AbstractA distinction is made between morals and ethics. Morals are not critical, but enculturated, more like learned habits or rules than thought out behavior. Ethics is a critical examination of morals and cultural practices. The medical system of a culture is also based on such morals. Common morality is basically self-contradictory. There is ignored moral inconsistency and searched ethical consistency. According to the ethics versus moral view, something can be moral, but unethical; immoral, but ethical; both immoral and unethical; both moral (by chance) and ethical (by reason). As to suggestions for a specific ethical theory, which is consequentialistic and combines the scientific basis of medicine with the philosophy of medicine one may recommend a naturalistic, humanistic theory of ethics. It also benefits from the philosophy of science and pragmatic Philosophical Practice. Show
Keywords
† Deceased 5.1 IntroductionSocrates said, “The unexamined life is not worth living – that you are still less likely to believe” [2]. Socrates is certainly correct that the average person, including the professional, is not “likely to believe” in an examined life. The statement is inaccessible to the non-philosopher. Such examination and critical thinking (speaking) are not tolerated as Socrates fatally found out especially by people who want to comfortably remain enculturated without asking any questions. Religion and culture oppose critical thinking. They must oppose critical thinking (speaking) if they are to survive as they do. Criticism would ruin them. By “culture” is meant traditional, and uncritical and commonly accepted societal practices of a nation or race no matter how they are. It does not here include those institutions critical of culture such as open education, and philosophy. “The teaching of medical ethics was traditionally…often skimpy and formulaic… [or] barely mentioned” [3]. Today we can say that critical philosophy of medicine is not mentioned at all. Even Medical Ethics Today (2004) supports a medical system following culture. On the other hand, they also state that medicine should not just support community values [4]. If one wants to be healthy and promote health, one will often have to go against culture and experience the rigid criticism of its members. Albert Schweitzer wrote, “The progress of ethics consists of our decision to think pessimistically of the morals of society” [1]. Cultures create the familiar and the strange. They like nearly everything else are changeable, dependent upon geography, place and time, and are socioeconomic products. The more dualistic, and metaphysical, the more alexithymic people become, that is, being unaware of their emotions, being irrational, and having a paucity of imaginative thought. You only think if you think yourself [5]. This is similar to John Dewey’s pragmatic view that you are only ethical if you yourself make rational decisions [6]. It is little known that people do not understand ethics. One cannot break ethical rules if one has none. People, including professionals, think ethics is innate and spiritual qualities. It is not. One main problem is unquestioned enculturation. People blindly accept tradition and culture, regard it as a standard of morality, and reject anything, which deviates from their particular belief systems. People think normative common and traditional practices are the standard for ethics because they are used to them in their culture. Culture can be a pejorative term, like prejudice, and dogma, and enculturation. “Speaking differently, rather than…arguing well, is the chief instrument of cultural change” [7]. We must, therefore, deprogram its irrationality, superstition and common (un-inquired) (non) sense. Dewey and Tufts state, “The intellectual distinction between customary and reflective morality is clearly marked” [8]. Reflective morality favors criticism of culture. In terms of change we need to go from customary to reflective morality [8]. Nietzsche states, “What is needed above all is an absolute skepticism toward all inherited concepts” [9]. Desires are habits and cultural tendencies and must be remade in terms of consequences [10]. GH Mead agrees that culture can and must be changed. It is in communicative evolutionary process [11]. Nietzsche wrote in The Gay Science, “Not to question, not to tremble with the craving and joy of questioning… that is what I feel to be contemptible, and this feeling is the first thing I seek in everyone: some foolishness persuades me ever and again that every human being has this feeling, as a human being” [12]. Schweitzer held that we must be highly critical of society and its past and present practices and through fundamentally individual critical thinking (speaking) renew it by making it ethical again [13]. This is also one task of the healthcare worker which cannot continue to be ignored. “Often ethics prescribes higher standards of behavior than does the law, and occasionally ethics requires that physicians disobey laws that demand unethical behavior.” [14] Physicians may have to promote their positions “forcefully” against those of governments, health system administrators, and/or commercial enterprises [15]. Children, like philosophers, are full of curiosity and questions, but they soon learn not to ask them. Questions irritate. We may wonder why by the time they are in high school there can be little curiosity left. They are captivated by the common beliefs by then. Philosophy is rarely taught or taken as a subject. (See Chapter 18) The result is an indoctrinated populace, which is largely emotionally dysfunctional (with anger, hatred, revenge, selfishness, etc.). On the common view, it is only the unexamined life, which is worth living. Cultures and religions are treated as being sacrosanct and enjoy absolute protection and tolerance regardless of the irrationality or harmfulness of the naturalistic consequences, which range from opposition to medical treatment and to medical research to favoring female and male circumcision and war. Philosophers try to show how and why people, including professionals, are so irrational and in need of education in the attempt to correct it. Also, bioethics can be no better than the rationality, emotional stability and moral soundness of the culture in which it is practiced. It will be shown why people are not and cannot be ethical. Bioethics shows in miniature what is wrong with society in general. We will not solve problems in bioethics until we solve them in the other areas of society as well. If, for example, money continues to be valued more than people, war more than peace, etc. medical care and advances in medicine will continue to suffer. In this sense we do not have an ethical right to be superstitious, irrational or dogmatic. Philosophy is a critique of culture. Virtually all cultures are based on absolutistic, traditional, supernatural and irrational thinking. A sound philosophy is an attempt to bring humanistic and practical critical rational reasoning into play in order to better society both individually and holistically and its institutions including medical practice. Bewußte Lebensführung (rational conduct of life) refers to a lifestyle, which is conscious, aware, critical and concerned with the social, environmental, ethical, and with learning as much as we can about our world. This is also what philosophy is about. Medicine does not exist in a vacuum. It is part of society. If the society is immoral, medicine is immoral, unless it takes on the task of influencing and guiding society in a more ethical direction. We can speak of normative uncritical morals as moral contamination. In this sense, medicine cannot just follow and be the servant of society, but must guide and lead it. It must set policies, which genuinely promote health and prevent death and change the culture to conform to this professional medical goal. Medical ethics should no longer be an aberration and contradiction to society. One American Medical Association Principle of Medical Ethics is: “III. A physician shall…recognize a responsibility to seek changes in those requirements, which are contrary to the best interests of the patient” [16]. A kind of dilemma is created. Medicine is practiced in a certain cultural environment. Should medicine continue to blindly comply with and encourage each culturally based or religious medical practice regardless of the naturalistic consequences? Physicians want to heal everyone adequately to what is clinically needed to continue one’s life with as much health, capabilities, insights and enjoyment for life. Physicians do not want to have to make decisions imposed on them by an unethical society which does not want to provide needed money and staff, but rather puts its wealth into areas which oppose medicine such as war. Only when ill themselves, people start to realize what healthcare provision is about, before that they have somehow the idea to never be getting ill themselves and not to have to contribute to others who are already ill. Medical decision-making is not to be taken over by uncritical societal issues such as putting economic, legal and