4. Discourses in Applied Ethics
We will now turn to several areas of Applied Ethics and see how the strategies and approaches of discourse ethics as elaborated in chapter 3 can be fruitfully exploited in those situations. There is not enough space (in terms of time and in view of this script) to introduce each field completely and to cover each and every hot topic that is characteristic and frequently discussed in its respective field. Moreover, it is not even clear what counts as a legitimate category of applied ethics. My choice is a pragmatic one: As remarked in the introduction, the goal of this course is to prepare you for the various professional discourse situations that you will face in your later job, and those in which you as a private person communicate with a professional practitioner (for example a doctor). I picked the following exemplary fields of practical ethics:
- Medical ethics (section 4.1)
- Political discourse (4.2)
- Science and Technology ethics (4.3)
- Profession and business ethics (4.4)
- Media ethics (4.5)
- Discourse with absent/silent stakeholders (4.6)
- Intercultural discourse (4.7)
Some people might argue that media ethics aspects are sufficiently covered either by technology ethics, political ethics or profession ethics so that it can’t be an own-standing field. Here, however, I believe that media competence is an important skill that is worth one class. Furthermore, the important fields of bioethics and environmental ethics are not particularly mentioned in this list. Instead, we will address topics from those disciplines in the context of other areas such as political ethics (the debate on PGD), profession ethics (how to debate with the boss about environmental pollution by the company), and – most importantly – discourse with stakeholders that have no voice (animals, the eco-system, unborn life, future generations).
4.1 Medical Ethics
Medical ethics is probably the “biggest” field in contemporary applied ethics. This is understandable since it has directly to do with human well-being, working with people, and sometimes life and death. The topics discussed in the context of medical ethics can be roughly grouped into three fields:
- Codes of conduct for doctors and other medical and health care personal:
- The Hippocratic Oath (希波克拉底誓詞) for medical professions.
- Principles of biomedical ethics by Beauchamp and Childress: Autonomy, Beneficence, Non-maleficence, Justice.
- Governance and regulation of medical issues:
- Protection of patient rights, autonomy, dignity, privacy, freedom.
- Distributive justice (公平分配原則), most prominently: organ transplantation (器官移植).
- The impact of technological advancements on medical treatments, health care system (justice), patient rights, etc., for example: reproductive medicine, nanomedicine, human enhancement.
- Patients in various phases of life:
- For “normal” patients: Doctor-patient relationship.
- Medical care at the beginning of life:
- Medical intervention before birth, e.g. PGD (胚胎植入前遺傳篩選).
- Medical treatment of children.
- Medical care at the end of life:
- Palliative care (安寧和緩醫療).
- Hospice (臨終關懷).
- Euthanasia (使安樂死, 無痛苦致死術).
The professional codes of conduct are an issues mostly for practitioners, and none of the participants in this course will be medical practitioners. Therefore, I won’t go too much into detail here, except that I’d like to hint at the possible application of virtue ethics in this context. We will talk about PGD in the next class when it comes to political debate on ethically relevant topics. Here, we will have a closer look at two situations: The communication between doctor and patient, and euthanasia. You personally might have found yourself in such a situation, or in the future you surely will.
4.1.1 Doctor-Patient Relationship
The success of a medical consultation depends strongly on the communication between professional (doctor, nurse, care personnel, etc.) and patient. Many things can go wrong. Let’s imagine two different situations:
- Situation 1: After examining the patient, the doctor briefly tells the patient what he found and what the patient should do next (e.g. take pills, or have an operation, or wait and observe, etc.). The patient will do as he is told.
- Situation 2: The doctor explains in detail what is the situation and the various options that are there to choose from. He also explains all the implications, risks, benefits, etc., of each option. The patient makes a decision based on this input. The doctor proceeds according to the patient’s will.
These scenarios are, somehow, the two extremes between which most doctor-patient communications can be classified. On the one side (situation 1), we have a paternalistic doctor, telling the patient what to do. This works well for those patients who trust the doctor as an expert and who don’t have the capacity or willingness to understand the medical information and to oversea the relevant implications of different options. Therefore, the doctor decides for the best of the patient on the basis of his professional competence. This is commonly referred to as paternalism: Like a father (Latin: pater) takes good care of his children by making right decisions for them, a professional (here: a doctor) decides for his clients (here: patient) in questions of his/her expertise and competence.
