Erich H. Loewy, M.D.
ALUMNI ASSOCIATION ENDOWED CHAIR OF BIOETHICS
Any action (or a failure to act when action is possible) affecting other sentient beings has important ethical components. While ethical considerations are among the most important in making a decision, they are neither the only nor in all instances the deciding factors. Problems are usually highly complex – if only because that "other" who is affected is generally not one but many and because "affected" must not be understood merely as an immediate effect. The most basic thing in ethics (and especially but hardly only in bioethics) is to be sensitive to the ethical questions lurking (and often lurking unrecognized) within a specific clinical or a wider social setting. Ethics is not an exchange of unfounded opinions. Ethics as the study of what is "good" and what is "bad" (or more commonly what is the least "bad") should not be equated with personal morals. These latter can be derived from one's religion, tradition, culture or "conscience" but cannot persuade others whose religion, tradition, culture or conscience happens to be different. Ethics tries to find a common framework within which various personal morals can be accommodated. It does that by using philosophical tools and a common framework of shared human capacities and inevitable experiences. That does not mean that "anything goes" Δ but it does mean that within such a framework tolerance for other points within that framework is necessary. Bioethics deals with ethics as it relates to biological systems or organisms and health-care ethics is a part of that. Health-care ethics deals with four sets of problems: 1) individual problems (such as problems at the bedside); 2) problems of experimentation on human and other sentient subjects; 3) problems of social justice; and 4) genetics which presents individual, experimental and profound social problems.
Good ethics starts with two preconditions: 1) Good facts (or at least the best "facts" that one can get); and 2) an institutional and social setting which permits deliberating about ethics and gives enough latitude to carry out ethically acceptable decisions. Ethical speculation not grounded in good clinical and social facts is just that: speculation and a form of mysticism that can be more dangerous than it is useful. Since the practice of medicine is of necessity social and since it takes place within the confines of institutional and societal frameworks bioethics must be attentive to the social circumstances which make ethical practice possible. The institution within which the actor must act constrains not only his or her action but likewise even constrains examining a variety of options; the societal framework, in turn, constrains and shapes the institutions existing within it. Managed care (in which physicians can only see the patients insured by that company and then are often put into the quandary of "fudging the truth" or not doing what they consider best for their patient) may serve as a typical example. The problem of PAS or euthanasia is another problem that, without understanding the basic questions or the social setting, is one that one cannot properly address.
Ethicists are not here to "answer questions" in the same way that textbooks or manuals are here to "answer" technical questions of practice. Ethicists function in helping think through questions, analyze logical process, question assumptions and ask questions that may help clarify attitudes towards a given problem. There are no "right" answers (albeit there certainly can be wrong ones), that is, answers that fall outside the framework of what we have accepted. What ethicists can do is to help work through to a set of not-inappropriate courses of action. The final responsibility, of course, remains and must remain with the person who ultimately must act — albeit that all those who advised him or her share in that responsibility.
In these pages we would like to respond to your questions and when possible engage in dialogue with anyone interested in pursuing a problem or a question further. To that end I shall append our program's e-mail address: Bioethics@ucdavis.edu.