religious viewpoints over the medical issues. The principles of autonomy and equality require that all be served equally according to the subjective desires of the individual. These principles, however, contradict the principles that one should base one’s decisions on a sound ethical theory, reason, and a concern for the naturalistic consequences for others as well as for the individuals involved. Should those who are destructive, selfish, uncaring, unwilling to follow physician’s orders, etc. just be treated without ethical considerations? If not, which ethical considerations apply? A solution to the above dilemma. Both the principles of autonomy and equality, and an altruistic ethical theory may be used to resolve the dilemma. (See also Chapter 12) We can have rational equality rather than blind equality, caring rational understanding rather than absolute autonomy. Destructive people can be treated, but an attempt must be made to correct their negative behavior through therapy or education in addition to the physical medical care given. In this way, all may be medically treated regardless of the destructiveness or negativity of the personality, irrationality of the belief system or harm they do to others, if we can understand them and not blame them for their condition. The psychotic cannot be blamed for such condition, but recommended for additional treatment. In the typical American prison system the prisoner is blamed and punished, but virtually no needed education, therapy or genuine correction is given. On release, the prisoner returns uncorrected to the street to commit crimes again. Instead of this, education, correction and therapy are needed. Similarly, a limited, physical centered medical model should go beyond the blaming and physical approach and see that education and therapy is given at the same time. In short: Autonomy becomes rational understanding and concern. Blind equality becomes fair and rational consequentialistic distribution. Physical medical treatment becomes holistic psychological and physical medical treatment. Blame becomes blameless understanding, but offering correction of personality negativity, destructiveness, faulty beliefs and enculturation. Partial local health coverage becomes worldwide universal health care. Medical health becomes medical, psychological, and societal health. (cf. WHO-definition of health) Medical health care cannot be effectively separated from psychological and societal health care. (cf. the psychosomatic approach) The physician has a direct and indirect task to see that the destructive patient obtains the needed psychological help. This may be provided through therapeutic referral or philosophical counseling and preventative measures. Stress here may be placed on preventative medicine and preventative therapy. “Non-ethical” is used here in the sense of not knowing about ethics. It means that one is neither ethical nor unethical. They simply do not know about the use and misuse of ethical terms or about ethical theories. This may also be termed “ethical illiteracy,” non-ethical thinking and behavior. One may also be unclear about morals and so be “morally illiterate”. One may not be aware of morals or not follow normative cultural practices. If one has not studied ethics, there is nothing upon which to base a judgment. 22% of Americans are functionally illiterate [17]. People at all levels of education and society are usually “discussion illiterate,” that is, they are not able to give arguments for or against most subjects. When asked for arguments regarding war, god, abortion, etc. they do not know any and cannot give any, but they “know” what is wrong or right according to mostly common or societal views. They show little knowledge of critical thinking such as giving arguments. If they are capable of giving one or two they are incapable of critically evaluating them. The philosopher’s task is honest, open inquiry and critical thinking. Non-philosophers oppose them and are therefore against rational thinking. There is widespread aversion to any kind of deeper inquiry. People turn their heads from it. It is regarded as being anti-social and improper if not insulting. It is regarded as an attack on one’s cherished beliefs. Do not ask too much, do not inquire – it might make you feel uncomfortable. There is resistance to thought. Beliefs are held in spite of evidence. This irrationality prevails in and outside of the academic world. Scientists are often captivated by their models in spite of the lack of evidence for them. Scientists seldom have a background in the philosophy of science or ethics of science. Medical practitioners typically know little about the philosophy of medicine or ethics of medicine. Dewey and Tufts wrote, “Ignorance is the root of all evil” [18]. Ethics and philosophy courses are beginning to be taught in relation to the medical field. For example, Baylor College of Medicine and Rice University Center for Medical Ethics and Health Policy offer a Graduate Program in Philosophy with a Specialization in Bioethics. The final thesis is written in philosophical bioethics [19]. Students may engage in clinical ethics work, attend meetings of ethics committees and institutional review boards, participate in clinical teaching experiences, and observe ethics consultations. They are also given the opportunity to participate in Baylor training programs for those wanting to do empirical research. Advanced degrees are no guarantee of being a critical thinker. Academics, healthcare workers and scientists of all sorts usually still have religious beliefs, which would outrage the rational person. Their enculturation may prevail over their reason. Even philosophers are often no better than anyone else in this regard. For example, they often believe in metaphysics and the supernatural, are captivated by symbolic (or formal logic) or Aristotelian logic neither of which bakes any bread. They may not have any use for the pragmatists (e.g., John Dewey) and ordinary-language philosophers (see bibliography for Wittgenstein) who have extensively and convincingly argued against the myths of formal logic. (See Chapter 18) 5.2 A Naturalistic Theory of EthicsJohn Dewey and the pragmatists pointed out that an ethics based on supernaturalism, including religion, is unethical [6]. To correct the unacceptable substitutions people usually give for open-context ethical terms we could substitute a naturalistic theory of ethics. On such a system, by ethical terms, e.g., good, right, etc. we may mean or refer to the following: To bring about our (a) informed, (b) wants and likes (c) deliberately (d) on the basis of inquiry (e) with as adequate and full consideration (f) as reasonably possible (g) of the naturalistic and global naturalistic consequences of bringing about the informed wants and likes of everyone including concern for animals and nature. In a word, it is humanism or human and natural ecology on a world-wide, all-encompassing level which includes the knowledge found in the various natural and social sciences including philosophy and aesthetics, mathematics, and astronomy. It is in this sense that we may speak of an adequate, holistic ethics. Ethics in medicine could be based on such a rational, holistic consequentialism, on humanism [20]. Humanism means simply that it is in my informed and sensitivity-based interests to help others. “A workable biomedical ethics is humanistic” [21]. “Humanism and the humanities are essential to the fullest maturation of the physician” [22]. Elliott, a physician and philosopher of medicine presents a holistic, naturalistic, pragmatic view combined with ordinary language philosophy [23]. Joseph Fletcher proposed an utilitarian “situational ethics” which is like clinical ethics stressing the concrete circumstance rather than the imposition of set apriori rules, or universal theory. Though a theologian he favors humanism over theism. He stresses the rational over the revealed and authoritarian [21]. On this theory, nothing is good or bad in itself. The theory is grounded on naturalistic wants and likes [24]. Ethical questions take the form: (1) What do I want? (e.g. goal development, career guidance) (2) How do I resolve conflicting wants? (3) How can I bring about my wants? These wants must, however, be carefully considered and based on inquiry. Aristotle thought that people are basically beings of desire. Virtue ethics arises out of desires, not out of duty. Duty and rights are basically denials of desires. If there are no desires and goals there is no ethics [25]. Goals influence all of our lives even when we are unaware of them as doing so. Without a clear and adequate ethical, rational and critical knowledge of our goals we cannot begin to establish or critique a bioethics. The U.S., similar to many other nations also in Europe, has more or less questionable moral goals. It has no ethics. Decisions are based on enculturation, power groups, economic self-indulgence, an anti-philosophical and anti-critical public, consensus, problematic legal methods, and supernaturalism. Bioethics and medicine are subject to these factors. This morals based on