Worrying undercurrent of economics in debate on euthanasia – Professor William Reville

This article appeared in the Irish Times on 16th December 2010

Ethical standards are a cornerstone of civilisation, but traditional medical ethics are currently under intense pressure, writes WILLIAM REVILLE

IT IS WIDELY assumed that all medical doctors take the Hippocratic Oath. However, the oath is no longer administered in most medical schools worldwide, including Ireland. Ethics is taught on the medical curriculum and medical doctors follow a code of ethics, but the full-blown Hippocratic tradition, which was fused with the Christian tradition, is significantly modified from its traditional form nowadays.

The Greek physician Hippocrates (460-377 BC) is generally regarded as the father of medicine. The professional sect of physicians who followed Hippocrates trained selected initiates in healing methods and required them to swear a solemn Hippocratic Oath dedicated to the pagan Gods, including Apollo and Aesculapius. The new doctor promised a binding, life-long allegiance to his teachers; he swore to help the sick and to do no harm; he swore never to take human life by administering poison or effecting abortions; he swore to protect vulnerable patients from abuse and from sexual manipulation; he swore to protect patients from scandal by maintaining confidentiality. The oath was a remarkable expression of moral values in a world that was generally quite cruel and inhumane.

The Hippocratic tradition was founded on a view of humanity similar to that of the coming Christian religion, with which it blended into a Hippocratic-Christian consensus. Christianity enhanced the Hippocratic vision by providing a new definition of neighbourliness, by emphasising the rationality of the world, created by God, and the human body in particular, the form in which “God became flesh” and therefore deserving of awe and respect.

The early Christians built hospitals and cared for the sick as a practical demonstration of love of neighbour and emulation of the healing practised by Jesus Christ. (Unfortunately a parallel tradition of asceticism also developed that loathed the human body and later persisted as an unhealthy preoccupation with sexuality.) Many monks became Hippocratic physicians and it was largely the Christian monasteries that preserved the Hippocratic tradition during the Dark Ages. Later, medicine and nursing spread around the world, largely driven by Christian ideals. Most major hospitals founded in these islands have Christian roots.

The Hippocratic-Christian consensus remained intact until the 1950s, but has since been very significantly eroded. John Wyatt, in Matters of Life and Death (Inter-Varsity Press, 2009), identifies five main reasons for this: reductionism, technology, consumerism, resource limitations, and bioethics.

Reductionism is the prevailing approach in biology, as in the other natural sciences. Organisms are widely seen as “robot vehicles blindly programmed to preserve the selfish molecules known as genes” (Richard Dawkins). Consequently, one may not feel as motivated to help an individual “robot” with defective genes as one would be to care for a sick being made in God’s image.

The methods of medicine, for most of its history, were extremely limited and offered very little. The emphasis was on healing the sick, however inefficiently this could be done. But, today, medical technology is very effective. Not only can medicine heal, it can improve healthy but “sub-optimal” bodies using a wide range of technologies, thereby refocusing the values/aims of medicine.

The traditional relationship between doctor and patient was paternalistic. Today we live in a consumerist culture. The patient is the doctor’s client, medicine (“health care provision”) is a service industry and the customers (“health care consumers”) must be kept satisfied. “Effectiveness”, “efficiency” and “non-directive counselling” are the watch words of the day.

Economics is now the single most influential way of assessing human activity. For example, we hear more and more arguments in favour of euthanasia. Whatever about other dimensions, there is a strong economic undercurrent to this debate. People live longer today and complications of old age are much more common (eg, Alzheimer’s). Baroness Mary Warnock (UK philosopher and adviser to government) has stated that “if someone desperately wants to die because they are a burden on their families, or on the State, then I think they should be allowed to die”. Euthanasia will always be cheaper than multidisciplinary care of the dying.

Modern bioethics, which began in the 1960s, initiated, according to Wyatt, a fresh approach to values in medicine in which doctors are regarded as having little to contribute. The new bioethicists (eg, Peter Singer, Princeton University), mostly philosophers, ethicists and lawyers, claim that the Hippocratic tradition is obsolete and propound radical new theories. For example, traditional medical ethics defend the intrinsic value of human life, but Singer declares that this ethic has disintegrated in the light of modern understanding of human nature.

Ethical standards are a corner-stone of civilisation. Traditional medical ethics are currently under intense pressure, but the new bioethics leads to some uncomfortable conclusions, as illustrated by the quotation from Mary Warnock. In the words of Sergeant Esterhaus from Hill Street Blues – “Let’s be careful out there”.

William Reville is associate professor of biochemistry and public awareness of science officer at UCD. understandingscience.ucc.ie (c) Irish Times 2010