"I 'm sick of reading things about ethics, why should I read another one? Here's a whole issue of Pediatrie Annak on ethics! I've always been ethical, and I'm tired of being preached at!"
Of course you're ethical! Who would have ever thought otherwise? All doctors are ethical. They have to take the Hippocratic oath that begins, "On my honor, I will do my best. . ." Sure, there are a few quacks, occasional charlatans, and even a few who distort the system to make outrageous amounts of money. But even those physicians aren't really unethical, they're just - well, you know - taking advantage of the system. On the other hand, lawyers are a different matter. Not the ones that I know, but I read all the time about the sleazy things that lawyers do, and how they defend those people who are clearly guilty, now that's unethical. And when lawyers get together with businessmen, well, 1 don't think that there are any ethical businessmen either. Together with lawyers, well, Tm hardly sure any more what's ethical and what's not. Maybe if it's legal, it's OK. People will do just about anything to make money these days.
No one worries about doing the right thing; all they want to do is make money. That's even getting to be true of medicine. We used to treat the poor for free because it was the right thing to do. Now with all the regulations and the pittance we get paid by medical assistance, well, it hardly pays. . . I guess that's why we need all those medical ethicists, to tell us the right thing to do. It's not that I'm unethical or anything, I've always been ethical, but it's harder than it used to be. I guess the standards have changed or something. I used to know what was moral and what was immoral, but now all 1 know is that they don't do things the way they used to; I guess that's immoral. It isn't the way I was brought up.
There! That should take care of most of the old cliches, biases and prejudices! Now, let's go on to something useful.
A politically correct attitude has arisen amongst the "cognoscenti* toward terms such as "paternalism* and "beneficence," toward "the handicapped" and the "underprivileged," and toward "death and dying." What I have tried to do in this issue is to take a "contrarian" perspective on some of the issues facing us today. I have deliberately asked the authors of these articles to abjure the "politically correct" and "ethically correct" approach to these topics and to present a different bias and perspective, that of the practicing pediatrician. The purpose of these polemics is to make you think, argue, agree or disagree, and hopefully to discuss your thoughts with others. It is not their purpose to persuade, inform, or give "correct" answers.
The teaching of ethics is not the process of giving "correct" answers. However, neither is it allowing everyone^ opinion to stand unchallenged. It is my bias that the teaching of ethics is the teaching of a process by which we test - either some, most, or all - of what we do against the reasons that we do it and against the standards and mores of society, in order to assure that our actions are within the currently acceptable standards - to assure that we are acting in an ethical manner.
There are some actions or proposals that all of us would clearly agree are unethical. They are clearly outside the boundaries of what society finds acceptable. Some of these actions are illegal, others are merely immoral or unethical. You are supposed to know when things are illegal, at least that is what the law says. How do you know if something is immoral or unethical? Is there a difference between immoral and unethical? I have asked Dr Kevin McDonnell of St Mary's College and coauthor of Tougfi Decisions: A Casebook in Medicai Ethics to begin this issue by addressing the question, "How do you know if you're ethical?"
There are many times when the ethics of an issue or an action are unclear, when society is still debating and sorting out its feelings. We hear discussed frequently issues such as maintaining people on respiraors when there is no hope of recovery; issues of futility; of the right to treatment; questions about the proper roles of paternalism and autonomy; about who is to decide, and who is going to decide who will decide. These are classically thought to be the "big" ethical issues. When you begin to think in ethical terms, however, there are myriad other ethical issues that confront (or should confront) us everyday. For example, if there is a laboratory in your office, is it unethical to order a throat swab and a complete blood count? Is there a difference if you make a profit on the test, or if you only do it as a service to your patients? Studies show that when available and profitable, physicians are more likely to order those tests. Does this represent an ethical problem? Should it be an ethical problem? How about the big ticket items such as computed tomography (CT) scans, magnetic resonance image (MRI) scans, or positron emission tomography (PET) scans? Is it an ethical problem if the physician owns or invests in these very rewarding pieces of equipment?