bringing about one’s wants may seem selfish. But selfishness involves bringing about one’s own wants at the expense of those of others. It is to do good for oneself, but bad to another. However, by definition, bad is nothing one would want to do. The naturalistic theory is also not for selfishness because this humanistic ethics is based on inquiry and naturalistic consequences leading to the understanding that one of one’s wants is to live harmoniously and ecologically in the world and society at large. Naturalistic ethics, more than any other ethics, has led to humanism and altruism. It is the opposite of selfishness. Basically, the view of John Dewey, the humanists and pragmatists is that ethics is consequentialistic involving enhancing human wants and abilities to the maximum in harmony with others and with nature now and in the future. The value of life constantly changes with our knowledge, and ability. In regard to ethics being based on bringing about our naturalistic wants and likes, Dewey even argues that these can be changed. We can change our desires [26]. The value of our life is accordingly not an absolute, but is in process. On this view, it is a teleological fallacy to look for or state the purpose or the goal of humans. The value of life reduces to naturalistic, consequentialistic criteria as opposed to non-naturalistic ones. Similarly we cannot ask for the purpose of medicine, but only how medicine may best be used to naturalistically, holistically and consequentialistically help humans and humanity. If this method were applied, it would cause a revolution in present medical practice. There are no moral reasons in medicine, only reasons. In a strong sense, this naturalistic ethics is to be scientific and efficient. Aristotle said ethics cannot be a science. Why not? Medicine also benefits from the philosophy of science and pragmatic philosophical practice [27]. According to the “naturalistic fallacy” held by G.E. Moore and people in general, one cannot reduce ethical terms to naturalistic terms because ethical terms supposedly are not scientific terms. People identify ethical terms with normative and abstract terms. But if so, then ethical terms have no relevance to our naturalistic and scientific lives. If they cannot be reduced to naturalistic terms then they must remain meaningless. Thus the “naturalistic fallacy” is not a fallacy at all, but the metaphorical technique of reversal: the fallacy is to think that ethical terms have meaning in themselves. People falsely use ethical terms as if they were “non-natural [supernatural or religious] properties” as G.E Moore held [28]. People falsely think that ethical terms are really religious terms and so ethics should not be taught in schools except as a special kind of religion. Rather ethical terms have naturalistic, scientific and descriptive uses and misuses. For example, Molewijk does not define ethics so he does not know how to integrate ethics and medicine or resolve Moore’s “naturalistic fallacy” [29]. It is simple just adopt a naturalistic theory of ethics. The use of ethical terms is not mystical. It is these commonly held normative views, which need justification.
A problem is not a problem as such. A moral problem is not an ethical problem. Should we bomb the village or the city is a moral problem based on normative acceptance of war, not an ethical one which questions war and comes to the conclusion to oppose it. We may now contrast the present policies with a humanistic policy. On a humanistic philosophy the following would have priority:
5.3 What Is Ethics in Actual Usage?Those who have not studied ethics or philosophy are not in a favorable position to make ethical decisions. The ordinary language approach in philosophy deals with what the healthcare worker and others actually say. Davies and Hudson [30] presented actual statements of physicians who were in important decision-making positions as follows: “‘I’m the judge and jury…and that may be the patient’s bad luck’” [31]. “‘At the risk of sounding arrogant, I really don’t care what they [ethics committees] think’” [31]. “The physicians often defined ethical dilemmas as situations with ‘no real answer’” [32]. This last statement is both circular and false. “Dilemma” means “a situation with no real answer.” “‘I think it’s a matter of finding something that a family can live with and you as a physician feel is justified’” [32]. This statement stresses a mere consensus rather than informed argument. Rather, we need to know what the basis is for the justification and if one has knowledge of ethics upon which to make such judgments. One physician stated, “Medical ethics is not a useful field of study” [32]. “‘I don’t know what an ethicist is, and I think that’s a made-up jargon term. It was noted that opinions about medical ethics were extremely varied’” [33]. “Doctors are no better qualified to make ethical decisions than most people” [34]. Nevertheless, the American Medical Association and other medical bodies set ethical standards. People are not able to specify the difference between a descriptive statement and an ethical one. This is also true of members of nearly every profession including many philosophers. They have the view that values are somehow within us, and that one just knows what is ethical without having to have any training or education about it. The same is true of religion. One virtually never reads the literature in the philosophy of religion about the arguments for and against the beliefs in religion. Yet, it is erroneously thought that religion is a good basis of ethics. Religion is in fact not a proper basis for ethics at all [35]. John Dewey wrote, “Religionists disparage…intelligence as a force. They properly feel such faith to be a dangerous rival” [36]. “Religion and ethics are different categories of human enquiry. Religion is as different from ethics as it is from mathematics. Religion is about faith; ethics is about reason” [37]. It is also thought that ethics is characterized by being judgments or opinions. But many judgments do not at all appear to be ethical ones, e.g., “I think he has cancer.” Some issues are said to be moral issues or ethical questions, so as to suggest that ethics might be characterized by the subject matter in question. Accordingly, if an issue is about abortion, killing, lying, cheating, sex, pornography, cancer, etc. it can be characterized as being an ethical one. But, “He lied about his illness,” is a perfectly descriptive statement, so an ethical statement cannot be characterized by just being about a certain topic. What makes a statement ethical is if we add that something is good/bad, best/worst, better than/worse than, right/wrong, or that one should or shouldn’t do something (duty). “He lied,” is descriptive, but “He lied and that is bad,” is an ethical statement. An ethical statement is like a meta-statement, a statement about a statement. Any descriptive assertion can be regarded as good or bad, so there are no ethical questions or topics as such. Contrary to what people say, nothing is as such an “ethical issue.” Thus, one reason why one cannot be ethical is that one does not know what an ethical statement is. Thus far we have only identified what an ethical statement is. Another reason why one cannot be ethical is that one does not know what ethical words mean. What is meant by “good”? An examination of its use in everyday language will show that it is in itself meaningless. Although people think ethical statements are the most important statements there are, they neither know what they are nor what they mean. People were taught everyday moral rules, but virtually never taught ethics in the schools. One has absolute rules such as “abortion is always wrong,” to avoid thinking about the naturalistic consequences. “Some think that all we can ever do in ethics is state our own position.” Or that ethics is just a matter of taste [38]. William Bartley wrote, “Words like ‘nice’ and ‘good man’ are virtually meaningless in most contexts” [39]. If a physician says she or he will give you the best care, you have no idea what kind of care you will receive, because “best” means nothing. It could mean that they will try to find you an organ for transplantation, but in the U.S. roughly half of those on the waiting list do not receive such organs. You only know what “best” means if a meaning or reason is given which specifies what is in fact signified by it. Rachel’s statement reflects this view when he writes, “Whether something is good or bad depends entirely on the reasons that can be given for or against it” [40]. Such empty ethical terms as “helps,” “quality care,” and “best treatment” are frequently found in advertisement claims for medications, healthcare products, drugs, etc. In short, ethical terms have no meaning until one is given to, or substituted for them. What people do in practice substitute for ethical terms are usually fallacies. (e.g., circularities, wrong in-itself fallacies, or absolutisms.) Good-in-itself or duty-in-itself are unacceptable substitutions. They say nothing and even preclude reasons or meanings from being given. If “good-in-itself” did have a meaning or reason it would no longer be good-in-itself, but good for that reason. The substitution for “good” based on cultural or normative practices, supernaturalistic, dogmatic, relativistic theories, would also be unacceptable, because they are irrational [41]. Good in-itself falsely implies there is an intrinsic good. “‘Intrinsic nature’ is…an expression which has caused more trouble than it has been worth” [42]. The following are examples of the misuses of ethical terms. Most everyday uses of ethical (moral, value) terms are misuses especially in the sense of being circular or absolutistic (e.g. wrong-in-itself). Examples: Morally justified. (circular, redundant) This means not justified by any reason, but enculturated and so not even to question. Utilitarianism is to produce the greatest good for the greatest number but it does not say what good is. To find that out we would need an ethical theory, which utilitarianism is not. Utilitarianism is based on agent-neutral intrinsic [that is, good-in-itself] good [43]. This treats utilitarianism as an absolutistic view, which it need not be. One could say that a dogmatic utilitarianism produces the greatest dogma (fixed belief) for the greatest number. We usually call this an absolutistic morals or non-ethics. It does show that utilitarianism is not an ethical theory, but rather presupposes one such as a naturalistic theory of ethics. As such, utilitarianism is just an empty mathematical-like formula, which does not allow us to decide between the greatest good or the largest number to try to produce the greatest good for the greatest number. Utilitarianism is also a limit of the good one can do otherwise it would state, “Produce the greatest good for all, not just for the greatest number.” Even universal utilitarianism, then, is not universal. In any case, most people are at best limited utilitarians, limited to very few, immediate people, or often only to oneself. Circular: “The wrongness of an act is just its moral objectionableness” [44]. (circular) We should have respect for all humans. (circular) There are morally right ethical values. (This is four times redundant or circular.) “Regardless of how their disease developed, it is morally wrong not to attend to their needs when they arise” [45]. “Morally wrong” is redundant and an in-itself fallacy. We do not know why he thinks it is wrong. It is just a misuse of ethical language. It is wrong because it is against my conscience. (circular) Furthermore, conscience is not an acceptable criterion because it is enculturated and based on whatever one by chance happened to learn. Nevertheless, it is held for the usual orientation not challenging this concept. It is wrong because against the consensus. (Appeal to majority and appeal to authority fallacies.) Consensus does not determine ethics.
To speak of ethics as bringing about naturalistic consequences-as-such is also an in-itself fallacy. We need to know which naturalistic consequences are meant and if they are good (in some specific sense) consequences. Each person has a right to health care. (Right is open context and can be neither true nor a reason.) It is unacceptable to base ethics on rights because rights is an ethical term and this just generates circularity. For example, “X is ethical because it is a right,” is circular. Secondly, to claim a right in itself is an ethical fallacy. A right is like a law, both of which may be unreasonable and unfair. One may have a right to inherit, but be totally undeserving. Consequentialism opposes the idea that some things are just wrong. War is wrong, but only for reasons. Because people have the thought (or intuition) that war is just right, their thought (intuition) cannot be trusted about anything. The blastocyte or the fetus has a right to life. (There is a right to life only given by the pregnant woman.) Intrinsic rights. (This is unintelligible and an absolutistic fallacy. Compare “intrinsically guilty” or “intrinsically true.”) Abortions, cesarean sections, for example, are neither intrinsically good nor bad. Nor is medicine intrinsically good or bad. It is good only in a certain sense or for certain reasons, for what it is capable of doing. To say money is intrinsically good or good-in-itself is to value the currency itself, not what it can buy. If anything is intrinsic in ethics it is intrinsic ignorance. Singer holds that nothing has intrinsic value if it has no awareness, desire or “will” [48]. Thus, if one has no knowledge of ethics, one cannot be ethical or unethical, one rather is non-ethical. Ronald Dworkin in ethics stresses rights over consequences [49]. But rights are open context terms. There are no rights as such. Rights easily become rigid absolutisms and ignore consequences. Countries claim a right to go to war or a right not to help people in need. A person has a right to autonomy regardless of how irrational one is. To insist on one’s rights is like a form of principlism, which is a way to prevent healthcare workers from making decisions on the basis of reason. Stress on rights would substitute rights for reason and consequences, exclude consequences and rational decisions. It is like an egoistic demands-based ethics. Rigid rights, principles and autonomy tend to disallow the reasoning and expertise of physicians and healthcare workers. We need the courage to open ourselves up to questioning. Students often think that questioning and education are tricks to make one think. Critical thinking (speaking) goes beyond the level of comfortableness and is thought to be antisocial and smash one’s comfort zones. There is a fear of questioning. Open-mindedness may make one vulnerable. When Shakespeare says that we die many deaths before our own, he is partly saying that death is the uncritical, emotional dullness of not using one’s reason. It is not just the average person who is non-ethical. Professionals in any field, including many philosophers and ethicists themselves, are often quite confused about ethics and morals. Ethical theories themselves need evaluation. The literature on bioethics often refers to Kantian principles for guidance, but who is really clear about Kant’s view of ethics? Onora O’Neill, a Kant scholar, wrote, “Kant’s Groundwork [for a Metaphysics of Morals] is the most read and surely the most exasperating of his works on practical philosophy” [50]. There are many interpretations of Kant’s philosophy. Fletcher interprets Kant as holding that we should just obey rules because we should. Kant does say we should do our duty because it is a duty. [Pflicht an sich. Duty in itself] [51]. This is circular as well as an absolutist or in-itself fallacy. The literature on bioethics stereotypes philosophical views and uses them as slogans without needed criticism and clarification [52]. Philosophers are needed to clarify such views to show their meaning as well as criticisms of them. Kant says we should act out of a “good will,” but this is an obscure notion and assumes also the mentalistic unscientific notion of a “will”. To say we should act out of a good will is also redundant and circular. The Yale philosophy professor, Allen Wood states, “Good will” is “unknowable metaphysics” [53]. It is also circular to say, “The best will in the world does the right thing” [54]. On another interpretation we may briefly characterize Kant’s ethics as follows: Ethics is created by humans. It is a form of our understanding imposed on the world. There is moral law within us. According to Kant’s theory of knowledge concepts without sensations are empty, sensations without concepts are blind. Similarly one might suggest, law/ethics without action is empty, action without law/ethics is blind. The ethical form is law-like for ethics to have a standard, which is assumed to apply to all alike. His formal principle is: “Act only on that maxim through which you can at the same time will that it should become universal law” [55]. It is hard to know what Kant means by universalization here. In bioethics it is assumed that one can just somehow universalize, but it is not clear how to do it especially as, on one view of Kant, he cannot primarily consider consequences or wants. On what basis could one then universalize? O’Neill does say that the basis of the principle is non-contradiction [56]. It will not help us then to know what to do, just to know we should not contradict ourselves. Universalizing will also be further discussed below. On one view, the Kantian categorical imperative tries to approach a “universal” decision making program, aiming at inter-individual exchangeability in the sense of consequences for the decision-maker as well as the ones concerned by the decision. The definition of the quality of consequences remains unsolved. Rational decision makers are required to bring about rational consequences. On the other hand, he tells us not to primarily consider consequences, wants or likes. The principle of non-contradiction is used to oppose lying (because it undermines assumed truth telling and confidence in each other), to oppose suicide (because contradictory to remaining alive to be the ethical