This article was originally published in the Turkish Journal
of Medical Ethics, Vol. 2, pp. 53-56, 1994. Please see our Pioneer
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The Universal Ethic of Mutual
Benefit
Philip
G. Ney, MA, MD, FRCP(C), FRANZCP
Pythagorus
and Hippocrates
Pythagorus
groaned as he rolled over on his pallet in his villa with a view
of the sea. "Where is that wily old physician?
Why doesn't he come? Surely he must know about my pain.
I wonder what he has for me? I don't really trust him.
I suspect that my wife, who now has a young lover and wants my
estate, has paid him to give me hemlock. Physicians now
a days believe they have a duty to either cure the patient or,
if not, kill them as mercifully as possible. They believe
that since the gods have cursed us and we are going to die, why
shouldn't they do something mercifully quick. Unfortunately,
many of my old friends have gone before they wished because somebody
has wanted them out of the way."
"There
you are you old codger. Moaning and feeling sorry for yourself
won't make you better. Here, take this. It is the
latest medicine imported from a reputable pharmacy in Alexandria."
Pythagorus
was even more suspicious. "Don't call me an old codger,
and don't expect me to believe that line. Don't try any
of your persuasive arguments. I know the more cogent you
sound the more unlikely your story. You'll just try and
tell me something that is good for me because you think that your
greatest help is in making me feel optimistic even when your real
intent is to send me on my way.
Hippocrates
had spent a long night with another dying patient and then in
long discussions with his students in the morning. He was
understandably impatient, but he tried not to let it show.
"I'm sorry I insulted you. You are a wise old mathematician,
well respected by your students, and will undoubtedly go down
in history as one of the greats. But you can trust me.
When have I ever let you down."
"Now I
am absolutely sure my wife has given you a fat fee to do me in
and get the estate. Just get out of here."
Hippocrates
was beginning to lose his cool. "I'll leave you alright.
But not before I remind you that you have never properly paid
my fee, and not before I give you a piece of my mind, and not
before you take this medicine. You unrepentant old sinner.
By Zeus, by Jupiter, by Mercury and the whole Pantheon I swear,
as do my colleagues, I will not poison you. We have also
stated we will not abort women and we will not take advantage
of patients by having sex with them. Now take this before
I sit on you and force it down your throat."
Pythagorus
had never seen his old friend quite so angry nor had he heard
him swear so much. "O.K. I'll prevent you from
the recriminations of guilt in having killed me trying to make
me feel better." Glug, glug...
Some moments
later. "You are right. I do feel better and maybe
I can trust you. Do you really mean that part about not
aborting or having sex with patients?"
"Yes,
my colleagues and I have banded together in making an oath we
will not break less the gods vaporize us with a bolt from heaven.
We have sworn we won't poison anyone because we know relatives
often lean on doctors to hasten their demise. We won't abort
women because we know the State, in its perverted self interest
has often wanted to limit population for the benefit of the haves
who fear the intrusion of the have-nots. We won't have sex
with or take advantage of any patients because we fear that tendency
within our profession. I can tell you, having made this
oath, medicine has become a lot easier. Apart from a few
curmudgeons like yourself, patients are much more cooperative.
Who knows, eons from now patients may actually begin to trust
doctors. Yet, in my bones, I suspect the tendency of doctors
to destroy themselves and their profession. Someday they
will probably throw this good oath away in favour of ethics by
committee."
The
Basic Problems
Humanity has
often tried to achieve security and immortality by a whole series
of devious arguments.
1. Denial.
We want to pretend we are not ignorant, disabled, dying or mentally
ill. The facts are all of us lack wisdom and knowledge.
We all have some disability (mathematicians can't carry a tune
and musicians cannot lift heavy loads). We are all dying
(sooner than we wish, aging will overcome the processes of regeneration).
Because of subconscious quirks we are continually undermining
our best interests and recreating tragedies for ourselves and
others.
2. False Dichotomies.
With the assistance of the on/off mentality of the digital computer,
we have been able to divide and segregate people. Thus we
can convince ourselves we are not one of that sick, deranged,
dying, or handicapped group of people. We are not mentally
ill because we are not in a mental hospital. We are not
dying because we are not eighty years of age. We are not
disabled for we do not have an observable mental defect or physical
deformity that requires special assistance. We are not ignorant
for behold, look at the size of our library. The unavoidable
fact is that all aspects of life are on an continuum as is every
other observable phenomena in the universe. We are all part
of the bundle of life and differ only in degree on some measures.
We have far more similarities than dissimilarities, even with
the most obviously handicapped person.