On the other side, we have an extreme case of informed consent: The doctor serves solely as an information source whereas it is the patient alone who makes decisions. The doctor would accept the patient’s choice no matter what, even when it is irrational, emotional, inconsistent, etc., because it is the patient’s most fundamental right to make autonomous and free decisions. In reality, this very strong form of patient autonomy won’t be found, because in view of the complexity of some medical treatments, decisions always need an advise and the counseling of a doctor.
We can imagine conversations with a high conflict potential: When a paternalistic doctor meets a patient who expects a high degree of self-determination, and when a patient who wants to be told what to do meets a doctor who is used to informed consent. For the former, I can give an example from myself: When I visit doctors in Taiwan, they often prescribe medication without any explanation, and when I ask what it is for and that I would like to know about alternatives, they are surprised or even upset that I doubt their competence. It seems to me, in Taiwan, the more common form of interaction is a rather paternalistic one. Patients usually don’t question doctors’ decisions, and most Taiwanese, especially the older generation, even expects a paternalistic treatment in hospitals and doctors’ offices. For the latter, we can imagine the situation of many immigrants and refugees from Africa and the Middle East in Germany: German doctors respect patient autonomy a lot and would never dare to judge what is the best to do without the patients’ consent. However, in this special situation (including language barriers), what would be most efficient is a paternalistic decision-making by the doctor, because the patients don’t have the capacity to decide for themselves.
Both concepts have their limits and difficulties. Paternalism usually doesn’t work in modern knowledge societies. Most people have basic background knowledge, or they find it somewhere (mostly on the internet). They want to be informed about their health condition and be included in the decision-making. Moreover, the trust in experts (including doctors) is decreasing nowadays. Reported frauds (for example, corrupt practices in organ distribution for transplantations), economic interests of doctors and hospitals (for example, a doctor has more income when he prescribes pills, even when they are not necessary, or hospitals earn more money when they make sure that all beds are occupied, so they keep patients longer than necessary), low quality education (“Medicine” as a university major for the masses, not for elite future doctors), etc., have eroded the honourable position of doctors in society. Furthermore, in “deontological” societies like the German, self-determination (自主) is regarded as the most important personal right, so that a paternalistic doctor wouldn’t be accepted by most patients. However, also informed consent reaches some limits. Some medical issues are too advanced and complicated to be explained in simple terms to a layman, or they are only comprehensible with special knowledge and education. To a certain extent, the doctor simply does know better what would be the most reasonable thing to do. Nevertheless, it is still necessary, of course, to inform the patient and let him participate in the decision-making process. This, of course, might also be difficult: The patient’s choice may be irrational or based on misunderstandings.
The solution is – as often in life – a middle way between the extremes: Open, honest, clear and direct communication from both sides. Doctors should give patients a chance to make an informed free decision, and patients should trust the medical and professional competence of the doctors. A dialectic communicative exchange of medical knowledge, preferences, values and emotional states (such as doubts, worries, fears, etc.) is the best way to come to a decisions that all involved parties are somehow satisfied with.
Euthanasia is a term that describes acts of intentionally letting people die or to enforce or support the dying process in order to release the dying person from pain and suffering. Legally, it must be distinguished between active euthanasia (inducing death of a patient by literally killing him/her), passive euthanasia (letting the process of dying happen, for example by not applying counter measures or by switching of life-supporting machines), and assisted suicide (giving terminally ill and immobile patients a chance to end their life, for example by handing them a poisonous drink).
- 主動安樂死（Active Euthanasia）: 主動為病人結束生命（例如透過注射方式）。
- 被動安樂死（Passive Euthanasia）: 被動安樂死是停止療程（例如除去病人的維生系統或讓病人停止服藥）使其自然死亡。
- 協助自殺（Assisted suicide）: 協助自殺是病人主動要求，並親自執行結束生命（例如通過服藥方式）。
Active Euthanasia is not legalised in most countries, whereas assisted suicide is debated heatedly in some legislations. Passive euthanasia (allowed in many countries) is the form of euthanasia that puts many people into severe ethical dilemmas.
Imagine this situation: After a stroke, a 85-year-old man is in a coma and doesn’t respond to stimuli. He is connected to life-sustaining machines (LSM). The doctor talks to the man’s two daughters about how to proceed. He informs them that the chance to awaken again is around 40%, but it can’t be excluded that the man will suffer from brain damages. The two daughters argue about what is the right thing to do. One daughter regards the chances of waking up as high enough to keep the man alive and wait. Everything else would be an act of killing, from her point of view. The other daughter urges to switch the machines off and let him die with dignity. She remembers that he “once mentioned” that he wouldn’t want to depend on LSM. During the debate, it turns out that she obviously has an interest in inheriting the man’s money and property, causing an emotional outrage in her sister.