law-giver), to oppose the development of one’s natural talents and capacities (because as a rational person it is self-contradictory not to or to instead seek only pleasurable indulgence). For Kant the goal is a community of ends of everyone, a shared commitment to universal principles. One could understand this as a consistency principle: If we are to live in an ethical world all must have ethical principles. There is certain logic in the non-contradiction principle. We ought to know that if we go to war it supports the institution of war and is contradictory to staying alive. “Reason” is given special interpretations such as a “faculty of principles.” We supposedly must ground morality on our rational “reason,” even if we do not know what that is. Unlike others, Wood sees Kant not as a deontologist, but as a consequentialist [57]. We must follow law-like duties because the natural desires and behavior of people are untrustworthy. We must therefore try to make our culture and society more reasonable. If we think about law, it is something one should follow and so one might conclude that if there is to be law there must, by definition, be the duty to obey it. One reason for following law is because people are not very rational and their wants and inclinations depraved. Accordingly, Wood refers to “Kant’s picture of human beings as arrogant, antagonistic, deluded, and unhappy” [58]. This account is not meant to give the correct interpretation of Kant, but to indicate the problems with even trying to interpret Kant. Kant spoke of the forms of understanding, and other “faculties” creating an outdated mentalistic “faculty psychology.” His follower Ernst Cassirer, in The Philosophy of Symbolic Forms, replaced “faculties” with symbols and language such that experience is transformed into language, which then constitutes “reality” [59]. Wittgenstein [60] brought the trend full circle by holding that language has epistemological primacy and that the limits of our language are the limits of our world. On this view, ethics is a linguistic, rather than mentalistic construct. Ethics becomes a use of language. To investigate ethics is to investigate the uses and misuses of language. This is the position of ordinary language philosophy and the one stressed in this book. (See also critique of Kant in the Chapter 17) What could it mean to seek universals in ethics? Universal principles are like algebra of morals. Do not look for a common morality. If rules are absolute, absolutism is a way to avoid deciding. Carse wrote that universals and vague appeals to an absolute justice are ways to block rational discussion [61]. Pellegrino argued that it is futile to look for one unified theory of all medicine [62]. It is as if to say we are not intelligent enough to make decisions, therefore we must appeal to an absolute commandment, law or fixed mathematical formula such as utilitarianism. Universal can just mean a plurality. A particular can also be considered to be a universal in many ways, e.g., in that many can understand a particular, or perceive a particular and that language involves such universal principles. Laws are statements using or implying empty value terms such as commands, should, should not, duty, right, wrong, good, bad, better than. Law as codes or canons of morals or wants is neither ethics nor as such ethical. Law as rules, statutes, regulations, ordinances is empty of content and so not ethics. If the legal statement stresses the value terms, ought, should, duty, responsible, negligent, and their negations it places stress on action. Law as commanding action is similar to concepts such as: proselytize, indoctrinate, promote, persuade, enculturate. On this view, the rules should be followed. In this sense, it means no more than that something or other should or ought to be done or the command to do or not do something. Again, this is not an ethical theory nor is it based on one. Similar value terms are used in every area of life, but it does not mean we should follow them. The law, however, can be based on an ethical system, but it is typically based on an unacceptable cultural belief system instead. Law based, for example, on a naturalistic and humanistic ethics would be such an example. As the law often punishes instead of providing education, therapy or correction of the offending cause it is especially unethical. It is not an ethical system when action is based only on threats of punishments. In sum, the law is neither theoretical ethics nor practice of an acceptable basis or standard of ethics. There is no duty in itself, no free-floating duty. On a naturalistic theory of ethics absolute or abstract duty- and ought-statements would be reduced to consequentialistic or hypothetical if-then statements. “It is your duty to do x,” becomes, “If you do (not) do x, y will (might) happen.” We may refuse to obey an unfair law because the consequences are thought to be unacceptable. Even some religious physicians do not follow their religion regarding certain medical practices because the naturalistic consequences would be too disastrous. On a naturalistic theory, we would always first ask for the reasons for and consequences of doing an alleged duty or obeying a rule or law. What will happen if I do (not) obey this law? This theory would oppose blind obedience of the sort taught in society, schools, in the church and in the military. To obey blindly, and to have blind belief, faithfulness or unquestioning loyalty is unethical. In science there are no absolute laws, truths, or absolute facts, there are rather hypotheses. For some reason, ethicists have sought to try to create or discover universals. It is not clear what universal means in this context. Universal is, in the first case, not a substantive but a modifier. “All life dies” is a universal statement, but it is a descriptive and quantitative, not a value statement. It is a descriptive statement, which is universal. We may desire universal healthcare. This often refers only to a certain country, e.g., hoped-for universal healthcare for the United States. Universal really would be universal world healthcare. Here universal is a modifier of healthcare. We may say “All people in a society act in such and such a way.” Universal action is limited to the society and only gives custom, practice and morals, not ethics. To seek to universalize action is not an ethical principle. Universalizing is merely a quantitative notion. To merely apply a rule to everyone is not an ethical principle. It is only to include everyone. In ethics, universalization means an ethical term is combined with a form of the term “universalize.” In order to determine what to universalize specifically means, a theory of ethics is needed. In ethics we may speak of universal rights, universal good, universal duty, etc., that is, to apply universal as a modifier of ethical terms. But what is attempted to be universalized, can be beneficial or harmful. Kant gives us the principle, “act only on that maxim whereby you can at the same time will that it should be a universal law.” Universalization is, for example, to have rules that affect everyone without exception. As that demand is too stringent we can say “try to” affect all. It is like seeking a law in science. One problem is that it commits the “all-fallacy.” No law is absolute or applies to everyone, nor is there universal agreement. How is one to determine universality – by what criteria? Again an ethical system would be needed to determine that. The non-ethical utilitarian principle of producing the greatest good for the greatest number is a form of the principle of universalization. Universality as equality suggests equality of treatment, but equality is not an ethical principle. There are also many different interpretations of what Kant meant by universalization, but whichever interpretation is used, the above points should be considered. If law and universalization are used as principles in bioethics their full and detailed meanings would first have to be clarified much more than they now are. In view of the above we can make a distinction between an ethical (critical) ought/duty and a moral (uncritical) ought/duty. There can be rational ethical and irrational moral duties. A rational medical obligation is much different from a supernatural religious obligation. Ethics is not consensus. Such misuses of ethics dehumanize humans. They are contradictory to being human. “Non-decision is subhuman” [63]. Consensus is regarded in philosophy as a fallacy. Consensus, like democracy, presupposes the existence of educated participants, and those interested in the interests of all, not just one narrow group of people or political unit. A broad democracy or consensus would include the representation of all people, e.g., as represented by international bioethics organizations. It is not merely a survey of uninformed individuals or local preferences [64]. We cannot uncritically base ethics on conscience. Conscience is whatever we happen to believe or have been enculturated into. It would have value if it were based on a sound ethics, however. Thus, the following position of the British