3. Limited
Resources. We prefer to believe that there are limited resources
and thus feel justified in getting rid of many of the have-nots,
lest they sink the boat of the haves.
Yet, the universe
appears to be limitless and expanding. We only lack the
courage to pool our resources and sharpen our technologies so
we can colonize the stars.
4. Wanted Children.
It is argued the first right of every child is to be wanted.
This apparently plausible philosophy stated with a short sentence,
is the death sentence for millions of people, particularly those
pre-born. For if this is so then anybody who is unwanted
has no right to be. It may seem surprising that being alive
because you are wanted is in itself a sentence to a life of misery.
Trying hard to stay wantable but suspecting your siblings and
your peers died because they were not, without any real difference
being between you creates deep doubts and fears. Wanted,
chosen children have; 1) survivor guilt (an impending sense of
doom or feeling you don't deserve to be alive), 2) existential
anxiety, 3) ontological guilt (a feeling that you are not using
your potential because you are never sure how long you will exist),
4) distrust (difficulty in trusting those who state they love
you when your parents have terminated others for your benefit),
5) inhibition (a need to monitor your thoughts, questions and
expressions lest you break the collusion of pseudo-secrets about
what happened to your siblings), 6) anxious attachment (difficulty
attaching to your parents or making a key commitment to anyone),
7) self doubt (a tendency to doubt your parents who doubt themselves
and doubt you, and therefore you doubt yourself). Our research
has found that where there is more abortions there is more child
abuse and lessened partner support.
These arguments,
attempting to maintain immortality and security, have resulted
in; 1) rampant euthanasia, eg. in Holland 44% of old people die
directly or indirectly at the hands of their physicians,
2) 60x106 abortions because of inconvenience, wrong sex, disability
and increasing sexual misconduct and 3) physicians taking advantage
of the patient's dependency and having sex with them, declaring
it was for their benefit.
The net effects
of ignoring Hippocrates are;
1. Patients
distrust doctors. Consequently;
a. the
cost of medical care increases because there are more malpractice
law suits,
b. there
is an increase in premiums for malpractice insurance,
c. doctors
have to practice defensive medicine and order many unnecessary
tests,
d. more
children are born by caesarian section because doctor's fear law
suits brought on by mothers who might see some imperfection in
their child.
2. Doctors
must spend more time convincing patients to cooperate. This
means doctors see fewer patients and must charge more per patient.
3. There is
increasing pressure to hasten or allow the death of those who
have a "lower quality of life." This is a superficial
cover for selfishness. The haves demanding of the have-nots
even more. As medical costs increase there is increased
pressure for euthanasia and eugenics so that there will be enough
resources for the middle aged to have MRI's, cardiac transplants,
etc.
4. Patients
will no longer cooperate as a result of trusting their doctor,
but they might if they like their doctor. Doctors feel they
need to be popular with their patients and therefore tend to accept
politically correct morality. This is often created by the
press (eg. people want abortion on demand).
All of the
above tends to create a vicious cycle. Doctors are continually
attempting to adjust their ethics according to changes in the
morality of their pluralistic society while the patients are trying
desperately to find out what their doctors really believe in order
to know whom they can trust.
Basic
Tenets.
1. We believe
that Truth is unitary. There cannot be a division between
science and ethics, otherwise there will be continuing conflict
and no guidance provided for those who must make decisions daily
about the existence of other people.
2. We must
learn from history, because if we do not we will repeat it.
We must recognize that as we treat the most limiting infected
part of the body for the benefit of the body, so we must care
for those who are designated as the lowest and the poorest because
they are part of us.
3. We are all
part of the bundle of life. What happens to others happens
to us because we are intrinsically united.
4. The Universal
Ethic of Mutual Benefit (U.E.M.B.) reminds us that we cannot benefit
at the expense of our neighbour. If it is not good for him
it is certainly not good for us. If it is not good for a
woman it is not good for a man. If it is not good for the
unborn baby it is not good for the mother. Science basically
supports this proposition.
We are all
a part of the continuum, the bundle of life. The vertical
continuum shows that humans exist from conception to death.
The horizontal continuum shows that we are all much more equal
than dividing and categorizing allows us to believe.
Ethics must
be supported by science and vice versa. If philosophy disagrees
with science there will be continuing confusion for a practising
physician.
Applications.