From this short scenario – which is not an exotic or seldom one, but may happen to all of us! – we can see why euthanasia is such a difficult and yet important topic in medical ethics. Several considerations play a role in discourses like this one:
- When is someone “old enough to die”? Does it make a difference if the comatose patient is 65, 75 or 85 years old?
- Is “quality of life” a relevant factor in this decision? How can we judge this for someone else?
- What does “dying with dignity” mean? Doesn’t it violate the doctor’s professional duties to “let someone die”? Are there cases in which “keeping a person alive” is not the most ethical choice?
- Can we guess or estimate what another person would decide with sufficient certainty?
- Can we be free from biases (like financial or other interests)? How?
Obviously, the biggest problem is that someone is in charge of making a decision over life and death of another person that can’t express itself. Doctors can’t be in charge of this, so it is usually in the hands of the closest relatives (marriage partner, children, siblings). In case they are too overwhelmed by the situation or need advise, many hospitals have ethics boards that assist relatives of patient in this decision-making. Most distressing for those family members is the imagination that they “kill” (often understood as synonym with “letting die”) a beloved one even though he or she could “wake up” again and continue life with sufficient quality, or that the person that is decided upon is, actually, conscious and can hear what they are debating. Moreover, there are reported cases of people judging a situation differently from before as soon as they find themselves in it. Even though this last concern can’t be solved with it, the best way to find out what to do is letting the patient state it by him/herself. Then, principles of autonomy (self-determination) and freedom (of will) are respected. Naturally, this statement must be made beforehand and in a somewhat “official” way. Many countries, including Germany and Taiwan, have set the legal framework for this procedure: People can declare their will in form of a living will or patient provision, in Chinese 預立安寧緩和醫療暨維生醫療抉擇意願書. The official document used in Taiwan looks like this (taken from this source):
For some people – maybe also in view of cultural customs – a conversation about this topic is not very easy. Maybe your parents or grandparents refuse to talk with you about this when you bring it up. Discussing it is an ethical issue in itself. Why would someone declare that it is better to die than to live with a lower quality of life after recovering from am accident, a stroke, or a coma? Is that a justifiable argument? Religious people might state that “If God wants me to die, I should die and not be kept alive artificially!”. Since this is a spiritual personal conviction, from a certain perspective it is easier to accept than an estimation of life quality that may be full of flaws and misconceptions. Another often raised argument is “I don’t want to be a burden for my family, so I better die before being in need of enhanced care around the clock!”. This is a form of negative utilitarianism (good is what causes the least trouble for as few people as possible) that doesn’t withstand scrutiny at a closer look: following the same logic, the best would be not to be born at all. It underestimates that other people value one’s existence and being-alive, for example partners, children, etc., so that they will be willing to take care of the family member in need!
Reasons against declaring the will not to be kept alive by LSM (or stronger: reasons for declaring the will to be kept alive even at the slightest chance of surviving) are the abovementioned possibility that patients change their mind when they find that their situation is not as bad as expected when they were a healthy (fully functioning) person. Life quality can still be perceived as high and “worth living” when sitting in a wheel chair or living in a nursery home. A former athlete might find it disturbing to imagine a life without mobility, but when he ends up in a wheel chair or a bed, he might realise that activities based on brain work can also be inspiring and fulfilling. Therefore, the declaration can be regarded as invalid because it has been made under biased conditions. In detail, conflicting arguments in favour of or against the patient provision can be characterised as utilitarian (weighing the benefits of being alive against the negative side effects like being a burden or being in need of expensive care) or deontological (dignity, autonomy, the right of free will), as such being a source for conflicts and disagreements.
Euthanasia is one of the ethical dilemmas that can’t be solved easily with one standard solution. The only way to proceed is to analyse each individual case, its conditions, its medical situation, the decision competence of family members, their reliability and trustworthiness, and many other factors. Again, the best method to achieve satisfying results is an efficient discourse with open and goal-oriented communication and the skill to understand the arguments and what is at stake for whom.
4.1.3 Practice questions
- What is your own approach when consulting a doctor? Do you trust him and do what he says, or do you want to be informed about everything and tell the doctor what you choose?
- Imagine (and write down) a dialogue between a paternalistic doctor and a self-determined patient, and a dialogue between a patient who expects a paternalistic doctor and a doctor who expects a self-determined patient.
- Did you talk with your parents (or grandparents) about the 預立安寧緩和醫療暨維生醫療抉擇意願書? If not: Do you expect any difficulties? If yes: did you exchange arguments? What did they think about it?