SERMON
The story you are about to hear, though unusual, could have happened at any medical center in this country. Its purpose is to illuminate the struggles of those working in the field of medical ethics today. The problems arise not just from the advances of technology but also because we live in an increasingly pluralistic society. Our story begins with Dr. Gray who is on call for his hospital's ethics committee one Sunday evening:
"We've got to decide now! I could lose the baby at any minute!", shouted Dr. White.
"Mr. Bono richly deserves it. Let me begin the pre-op.", Dr. Black demanded firmly.
Dr. Gray sighed wishing the battery in his beeper had been dead so he wouldn't be confronted with this life and death choice which had to be made in the next thirty minutes or so. Some poor teenage boy had died an hour ago in a head-on collision from massive head injuries. The parents of the boy, probably overwrought with grief, consented to have his heart and kidneys harvested for transplant. The kidneys were on their way to two people waiting in Los Angeles and the strong carefully packed young heart was on a helicopter coming to the hospital, arriving probably within the hour.
One family's loss is another's gain. Mr. Bono and his family had been overjoyed at the news. A vital man in his middle sixties, a recently retired and well loved university professor, he had suffered a massive heart attack which had severely damaged essential muscle tissue in his heart. He had just barely survived and his activity was severely restricted. Because his health had been good before the heart attack, his doctor, Dr. Black, felt he was an excellent candidate for a transplant so he was put on the waiting list. The boy's heart was a good match for Mr. Bono so Dr. Black had him hustled to the hospital in an ambulance to ready him for surgery.
The Sunday must have been somewhat unholy because there had been another serious auto accident. Mary Smith, a woman in her early thirties and five months pregnant had been riding on the passenger's side of a car driven by her husband. They had been exiting an six lane intersection on a yellow light, probably as the light was just turning red. Someone in the far right hand lane with their vision obstructed by some cars waiting for the light to change had entered the intersection at the speed limit and struck Mary's door. Mary suffered some serious injuries but they did not appear to be life threatening. She was rushed to the hospital. During surgery to set broken bones in her shoulder, she went into cardiac arrest. Dr. White discovered from her husband that she had congenital heart problems. Dr. White figured the trauma of the accident, surgery and pregnancy were just too much and pushed her heart one beat too far. But even if her heart was failing, the baby was hanging on and had suffered no serious injury. To buy time for Mary and her unborn child, Dr. White decided to put her on a heart lung machine. He had heard Dr. Black had been paged and had a harvested heart on the way so he decided to take a chance and run a tissue sample to see if they might have a match. To his amazement (the odds not being very high) Mary was a good candidate for the heart.
Dr. White had immediately run up to Dr. Black with the news fully expecting he would be able to get the heart and have Mr. Bono wait for another one. Dr. Black as you might expect from their names, quite often didn't see eye to eye with Dr. White and they immediately got into a big fight about who should get the heart. Seeing they couldn't agree, they paged the ethics committee and the hospital administration pulling Dr. Gray and Mr. Dinaro into the dispute.
The four of them were now sitting around a table in a windowless conference room under glaring florescent lights with the air conditioning set a little too low. Dr. White had presented his case first. Given that both Mary and Mr. Bono were about equally good genetic matches for this heart, and that Mary will surely die if she doesn't get it, she must get the heart, Dr. White argued. And if the two cases were equivalent in every way, she should still get the heart because she was carrying an unborn child. If Mary died, so would the child as it was too premature to be delivered. Two lives were at stake not one. Dr. Gray knew of Dr. White's fundamentalist Christian, Pro-Life stance so he didn't want to get into an argument with him as to the right to life of this fetus.
Dr. Black was just as adamant that Mr. Bono should get the heart. Transplanting a heart into a pregnant woman was very risky at best with a questionable chance to save the fetus. Mr. Bono while not on a heart lung machine, was every bit as endangered of having complete heart failure in the next few weeks. This heart could very well be his only chance for a transplant. Mr. Bono was a great teacher and scientist in the area of genetics. Many people were looking forward to his reflections, essays and commentaries on the advances in this fast moving field. He had postponed writing a number of books until he could retire and have more time to collect his thoughts. Not only did Mr. Bono have a lot to gain from this transplant but so would the human race, argued Dr. Black. Dr. Gray knew Dr. Black's Humanist Utilitarian pro-choice stance wouldn't soften him up to the plight of the five month old fetus.