Medical Association (BMA) is not easily acceptable. The BMA says physicians should act within their own conscience [65]. Conscience may err. Conscience is often what we are “moralized” into. This reduces ethics to morals. Rather, on a naturalistic, consequentialistic, humanistic theory of ethics, we can and must use our intelligence to determine what ethical terms mean and how to be ethical. Phronesis is intelligent deliberation, practical reasoning and ability to figure out the most effective and useful action in each specific situation. Ethics is not the acceptance of a fixed theory, which will apply to all cases, times, and places, but the subjection of each ethical view to scrutiny. Our moral decisions are based on diverse relativistic belief systems and practices such as party politics, cost-benefit, punishment, war, rituals, etc. and thereby lack adequate overall consequentialistic ethical direction. We are literally and metaphorically nationalists, not internationalists. Most people have not reached the level of qualifying as world citizens or critical thinkers able to use their reason for the benefit of humankind. Accordingly, Kilner states, “Western ethics is impoverished and ultimately unconvincing to the extent that it lacks a story to explain and ground its concepts” [66]. The same would apply to other peoples of the globe. Brown and Singer state, “The idea of living an ethical life offers a revolutionary alternative to our present way of living” [67]. 5.4 Ethics and Morals: An Unethical Society
Michael Kline criticized that we do not question customs, which become deeply held and extremely difficult to change over time [70]. Smoking, drinking, drug taking have become norms and “any attempt to eliminate or modify or reverse [such] behaviors…often provokes resistance” [70]. Kline nevertheless recommends trying to change such behavior and customs for health reasons. If people are non-ethical, we must appeal to their irrationality and uncritical morality, but preferably help them to become ethical through discussions, courses, in-service programs, and providing models. Kossek and Block state, “Morality comes about as a result of the codification of traditional behaviors, conventional wisdom, particular familial or social orientations, and current public opinions. Morals are not subject to intense scrutiny, do not require a sound philosophical foundation (or sometimes any particular foundation) …. Ethics on the other hand, demand a supportable philosophical foundation” [71]. A distinction may be made between ethics and morals [72]. Ethics is critical thinking (speaking). Morals are not critical, but just uncritically taking over the unreflected values of society. Morals may be used to refer to the uncritical usual customs, rules, beliefs and practices of a society. They are not based on rational justifications or naturalistic consequences. They are enculturated and indoctrinated practices, more like learned habits or rules than thought out behavior. The medical system of a culture is also based on such morals. They are only descriptive of practices, customs, traditions and rituals. The popular, normative and common enculturated morality is often played off as ethics. People have familiar beliefs, which, regardless of how absurd, set their standard for what is right or wrong. They hold on to their beliefs tenaciously to their death simply because they are familiar. This is the fallacy of argument from familiarity and argument from tradition. Ethics, by contrast to morals, may be used to refer to an analysis of what ethical terms mean, and stresses the understanding of ethical terms, their uses and misuses and consequences. Ethics is a way of decoding and dismantling morals in order to evaluate outcome when morals are applied. It also involves the creation of rationally justified and sound theories of ethics with special concern for the naturalistic consequences of such theories in actual practice in specific contexts. Ethics is therefore not at all the same as morals, but a critical examination of morals and cultural practices. Ethics is in this sense a critique of culture. According to Albert Schweitzer, ethics must fight with three opponents: thoughtlessness, egoistical selfishness, and society [73]. To take one example of how the culture is harmful: 80 million to 114 million women were brutally circumcised including 80% of the girls in Alexandria. Sudan circumcision or infibulation of young women ages 15–19 in 1990 totaled about 90%. There are four levels of circumcision: 1. excision of the prepuce, 2. plus all/part of the clitoris, 3. plus all/part of the labia minora, 4. plus infibulation which includes the stitching up of the vaginal opening. The operation at levels 2–4 guarantees that the woman will never experience sexual satisfaction. Roughly 15–20% of the women have infibulation. It is a cruel, often fatal and totally unnecessary operation based on cultural morals, such as tradition and religion. It was performed usually by women without anesthesia or sterile instruments. Hemorrhaging, shock, infection, pain, lasting complications, and high maternal mortality result. A circumcised woman is so scarred that her genitals could easily burst during childbirth and cesarean section is usually recommended and normal birth prohibitive. This means that in areas without a hospital birth-giving women can easily die. Circumcision is not associated with one special religion [74]. Popularly and politically accepted are just the uncritical and enculturated morals of the society regardless of naturalistic consequences, or harm done. It is blind conformity, not ethical practice. Ethics is critical of one’s beliefs and of one’s familiar and comfortable practices. Ethics is therefore found by people to be incomprehensible, inconvenient, irritable, or outrageous. Ethics is often rejected out of hand. Ethics is regarded as immoral, and in a sense it is deliberately so. Often to be ethical one has to be immoral. In morals, as with the acceptance of some cultural practices and war, harmful consequences are totally accepted, rationalized, or covered. Something may be ethically right, but morally, normatively, traditionally, and commonly, as well as, legally “wrong.” Legal wrong is used in a non-ethical sense. It could instead be called common or legal practices and beliefs. It is often even thought immoral to question morality, to critique it, and so ethics is avoided or opposed. This was the problem with the questioning by Socrates. Ethics is usually not taught in schools as ethics, only as morals. To take the reverse view one could in disagreement say that it is unethical generally not to critique morals and the traditional practices and beliefs of a society. Ethics requires constant reevaluation of our values and has the practical task to oppose those views, which block it. It is for this reason that healthcare workers must constantly critique society and existing medical practices in order to be ethical. Bioethics is not just a critique of medicine and scientific findings, but is also necessarily a critique of the basic beliefs and practices of our society as these affect medicine. Bioethics’ problems stem from problems with society. Society’s “philosophy” is not the same as the “Philosophy of Society.” The former is the uncritical perspective of the society the latter is a critical one in the life we could lead. Society, as such, does not have a coherent philosophy rather a random contradictory collection of beliefs, practices, dogmas, and customs. Bioethics is not mere bio-morality, it is a critique of morality. The pragmatist-humanist John Dewey argues, that “philosophy is inherently criticism” [75]. It involves criticism of culture and humans in all ways as well as critical thinking about ourselves. We “live” in a world at war with ourselves, with billions of starving, in need of medicine, without jobs, punishing others or being punished, with illiterate people having, in addition, numerous negative emotions. The United States is a nation with the greatest technology, but not with adequate morality. In the area of morality there has been, in general, questionable progress. To the extent that the United States and European nations are in the best positions to improve the world, they have rather chosen to annihilate it and let billions die. Technology has advanced remarkably, but ethical behavior and critical thinking have not. Those who are in most ways significantly able to help those in need let them die instead. The morals of the major and minor countries consist of selfishness, of killing as a foreign and/or domestic policy, of the use of cruel punishment of prisoners and violators of the law, on the basis of cultural beliefs. This is the lowest form of morals and is distinctly a paradigm of being unethical. It is this unethical societal background, which imposes itself on the medical profession. Society believes strongly in moral retribution and that criminals should be punished for their crimes. They only in the most extreme cases allow psychological problems or similar reasons as a defense. “Not guilty by reason of