WMJ 05 2011 - World Medical Association

VATICAN STATE
Clinical Ethics
On the Epistemological Nature of Clinical
Ethics: Decision Making or Thinking
Ignacio Carrasco De Paula
The appearance of contemporary medicine
of the new “ethical dilemmas”, created by
the increase in technical-scientific possibilities
but also from social-economic and cultural
evolving, has changed the focus from
the formulation of general behavioral norms
in medical ethics – as was proper to ethics
as it was taught in university classrooms – to
problems with the method employed, at the
patient’s bedside, to come up with the best
clinical decision.
The particular “focus” on the decision in the
clinical area has had several positive effects.
It has placed emphasis on the need for a
rigorous ethical reasoning and, consequently,
for the development of tools for ethical
analysis supporting the diagnostic and therapeutic
choices. Indeed, since clinical ethics
began to define itself as an autonomous discipline,
between the end of the 1970’s and
the beginning of the 1980’s, it has become
essentially characterized by the application
of an analytical methodology – for a long
time Principialism developed by T. L. Beauchamp
and J. F. Childress and Neocasuistry
by A. Jonsen and M. Siegler – to the deciding
process in individual clinical cases.
I consider it undeniable that this practice
has produced good results. However, it is
also undeniable that, over time, limits have
increasingly emerged: the displacement of
the “focus” on the procedures tends toward
a marginalizing of the ethical judgment. It
seems to me that the juridical cases have
produced a noticeable influence – often resulting
in a failure of the ethical reasoning
in clinical practice –, to the point that today
it would be possible to outline a kind of history
of medical ethics according to certain
sentences from judges which caught the
attention of public opinion: Quinlan, Cruzan,
Schiavo, etc. This has often favored a
legalistic interpretation of ethical analysis
in medicine, which is continually more preoccupied
with observing certain rules, like
good clinical practices, respecting privacy,
informed consensus, etc. (naturally, all the
rules have to be rigorously followed), at the
expense of the reflection on what is the just
and reasonable interest of the patient.
When the center of the attention is taken up
by the decisional process, the ethical analysis
can be reduced almost automatically to
the evaluation of possible consequences; for
example, the choice between surgery or a
chemotherapy and/or radiotherapy in the
care regarding laryngeal carcinoma will depend
exclussively on the percentile of success
even though it is well known that, for
the patient, the physical image or the ability
to speak might weigh more heavily.
Moreover, an informed consent concentrated
only on the bare deciding factors which
are available in the clinical arena, would
render it difficult for the patient to express
a true free consent, in that the patient could
be compelled to accept something that in
reality they would not want. Consent is not
so much about the transition from the decision
to its being put into action as it is about
the transition from the ethical value to the
clinical decision. The doctor should help the
patient to consider not only the facts, but
most of all the reasons which are at the basis
of an eventual decision, otherwise it is easy
to subtly fall into the old paternalism which
we thought was buried once and for all.
Thirty years after its initial shaping as an
autonomous discipline, we can say that
the nucleus of clinical ethics still consists
in the methodology of analyzing the ethical
problems of clinical practice (moreover,
well accepted by medical doctors, who really
need a mediation between the general
moral principle and the individual case)
and recourse to ethical consultation (for
example, within the ad hoc committee) as
expertise in the most complex situations.
Nevertheless, it is important to confirm that
the efforts to elaborate an ethical approach
centered on the person should always remain
a priority. It is necessary to think and
to apply a clinical ethic which does not lean
exclusively on a decisional procedure or on
a methodology of analysis of the situation,
but which understands the attention to the
person – as it regards the patient and as it
regards the doctor – in its entirety. What really
exists, as a matter of fact, is the person
in its individuality and its singularity, while
all the rest, including the ethical analysis of
the clinical decision, constitutes a descriptive
perspective unfortunately partial and
sometimes even relative.
The same problematic often in the clinical
decision is only one side of a much greater
ethical issue, which effects the relationship
between the doctor and the patient in its
totality and, probably, the very essence of
the medical profession. Therefore, today it is
becoming increasingly more evident that a
clinical ethic which limits itself to offering a
solution only in terms of the decisional procedure
would not be capable of grasping the
complexity of clinical medicine, much less
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