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FROM A MEDICAL ETHIC TO A MORALITY OF HEALTH CARE

By Gabriel Moran

During recent years I have team-taught in two ethics courses, one for

business students, the other for nurses. I much prefer nursing studentsbecause they already have a sense that morality is intrinsic to theirwork. I think that in the business world ethics is usually seen as a set ofrules brought in from the outside.

The ethics course in NYU=s Graduate Business Administration wasrecently written up in the New York Times. On paper, it is an impressivesounding course but I find it frustrating in practice. The ethical questionsasked in the business world are how to live reasonably, how to besuccessful without hurting too many people along the way, how to

protect oneself against corporate power. This attitude ofreasonableness is not to be disparaged; it represents progress awayfrom ruthless conflict with one=s enemies. Nonetheless, this veryprogress reveals the inadequacy of modern ethics to cope with a worldthat refuses to fit the modern meaning of reasonable.

In contrast, the world of health care is never far removed from theunreasonable realities of pain, suffering and death. The first question inthis area is not how to act reasonably but how to care for human beings.The very category ofAhealth care@ is one of the forces that ischanging the entire field of modern ethics. When not reduced to ameaningless cliche, health care - the care of health - is a way of thinkingthat differs from medical thinking.

Modern ethics can be dated from about the 18th century. For severalcenturies before then, human reason had been making progress in thedirection of autonomy, technical skill and institutional order. A conflictinevitably arose with Judaism and Christianity. Jewish religion, centeredon the practice of law and ritual, suffered even more than didChristianity from a triumph of rationalism. Given a choice betweenChristianity and modern enlightenment, many Jews went with the latter -at least until the Holocaust revealed the tragic flaw of trusting in reasonalone.

There have been two main systems in modern ethics, although the twoare variations on a single theme. Pushed to the limit, one system willlead to the other. The first system, called Ateleological,@ begins from a

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conception of the good, and the argument is over which are thereasonable steps for accomplishing the good. The competing system,called Adeontological,@ begins from a conception ofAright@; the

argument is over which are the reasonable ways to exclude passionsfrom interfering with doing the right things and observing the rights ofhuman beings.

Not many people would wish to do away with the apparatus of rights.Anyone who has lived under the protection of the western ideal of civiland human rights would be wary of living in Iran, China or Iraq.However, the failure of a rhetoric of rights in much of the world indicatesthat this language assumes a context and a history. In the UnitedStates, the limits of this language are shown in the abortion issue. Bothsides use the language of rights, one talking about the right of thewoman to control her body, the other the right of the fetus to life. I doubtthat any progress can come while the language of rights is the only oneused.

In much of the world, including the business world, the first system, theteleological, is dominant. There is more concern for the acquisition ofgoods than for the observance of rights. Ethical rules in the businesscontext pertain to fairness in buying and selling. From the 18th centuryto the present, the image ofAmarket@ has dominated this kind ofthinking. This form of teleology is based on a remarkable premise,namely, that if each individual were selfish, everyone would be happy.AIf men were actuated by self-interest,@ wrote Bertrand Russell, Athewhole human race would cooperate.@ And today Edward Wilson still

insists on the same premise in the recently invented field ofsociobiology: AHuman beings appear to be sufficiently selfish andcalculating to be capable of indefinitely greater harmony and socialhomeostasis.@

Although it is not easy to spot a logical flaw in the position that greed isgood, most people know that something is awry. For a logical analysis

of what is wrong with a system of ethics based on selfishness, I referthe reader to Fred Hirsch=s The Social Limits of Growth. Hirsch uses adistinction between material and positional wealth. Although materialgoods may be indefinitely expandable, other values which aredependent on human relations are of their nature limited.

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The confusion in the twentieth-century version of teleology is indicatedby Hirsch=s principle: AMore wealth of the kind attainable by allparadoxically means an increased scramble for the kind of wealthattainable only by some.@ Here is an example of the problem: One ofthe things that the rich could once buy was a quiet place in the suburbs.But as more people acquire the means (including an automobile) to geta quiet place in the suburbs, then the very existence of quiet places inthe suburbs is threatened. An individualistic ethic makes both city andsuburbs disintegrate. The same is true for most kinds of human servicesthat are not available today at any price. What has become evident inthe large economic sphere is well known by people in their personallives; for example, you cannot buy good sex at any price. Human care,love and patient attention are not to be acquired by an ethic of marketexchange.

Health care thereby becomes one of the chief tests of modern ethics.Health care has been subjected to the market ethic. The free play ofcompetition, it was assumed, would produce skilled technicians whowould put their heads to curing disease. Everyone would profit, or atleast everyone who had the money to buy the physician=s time and his

expensive technology. Like civil/human rights, few of us who live underthe aegis of the American Medical Association would wish to abandonthe progress of medical technology. But the skills of the medical doctorand the impressive technology of the medical system cry out for a

human context. The impossible situation of astronomical costs is forcinga redesign of the whole area. The necessary reform is not a reformedprofession of medicine but a different profession of health care.

A Aprofession of health care@ is in a fragile moment of birth. Inherentto this profession would be cooperation between men and women, incontrast to the male-dominated history of modern medicine. The centralconcern would be the relation of body to environment, person tocommunity. A health care team has to include the patient and thepatient=s family as well as the people who have technical training and

specialized knowledge. The rights of the individual and the goods ofmedicine need a context in which every human being, indeed everyliving being, is a patient, that is, one who suffers and eventually dies.

The human being as one who needs gentleness, care and love is amuch better image for ethical thinking than is Francis Bacon=s image ofAman putting nature to the rack and demanding answers.@ Given its

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presuppositions, modern ethics has concentrated on Adilemmas,@conflicts of rights or conflicts of goods. A profession of health care wouldbe concerned not merely with dilemmas or cures but with what kind ofpersons we are becoming and in what kinds of communal settings.Stanley Hauerwas writes: AWe need an account of morality worthy ofrequiring ourselves and others to suffer, and thus releasing us from theprison of our own interests.@ There is no guarantee that talk abouthealth care is going to get us a profession worthy of that name. But themen and women who are working to fashion genuine health care arealso laying the foundation of a better way to approach all ethics.

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