insanity” is seldom allowed. Prisoners, however, are also products of an unethical society. The McNaughton rule became the standard for insanity in the United States and the United Kingdom, and is still the standard for insanity in many states. The “McNaughton rule” (1873) for insanity is not knowing right from wrong and was a standard to be applied by the jury, after hearing medical testimony from prosecution and defense experts. The rule created a presumption of sanity, unless the defense proved “at the time of committing the act, the accused was laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act s/he was doing or, if s/he did know it, that s/he did not know what s/he was doing was wrong.” If sanity requires knowing about the difference between right and wrong, and if people do not know about ethics, then they would to that extent also not be considered sane. Also in disease of the “mind,” mind is a pseudo-psychological notion. The definition just has the meaningless terms right and wrong as criteria. In 2005 the U.S. was thinking of drafting doctors. Doctors cannot complain as many of them seem to believe in war. Sidel and Levy state, “War is clearly antithetical to public health” [76]. Why does this even need to be said? Is it not obvious? They state that there were 45 million deaths caused by the military in the twentieth century [76]. They state that participation of the healthcare worker in the military may be contradictory to their profession and unethical [76]. When the budget is exhausted for war, it does not allow funds for healthcare and the U.S. is not able to give adequate aid to all people who would need it [77]. War is conventional culture. Culture is the uncritical eye. 5.5 Value ContradictionsCommon morality is basically self-contradictory. One could say that holding contradictory beliefs is a sign of uncritical morality rather than critical ethics. There is ignored moral inconsistency and searched ethical consistency. According to the ethics versus moral view, something can be moral, but unethical; immoral, but ethical; both immoral and unethical; both moral (by chance) and ethical (by reason). “People can and do frequently hold mutually exclusive moral beliefs, meaning they are in contradiction with themselves, yet most individuals holding such beliefs normally don’t see the conflict” [71]. As morals do not involve critical ethics it is understandable why there is contradiction and inconsistency regarding morals. The people of any nation are typically anti-inquiry and anti-philosophy, yet become puzzled and angry when they have to accept the consequences of that. The Chinese and Khmer Rouge and others purposely killed intellectuals and university people and in 2005 the U.S. government is known as an anti-intellectual government more interested in faith and business than philosophical, scientific and medical research. The anti-intellectual priorities are shown when a baseball contract for one single player was written for 100 million dollars in 2006. As an example of anti-inquiry R Moser, editor of JAMA and Director of the Division of Scientific Publications AMA, in “An Anti-Intellectual Movement in Medicine” [78] stated, “I have detected a subtle anti-intellectual, anti-specialty, anti-research movement developing” [79]. “I see a vast swampland of intellectual impoverishment in medicine ahead” [80]. This was in 1975. The anti-inquiry, anti-philosophy nature of people generally has never been subtle. His statement characterizes the situation also in 2009. People everywhere are opposed to at least some killing under some circumstances, for example, if someone intentionally runs over a child. One might then try to show that it would be a contradiction for one to oppose killing in these circumstances, yet not oppose it in war. This is not to say that it will convince them, for people, including professionals, are quite prepared to ignore or rationalize contradictions. The result is again that, in the end, they will probably not be embarrassed regardless of the number of people killed. Whether one killed 1,000, 10,000, 100,000, 1,000,000 in a war are just figures for which people have no concern. They support policies, which can kill nearly everyone alive immediately or over time. If one agrees to kill one, the actual number killed is of little concern. 5.6 Examples of Contradictions
5.7 On Being Non-ethical and Anti-InquiryThere is literally no personal value of life unless one knows what ethics is. It is not just that people do not know about ethics, they do not want to know. Enlightened management and personnel “conflict resolution” presuppose that one knows about ethics and emotions, which is usually not the case. Many people in virtually all cultures are anti-inquiry. Statements to this effect are abundant: “It is hardly possible for health care professionals – most of whom are either ignorant of or in disagreement with moral theories – to apply theory to their own very real moral problems as they arise in the specific cases for which they are legally, medically, and morally accountable” [84]. Rendtorff and Kemp under the principle of autonomy regarding bioethics refer to the necessity for an individual to have the capacity to create ideas and goals for life, and the capacity for moral insight, and self-legislation [85]. This assumes that one is only a moral/ethical person if one knows about ethics. John Harris even defines “person” as one “capable of valuing its own existence” [86]. “Value decision-making is frequently based on morally irrelevant grounds, is inconsistent and idiosyncratic, and results in much unnecessary suffering and the wasting of limited resources” [87]. “How little anyone cares about living philosophers” [88]. “Bioethics professors were trained in the arcane field of philosophy” [89]. Opting for a transcendental, supernatural, religious basis for bioethics, Smith’s main objection is that bioethics now begins to base its morality on critical thinking and “rational analysis” [90]. Anne Maclean asked, “Why should we attach more weight to the pronouncements of philosophers on moral issues than to those of other people?” [91]. The answer would be the same as to why we should attach more weight to the pronouncements of physicians on medical issues than to those of other people. “As long as there has been such a subject as philosophy there have been people who have hated or despised it” [92]. “Clinicians consistently argue that they cannot see how philosophy is clinically useful” [93]. “Ordinary people pay little attention to theories when they make their moral judgments” [94]. “The disadvantages of ethics are fairly obvious: they do not provide the answers…Some ethicists are accused of complicating matters further. On the whole, philosophy is better at asking questions than providing definite answers to them” [95]. Harding wrote, “I can make no sense of the claim that someone has a duty to die if the person has never been able to understand moral obligations at all” [96]. In short, it is as if ethics does not apply to medicine. The physician merely treats so as not to violate the existing laws without having knowledge of or concern for ethics or the philosophy of medicine. People are basically enculturated or indoctrinated into their culture or religion regardless of profession. Beliefs and practices are determined geographically. Where one is born determines what one believes. If the world is primarily non-ethical and children are enculturated into it, one may ask if it is justifiable to give birth. People are non-ethical because they non-ethically (without knowledge of ethics or morals) give or take rights away. Medicine is therefore practiced differently in the different cultures, religious communities and organizations. Even if the morals were taken over from a culture, it would not thereby be ethical. On the contrary, as was earlier mentioned, for a naturalistic theory of ethics one must be deliberate and the ethics must be based on rational inquiry. Fletcher says, “Whatever we are compelled to do [e.g., by culture, dogma, military, or religion] is amoral” [97]. Compelling and expected customs are no theories of ethics. In a strong sense, ironically, for most people, ethics, morals and values are valueless. Joseph Margolis even argues that life is meaningful (significant) or has value only if one acts morally [98]. This statement is supportable unfortunately being also circular. Metz notes that life is not meaningful independent of the choices one makes [99]. Just following rules or culture is not to make choices, but enculturation. Choice or deliberation involves our positive action, but choice also requires critical inquiry. Against the existentialist position of the philosopher Sartre, mere choice cannot be the foundation of ethics. Loewy maintains that one is a person to the extent that one can understand values, possess creative intelligence, have reflective inquiry [100]. Even in a society where killing is not directly justified, it is carried out and justified indirectly in daily practice. Moral choices are made even if one does not know about ethics, although such “choices” are blind