1. Abortion.
Unscientifically supported abortion creates a variety of hazards:
a. It
increases the frequency and severity of child abuse. It
interferes with bonding and disrupts the mother's normal nurturing
response to the helpless of her infant.
b. It
interferes with partner support. Without partner support
women are more likely to have an abortion and men are less likely
to support pregnant women and their own offspring. Men are
more likely to feel a sense of injustice, impotence and a rage
which, seeking revenge, results in increasing rape and domestic
violence.
c. It
results in growing numbers of the Post-Abortion Syndrome.
The aborted mother will tend to reenact the tragedy of her abortion
by having another abortion. It will also make her more depressed,
interfering with her immune function. Increasing female
cancers and infections increases the cost of medical care and
puts pressure on women to have more abortions.
d. It
increases the need for professional help to deal with unresolved
pregnancy losses, the abortion losses being the most difficult
to mourn.
The U.E.M.B.
shows that there are at least nine options for mothers who are
trying to decide what to do with their pregnancies. These
include a variety of ways to adopt or foster children.
It is important
that women who have pregnancy losses are helped to grieve that
loss in order to enjoy their next pregnancy and bond to their
next child. To facilitate that, we are providing training
in intensive group therapy in a number of countries.
We must welcome
every child. Then every one will have a sense of worth because
they are welcomed and not vice versa. The worth that they
feel they will also feel toward others and the world in which
they live. Therefore they will be careful with the lives
of others and the ecology of the environment.
2.Eugenics.
The hazards of eugenics are:
a. Amniocentesis
may result in detachment of the placenta, infections or other
disorders. Yet, it is almost routinely done in 40 year old
pregnant women where there is only a 1% chance of having Down's
Syndrome.
b. The
search and destroy mentality of eugenics is invading many departments
of genetics and forcing good people to either resign or adapt.
c. It
has placed life on a sliding scale, the value accorded because
of a person's I.Q. or sex.
d. It
is resulting in the increasing use of institutions to deal with
problems that are really part of a family.
The U.E.M.B.
encourages all to recognize we are brothers, and we cannot benefit
by alienating some. We have so much to learn from those
who are dying and from those who are handicapped.
3. Euthanasia.
As a result of euthanasia there is:
a. a
tendency to avoid dealing with our helplessness and the cry of
those who are helpless.
b. an
increasing tendency to deny we are aging, ill, disabled and ignorant.
c. subtle
pressure on the aged to consent to a "living will,"
etc. It encourages people to put their aged into institutions
where they gradually give up.
The U.E.M.B.
insists that a doctor treat and defend every patient, even when
the administration, as agents of the State, insists there are
no more resources. The U.E.M.B. insists that there is an
equal distribution of medical resources. Thus patients may
consent to having what is spent on their terminal care used for
the provision of nutrients and antibiotics in some developing
country. It encourages people to develop their spirit in
contact with the Father who gave it so that they can, when necessary,
dismiss their spirit.
Ethics
on Display.
I believe it
is unethical for physicians not to state and display their ethics.
How can patients provide an informed consent when it is impossible
to know where their doctor stands on the major issues of life
and death, suffering and treatment. Each doctor should work
out for themselves an ethic that clearly represents what they
believe and hang it in their waiting room where the patients can
peruse it and decide whether they can trust this physician with
their physical and mental health. I have done this for a
number of years. I am glad to report that, whether they
agree or disagree, patients are generally happy to know what I
believe. It certainly allays many fears and improves their
cooperation in treatment.
Summary.
The Hippocratic
Oath was not perfect, but it worked reasonably well because it
took an absolutist position and provided guidelines. It safeguarded
the patient from; 1) having abortions because of the pressures
of the State to limit or change population, 2) the family from
relatives who might poison their aged and infirm relatives, 3)
the doctors themselves from taking advantage of the patient's
dependency.
Now the Hippocratic
Oath is being dispensed with and replaced by relativism, but this
is creating measurable chaos. I have suggested that the
U.E.M.B. is a replacement. Its value can be seen pragmatically,
cooperative patients and diminishing health care costs.
Science and
ethics must agree. Science has constants (eg. the speed
of light, the force of gravity) and by these constants all other
things are measured. Because of these constants, comparative
values can be determined. Science and ethics must integrate
and this means that ethics must use constants. To be an
absolutist is like imposing a speed limit. This is not to
say everybody will or even should adhere to it, but it becomes
one that we can measure deviations by. It also provides
guidelines for day to day decisions by those who have to make
them. It will also help us recognize when we are using denial
to promote a false sense of security and immortality. The
U.E.M.B. can be widely accepted and will govern most social interactions
in civilized society. It is the heart of many religious
injunctions and unquestionably stems from God's directive that
we must love our neighbours as ourselves.