One physician told me that he couldn't see enough patients to make a living if he gave each new patient the hour a new patient required. But, if that same physician then ordered an electroencephalogram (EEG) and a Doppler flow study, or an MRI scan, then that initial visit could be underwritten by the profits from the ancillary tests. Needless to say, he owned that equipment. I was recently asked if I knew someone who could be recruited to a moderate size hospital to set up an epilepsy center. "We have a new PET scanner," the medical director told me, "and it could be a gold mine if used properly." Are these activities unethical? Or merely pragmatic? It is clear that they are common. Dr Lawrence Pakula, a practicing pediatrician and a former president of the Maryland Academy of Pediatrics, addresses some of these common ethical problems from the view of an ethical pediatrician.
Perhaps the main ethical problems are the things we do each day with each of our patients, our residents, and our colleagues. Should we ask if it is ethical to perform surgery on a handicapped, retarded child purely for cosmetic reasons? Is it politically incorrect to even ask the question? Is it justified to do bone marrow transplantation on the child who has a degenerative brain disease if the chance of cure is small? How small? Can I let Johnny stay an extra day in the hospital because it's difficult for his mother to get in today? Medicare will pay for it. In Mary's case, should the fact that her family has no insurance affect my decision? What do you do if Charlotte's mother doesn't want her daughter to have the pertussis vaccine, or if Robert's dad thinks he's too uncoordinated and wants him examined and "tested" with MRI and BEAM (electroencephalographic brain mapping)?
How paternalistic should the pediatrician be in directing the medical care of his patients? Should he or she insist on immunizations over the opposition of the parents? Do parents want their pediatrician to be paternalistic? Or do they want their pediatrician to allow this autonomy? (Paternalism is currently a pejorative word used by consumers to keep the medical field in its proper place while autonomy reigns supreme in the ethical literature.) I have asked Dr Henry Seidel, a former practicing pediatrician, teacher, and former Dean of Students at Johns Hopkins, to write his thoughts on the role of paternalism in the practice of medicine. Dr Seidel is one of the most paternalistic physicians that I know, in all the most fatherly senses of the term. He is my personal model of what a pediatrician should be.
Perhaps society at its most paternalistic is represented by the child abuse teams set up to assure the well-being of the child and the family. While prevention of child abuse is clearly a role of the state, when is it applicable? Are there situations where ethics and the law can be in conflict over an abused child? 1 have asked Dr Lawrence Wissow, a pediatrician who heads the child abuse team at Johns Hopkins, and Ms Peggy Mainor, assistant state's attorney for the Baltimore City Child Abuse Unit, to address the situations where advocacy might not be in the best interests of the child or family, and situations where ethics and the law might be in conflict.
In most everything that we do (or don't do) in medicine, there is an ethical aspect. We clearly do not have time to debate, discuss, or even to think about these myriad decisions at the time a crisis occurs. But if we think ahead about some of the problems, when we have the time and leisure to reflect and perhaps to discuss the ramifications, then we are more likely to be sensitive as we almost reflexly make the decisions daily. I look on the teaching of ethics as being similar to sandpapering my student's fingertips. The student or resident is more likely to find the correct combination if he or she has been sensitized to the issues. In many of these situations, there are not correct answers, but there is always a correct process for making an ethical decision. That process involves being sensitive to the messages, feelings, and needs of everyone concerned, being certain that all of those involved have been heard and that a consensus has been reached, and that this consensus recognizes the biases and prejudices of the decision makers and those of the "minority." When the decision is unusual, counterintuitive, or contrary to the opinions of anyone involved, the process requires outside review by colleagues, an ethics committee, or an ethicist. On rare occasions, as suggested by Dr Stephen Ashwal and his colleagues, the courts may have to be consulted.
It is, of course, impossible to even consider covering all or even the most important ethical issues in a single issue of Pediatric Annals, but I hope that after reading this issue, if nothing else, you will have been provoked, irritated, or satisfied that you are ethical, or any combination of these. At least I hope that your fingertips are quite sore.