Dr. Black and Dr. White were not the only voices at the table. Mr. Dinaro had something to say. Ms. Smith had no medical insurance to cover the operation and the driver who hit her was an uninsured bricklayer. The Smiths both worked in minimum wage jobs as a checker and a bagger in a grocery store and had little or no hope of coming up with the money to pay for the hugely expensive operation. Mr. Bono, on the other hand had retired with excellent insurance that would cover the operation in full. Mr. Dinaro warned the group that the stresses and strains of managed care meant they had to be realistic about what kind of charity they did. The hospital was losing money as insurance companies refused to pay one week what they had paid the week before.
Dr. Gray sighed because he knew that this would be a tough case to decide. Dr. White and Dr. Black were clearly entrenched in their positions and Mr. Dinaro was more worried about who might sue the hospital than who got the heart. Dr. Gray pondered this God-like moment in which doctors sometimes find themselves when their choices really are life or death decisions.
When the ethics committee was formed five years ago, they had agreed to generally follow Beauchamp and Childress' four ethical criteria for their decision making. First the patient should be allowed the maximum autonomy. The committee should put both beneficence or doing good and non-maleficence or doing no harm forward as guiding principles. Finally the committee should pay close attention to the justice issues and do the right thing. Given that Mr. Bono wanted the transplant and Ms. Smith would almost surely want it if she could make the request, the autonomy criteria was satisfied. Giving the heart to either one would satisfy the beneficence and the non-maleficence criteria. Trying to decide the justice criteria seemed to Dr. Gray to be the toughest one to meet. Did a young woman carrying a healthy new life in her belly have a greater or lesser right to live than a wise older man with potentially a great deal to contribute to society. Who can know the course of Ms. Smith's life and the future possibilities of an unborn child?
Dr. Gray was grateful he had taken an ethics class in college while he was preparing for admission to medical school. It had helped him understand why making these decisions was so difficult. There is not just one way to think about ethics but a number of different ways. Immanuel Kant felt that the whether the action warranted blame or praise should guide the ethical decision maker. John Stuart Mill argued that maximizing the happiness or satisfaction produced by the decision should rule. Thomas Aquinas felt what was of paramount importance was realizing and actualizing the good by reference to the teachings and authority of the Holy Church first and second the abstract conception of the good. Depending on what approach you take, you can get different answers.
Whether the hospital would be sued, blamed or praised, based on which decision it made didn't seem like the right way to go in deciding this case to Dr. Gray. He was quite unable to determine whether the world would be better off and have more happiness or satisfaction if Ms. Smith or Mr. Bono survived. He was insulted at Mr. Dinaro's suggestion that this be a monetary decision. Being a secular hospital, Dr. Gray felt deciding Ms. Smith or Mr. Bono's fate on a Biblical passage or a theologian's musings on the meaning of life rang false.
As the seconds continued to tick away on the round nondescript clock hung indifferently on a wall painted a bland institutional tan, Dr. Gray mentally reached for some resource to come to his aid. He had been an avid reader in the area of medical ethics since the landmark Karen Ann Quinlan case in the 1970's. Driven by liability concerns, hospitals began ethics committees in part to limit their risk of law suits but also to grapple with the new choices modern technology gave the medical practitioner. Death more and more often was changing from a final event to a human choice. And with choice came important decisions to be made.
A number of theories had been proposed for making these tough choices. The simplest seemed to be the intuitionist strategy. Go with your gut feeling. Doctors don't need to worry about elaborate theories. They just know what is right in their bones - a kind of the common sense approach. Dr. Gray discarded this one immediately as his bones weren't tingling one way or the other and he could see Dr. White and Dr. Black's bones certainly didn't agree. An opposite way to decide the question would be to try to formulate an unbiased choice by removing all the different self interest motives. Dr. Gray couldn't begin to imagine how to exclude these issues in a life or death decision. Another approach would be to try to settle it on rational choice narrowing the focus purely to the medical procedure and the best likely outcome. Who had the best chance of surviving successfully? From the medical data both Dr. White and Dr. Black presented, each one would be a good candidate and have a good chance for long term survival. Trying to decide what to do based on following natural law didn't seem useful. Transplants weren't very natural to begin with and wouldn't work without suppression of the body's immune system to prevent rejection.
