
Needless to say the law has become the best ally
to sustain this technocratic conception and practice
of medicine. For traditional medical ethics and
medical practice have been changed by the continuous
chain of judicial rulings and court cases in the
USA, Europe (including Ireland), and Australia. That
is, with this new outlook, doctors are handing over
their ethical self-governance (it seems
that they have accepted that it does not belong to
them), while "society" and "the law" are taking full
control of the medico-ethical domain.10
With the acceptance of state medical services,
doctors' governing bodies may have failed to remind
their members and the State that doctors'
professional duty is subject to their own
professional commitment as a body. In view of this
commitment, doctors cannot be asked by the State-or
any one else-to carry out "health policies" which
would contravene their duty to cure and care, to
benefit and not to harm their patients. Clearly, the
law and lawyers of this new legal climate often ask
doctors to do so. Thus, the new norms become
medico-ethical requirements. If there are doctors,
or patients, who do not agree with these new
judicial requirements, a "conscience-clause" is to
be invoked, and sometimes granted.
This overtaking of the medico-ethical domain by
the law, in many contexts through its lawyers and
lawmakers, is depriving the medical profession of
its rightful ethical self-governance-partly with its
consent, whether implicit or explicit. This amounts,
in my view, to a disintegration of medical goals,
demanding increasing "conscience clauses" to cover
those physicians who cannot professionally agree
with the new legal rulings. This makes the practice
of medicine more and more difficult for them, while
it creates two strands of medicine, a
conscience-governed medicine, and a law-governed
medicine, whereby the truly ethical self-governed
medicine has disintegrated. The legalistic trend in
medicine is also, in my view, a direct attack on the
right use of practical wisdom, of true medical
distraction, of that prudent judgment of the doctor
on the spot, which medical practice requires. Moral
wisdom is "legalistically" destroyed, for the
legalistic trend is entering and changing genuine
moral thinking, genuine moral governance, and
genuine moral acting. I share my concern with those
who conceive our cultural task as a response to our
cultural crisis, which is "intellectual, moral and
spiritual."11
So in view of this crisis, what practical approach
may be suggested in the teaching of medical ethics?
In attempting to answer this question we can turn
our eyes to the original idea of medicine. It is
summarily presented in many of the medico-ethical
codes, which ultimately find their roots in the
Hippocratic Oath, as it has been handed down to us
over two thousand years.12
Looking back to ancient Greece for an understanding
of medicine and its timeless universal nature is not
to have an undue devotion to tradition or history,
nor to disregard the new scientific and
technological era in medicine. It is only to
recognize that the idea and meaning of medicine is a
legacy that we have received, not something that has
been newly invented. By looking at its origins in
history we can better understand and gain a deeper
insight into its meaning. We should allow the
Hippocratic writing to speak for itself. Then we may
ponder the inspirational impact it has laid on the
medical profession for about two thousand years. But
even if we leave this remarkable historical fact
aside, we may be able to recognize the writing as an
articulation of that understanding of human nature
and of medicine that captures its centre, its
essence, its core. This is what I have called "the
medical good," which makes the meaning of medicine
timeless and universal.
The fundamental reason why Hippocratic medicine
can speak timelessly and relevantly to us today is
because our embodied humanity is the same now as it
was in ancient Greece. Hence, the activity of
healing and caring for the sick is essentially the
same; it cannot change, nor can the desire of the
sick to get well. The basic understanding of our
being healthy, as a natural condition of our
embodied selves working-well, is also the same.
Clearly human beings have not invented animal or
human health. Whatever our difficulties in
understanding people of other times, other languages
and other cultures, "we are all products of similar
natural processes and we all live out our lives
under the same skies and this gives us at least
enough in common to recognize each other's humanity…
[I know] that honey tasted as sweet to Achilles as
it does to me."13
Medicine as a dedication to healing and caring is
founded upon our embodied and moral nature, that is,
on our human nature. CBHD
NOTES
1. Adapted from Teresa Iglesias,
The Dignity of the Individual: Issues of
Bioethics and Law, Pleroma Press, Dublin,
2001, pp.20-25.
2. Republic VII, 505e.
3. Nichomachean Ethics,
1094a-8.
4. See (1) above, p. 226.
5. Cf. A.G. Johnson, Pathways in Medical Ethics, Edward Arnold,
London, 1990, ch. 5.
6. Cf. D. B. Black,
"Iconoclastic Ethics,"Journal of Medical Ethics
10:179, 1984, p.82; there a "relativist" view of
medical ethics is portrayed.
7. Cf. R. Gillon, also for a
treatment of (5) and (6), in Philosophical
Medical Ethics, Wiley, 1986.
8. An exponent of the idea that
medicine serves the autonomy of the patient can be
found in M. Charlesworth, Bioethics in a Liberal
Society, CUP, 1993.
9. This is the main thesis
defended by M. Charlesworth in (8) above.
10. In an article in The Lancet
vol. 345 (June 3, 1995), p. 1423, "Cultural Lag and
the Hippocratic Oath" by Eugene D. Robin and Robert
F. MacCauly, in which the medico-ethical value of
the Oath is dismissed, the authors explicitly state
that "it is not physicians but society or women
themselves" who have to decide the fundamental moral
issue of abortion.
11. Cf. Leon Kass, The Hungry
Soul: Eating and the Perfecting of Our Nature, The
Free Press, Macmillan, New York, 1994, pp. 1-16.
12. See version of the Oath as
translated by L. Edelstein, in Ancient Medicine:
Selected Papers of Ludwig Edelstein, Oswei Temkin
and C. Lillian Temkin (eds.), Baltimore, The Johns
Hopkins Press, 1967, pp. 3-63; version adapted by L.
Kass and discussed by him in (1) above, pp.224-46.
13. C. Rhodes, The Necessity for
Love, Constable, London, 1972, p. 234.
Copyright 2003 by The Center for Bioethics and
Human Dignity
The contents of this article do not necessarily
reflect the opinions of CBHD, its staff, board or
supporters.