Part of my work is to act as an ethics consultant in hospitals. Healthcare providers, patients, their families, or sometimes doctors and nurses from outside the hospital come and ask us to help when they do not know how to act in a morally difficult situation. In order to help them, in order to go through ethical difficulties, there are a few steps that must be understood, and we are all better off if all physicians understand these steps. Step 1, when we are given a story or when we are faced with a case that has ethical issues, our brains are wired to jump to conclusions, to go immediately to, "This is really bad or this is really good." We are not usually aware of the steps we take in order to get there. The problem is, we are all very convinced that our conclusion is the right one. It comes bundled with the intimate conviction that it is the right decision and the right judgment. But of course, we do not all make the same judgments. So we have disagreements, and sometimes even fights about what the right judgment call is. It is important to unpack these steps because in these steps are pieces of common ground on which we can build consensus, on which we can discuss suitable solutions that we can all live with, but it requires that we take a step back. So the first part of the step back is to look at what are moral difficulties are made of? What are the components of a dilemma? Now, there is a story that I really like to tell in order to illustrate this. It's quite a famous story. Many of you may have heard it, just bare with me. It is used for this purpose by many people. The story is as follows. You have to imagine that you have decided to dedicate your life to pre-Colombian archaeology. I do not know if it is true for some of you, but imagine you are an archaeologist and you spend your time in the Amazon forest looking for sites to dig. This is quite a hard life. You must walk through the trees day after day. One day, you decide that you want to sleep in a village for once. When you arrive at the village, it is nightfall and you realize it may not have been such a good idea to come because this village has been annexed by a group of guerrilla fighters who have decided to make it their home base. In order to do so, they must get rid of the inhabitants of the village. So they have rounded up the population. There are around 200 people there: men, women, children, old people, and they are about to shoot them, and this is when you arrive. In this story, you have to imagine that you are incredibly famous. Never mind why? You can dream a little. You are very famous, and when you tell the guerrilla fighters who you are, they are honored and astonished by your presence. They decide to commemorate the fact that you are there by making a grand gesture. This gesture is that they will spare the inhabitants in your name. Of course, there is a 'but' because I told you it is an ethical dilemma so it can't end well, can it? So there is a 'but'. They decide to spare the inhabitants in your name with the exception of two people whom you will have the privilege of choosing and shooting yourself. So small recap, you are alone, you are unarmed. You cannot take back power in the village. Even the villagers are panicked. They cannot help you. The guerrilla fighters are loyal to their chief, armed to the teeth and so on. You get the picture. There is no way you can change the situation. However, you do have a choice. You are a guest of honor, and so if you want to leave, they will let you leave. In your absence, of course, no further reason to honor you, and they will kill the 200 people as they had initially planned to do. So what do you do? People vary in their answers to this question. Some decide to stay, kill the two people, and thus, save 198 lives. What are the days of your life when you can save so many people? Surely, it is a very good consequence and must count from a moral standpoint. Others choose to leave, not kill anyone and keep their hands clean. Killing is very wrong. It is considered wrong in every culture where this has been looked at, and it is completely understandable that we have rules against killing people. Surely, that must count, conformity to rules and principles must count from a moral standpoint. Many people do not know what to do. They hesitate between these two options. They feel the pull equally of the good consequences, saving many lives, and conformity to principles, keeping your hands clean. What rarely happens is that almost nobody doesn't get it. Everybody sees the difficulty. Because everybody sees the difficulty, we know that we have different components in our moral life. We care about consequences. We care about rules and principles. We also care about character traits, about being good persons. We care about keeping harmonious relationships with each other. All of these different goals are valid ethical goals. All of these different goals do not always align. Sometimes they are intention. Sometimes to get the one, you must sacrifice a bit of the other. This is what ethical dilemmas are made of. Now, in clinical ethics, we use tools to unpack this, tools that list different principles, different components that we must take into account. A very influential one is the so-called principlist approach in medical ethics, where on the side of consequences, we have doing good, avoiding harms, beneficence and not maleficence, and on the side of principles, we have respecting persons for themselves and respecting their choices as well, and being fair, autonomy and distributive justice. When faced with a case, one of the ways to resolve it is to look at the different things you could do and evaluate these different possibilities through the lens of what good does it do? What harm does it do? How well does it respect persons? How fair is it? This is one of the tools in order to discuss, to talk through an ethical difficulty. In order to talk through an ethical difficulty in clinical ethics, these tools are not enough. We must also have people, as diverse group as possible. The idea would be every affected person. Of course, that is rarely realistic. What we do is, as much as possible, every affected person. This means that the healthcare team must be heard. It means the patient must be heard. It means the people who are close to the patient must be heard as a rule. So we get every possible viewpoints, and people do bring new information and new opinions into the mix, and then a solution mostly emerges from this discussion. There is an additional component because we are physicians. If you look at the roots of medical ethics, the very old roots of professional medical ethics, you will see that there is something there, a hint of something important that I have not mentioned yet. The Hippocratic Oath mentions several values that we would recognize today. The patient's good will be my highest law. I will not use, therefore, the tools of medicine against him or her. I will not harm. That is very important because medicine was able to harm much earlier than it became able to help. Doing the patient's good, above all, is important as well because the more powerful the tools of medicine are, the more it becomes possible to do very bad things with them, to kill the one that people hoped to inherit from, or to torture, or to do very wrong things with the same tools. What patient would entrust herself to medicine if we did not promise that we will not use our tools against her? The trust that people put in us is part of our toolbox. We must do everything we can to deserve it and make it clear that we deserve it because otherwise, medicine becomes impossible. So at the root of medical ethics, there is another principle, and that is, I will not abuse my power. The professional ethics of every profession, since then as well, is based upon this principle. I will not abuse my power. I have to have power over my patient simply because power is nothing else than the ability to influence somebody's future. What kind of physician am I if I am not able to influence somebody's future? But I must never abuse it and I must promise never to abuse it and that must be clear. That too is part of professional ethics.