Two other approaches had particularly attracted him. One called casuistry had been getting lots of attention of late. This was the ruling principle used by the Catholic Church in the Middle Ages to resolve moral questions. In medical ethics it means using actual cases to build ethical paradigms. This case study approach allows a sort of common law comparison to previous decisions to guide decision making in new cases. Rather than using abstract ideas or subjective feelings and intuitions, the circumstances of each case often held within it important guidance. It created a way for the values of the community to enter the process of weighing each decision. Yet like interpreting the law, each person's understanding and interpretation of the facts of the case was colored by their individual values and beliefs. And the uniqueness of this case left Dr. Gray feeling that casuistry wasn't going to help him this time.
The last ethical theory he pondered was the development of middle-level principles to guide the action of the committee. The community could develop through public dialogue with the hospital ethics committee a sense of shared values which could guide their work. These values could be affirmed by different belief systems within the community but may not apply outside the community. Doctors could all agree to not do female circumcision even though this might be an acceptable practice by another community standard in Africa. Only what the community could agree on would guide their decisions. Of course, this could severely limit the freedom of a doctor who was willing to do abortion in a community which was strongly pro-life. And Dr. Gray wasn't sure what the community standard would be for a heart transplant decision.
After searching for some objective way to make an ethical decision, Dr. Gray finally sank back in his chair exhausted. There seemed to be no way to make this decision without injecting his own value system or the value system of Dr. White, Dr. Black or Mr. Dinaro representing the institution's fiscal values. Any one of the these people's values could be seen as primary depending on one's own personal beliefs. As H. Tristram Englehardt writes in his seminal book, "The Foundations of Bioethics":
There are insuperable problems with each of these approaches because (1) an appeal to any particular moral content begs the question of the standards by which the content is selected, (2) an appeal to a formal structure provides no moral content and therefore no content-full moral guidance, and (3) an appeal to an external reality will show what is, not what ought to be or how what is should be judged (p 41 my italics).
Dr. Gray straightened up in his chair and began to speak, "I don't believe there are any firm ethical grounds we can decide this case one way or the other. Who can measure the value of a human life or its future course. Can we find the good in a managed care decision based on the ability to pay? I think not. The beliefs and values which influence us cannot be ranked in the pluralistic society. And the community standards in a northeastern university town are likely to be quite different than those of a rural southern farming hollow. Both these people equally deserve this transplant in my mind.
"My recommendation is to speak with the only one who can really take full responsibility for this decision, the only one who can receive the transplant who can speak with us: Mr. Bono. I wish Ms. Smith could also be consulted but circumstances prevent this possibility. If Mr. Bono accepts the heart and Ms. Smith loses her life, he will be the one who will feel the burden of her life. If he declines the heart and gives her life, he is the one taking the risk that another heart may not be found in time. This is a profound decision at this point only he can make in the silence of his own soul guided by his most deeply held beliefs. It is in the human dialogue between the doctor, patient and family that we will best find our way through this ethical jungle. The medical profession is a tragic business as we must all one day die and the cure must eventually fail. In the course between birth and death there are opportunities for great acts of courage and love which gain their nobility through free choice. This is one of them where meaning can be made."
My story ends here partly because I'm out of time and partly because we can all put the right ending on this story which fits what we'd do if we were Mr. Bono. Some may object to this solution while others will applaud it. In the process, I hope I've engaged your interest in one of the most interesting problems of our age: how do we resolve medical ethics dilemmas in a pluralistic society? So far there are no sure answers to these questions. But what do Unitarian Universalists love more than challenging dilemmas and difficult questions to wrap our minds around. Perhaps the answers aren't found in the systems of ideas but in telling a meaningful story which suggest them.
Copyright (c) 1996 by Rev. Samuel A. Trumbore. All rights reserved.