ones. When one decides that it is acceptable to harm and kill others, to what extent should this nullify one’s right or preference to medical treatment and life, for example, when resources are scarce? It is clear that they put a low value on human life. “The capacity for and exercise of self-determination [autonomy] can be… the – fundamental ideal of the person [patient] within medical ethics” [101]. Firstly, what is the self to be here? Secondly, why is autonomy, e.g., of an uninformed or selfish person to be the ideal? And thirdly, it would seem especially an ideal in medical ethics and is often not realizable. According to the principle of autonomy the patient has the ability and a right to determine his/her own treatment. Some say the ability to be autonomous is the characteristic of being a person, i.e., have the rational and psychological abilities and behavior and knowledge of one’s own wishes and values and social abilities [102]. There are serious problems with the principle of autonomy. Patient centered therapy is not advisable where the patient lacks knowledge and is unable of critical thinking and finding out about the best, adequate decision. We must consider one’s ability to judge just as we consider the patient’s medical disability. Anti-inquiry is anti-medicine. The so-called “autonomy of the patient” means respect for the patient as a rational agent acting freely and not under constraint. But what, if a patient is not rational, and under cultural constraints and cannot evaluate his/her quality of life? Abandoning patients to their autonomy is all too easily done. Respecting autonomy in the competent person presupposes beneficence on the part of physicians (For further analysis see Chapter 9) [103]. It is also the assumption made in Rogerian therapy and Socratic oriented views of Philosophical Counseling, that the patient can solve his or her own problems and that the therapist need not actively guide and challenge the patient [104]. In opposition to this view, the patient should not be regarded as the expert in the areas of ethics, decision-making, emotion, or medicine, however patients should be encouraged to participate as much as possible in learning about all of these. The more the patients know about their condition and participate in the treatment, the better. The physician also depends on the patient to report the effectiveness of the treatment given, e.g., reactions to medications and drugs. The informed, not the uninformed, patient is necessary for successful medical treatment. One may be said to have autonomy only to the extent that one is qualified to have it. “The comprehension by patients of medical information is not outstanding” [105]. The information given is not as well. “Our own moral beliefs are often genuinely unclear, uneconomical, incomprehensive and incoherent” [106]. 5.8 Brief ConclusionPhilosophy may be defined as a critique of the concepts and methods in the various disciplines, e.g., of the concepts and methods of medicine. It is also therefore, a fortiori, a critique of one’s culture. Medicine is usually practiced without concern for ethics. Decisions are usually made intuitively, politically, culturally, administratively and according to law. There is little concern with holistic treatment or treating the patient as a whole personality in society. As to suggestions for a specific ethical theory, which is consequentialistic and combines the scientific basis of medicine with the philosophy of medicine one may recommend a naturalistic, humanistic theory of ethics. Ethics in medicine would refer to a rational, holistic consequentialism, be scientific and efficient. It also benefits from the philosophy of science and pragmatic Philosophical Practice [104]. In many areas people are working to promote death rather than to prevent it. Culture stands against medicine and philosophy. The armies, not medical care, lead the world and medicine helps them to do so, though the two are fundamentally opposed. Medicine, like philosophy, goes against culture and the beliefs and practices of the vast majority of people. It is understandable, then, that bioethics and the philosophy of medicine will clash with culture. It is understandable also that culture, religion, politics, economics, and law have succeeded in controlling and domineering medicine. Medicine is a mere disenfranchised servant of the society. Medicine must be made rational, whole, and humanistic again. It must lead, not follow, the culture. To do so it must hold its principles against the uncritical culture and society, and ironically against the average person, whom it helps and heals. In the words of Albert Schweitzer, Ethics must fight with three opponents: thoughtlessness, egoistical selfishness, and society [107]. Renewal of the culture is only possible if ethics becomes once again the domain of thinking people [108]. Medicine has the job not merely to serve society and culture to advance their welfare. It has the task of taking a leadership role in helping to develop their ethics and character. The AMA Principles of Medical Ethics [16] state, a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health [109]. Physicians and healthcare workers must lead society in medical decision-making, not merely blindly serve existing culture and political and militaristic programs. 5.9 An Ethics Text for British Medical SchoolsThe General Medical Council requires ethics and law as part of the core curriculum for medical students. The text, Medical Ethics and the Law, is a consensus outline of the core guideline [110]. Because of the importance of this book as official required reading for medical students it would be well to offer a critical review of the book. It is an attempt to provide a guideline and principles, which medical students can follow without having to engage in their own reasoning. A similar, but less official book in the U.S. is Jonsen’s Clinical Ethics [105]. An alternative to such protocol oriented books are bioethics anthologies such as Kuhse and Singer [111] whereby specific issues can be presented in depth for discussion. The following is a review of the book by Hope and his co-authors. Consequentialism is unfairly represented in this book as considering only partial consequences [112], utilitarianism is superficially critiqued, naturalistic and humanistic ethics of John Dewey – perhaps the most important and workable ethical theory – are not even presented, Kant’s deontology is uncritically stereotyped and as presented of little application in medicine [113], the four unacceptable principles (principlism) of Beauchamp and Childress [114] are uncritically presented (see extensive critique of these principles in the present book), the account of virtue ethics is also inadequate. Hope and his co-authors do not clarify the use and misuse of ethical terms and we never learn what ethical terms mean. Communitarianism is presented, but it is not an ethical theory and based by them on the fallacy of consensus [115]. The account of feminist ethics misses the central basis of the feminist approach, which is the anti-patriarchal model and fails to analyze the concepts of caring, and narrative. (See critique in the Chapter 9) They state that one should clearly distinguish between medical and ethical facts [116]. First of all, there are no absolutely true or objective “facts.” Secondly, on a naturalistic theory of ethics, both ethics and science use the same method of inquiring to find ways to achieve specified goals and consequences. Ethical methods and scientific methods are similar. It is a myth to think that ethics is separate from or cannot be reduced to or taught as a science. Such a myth is based on the view that ethics is religion or that we cannot derive ethical statements from factual statements called the “naturalistic fallacy,” or “is-ought fallacy.” But this so-called fallacy is not a fallacy because if ethical terms are to mean anything at all they must be reduced to naturalistic terms. Otherwise the abstractionist, empty ethical terms will have no meaning whatsoever [117]. Emotions are said to play a part in reasoning and ethical argument [118]. However, no clarification or theory of emotions is given. Formal and symbolic logic are given by Hope as methods of obtaining valid arguments and reasoning. This is a myth. Formal logic is abstractionist metaphysics and of no use in practical or any reasoning. (See Chapter 18) Informal logical rhetorical fallacies such as circularity and appeal to authority fallacy are necessary to be aware of for sound reasoning, but the ones given in the text are formalisms and do not represent the main ones and the ones given are trivial, e.g., the “No-True Scotsman Move” [119]. A discussion of desire-fulfilment theories is briefly presented, but again no definition or clarification of desire is given or explanation of how desire may or may not lead to action [120]. “Intrinsic goodness” is discussed without mentioning that it makes no sense to speak of such an empty category. Nothing is good in itself, or intrinsically good. “Best interests” of the patient or infant is discussed, but “best” is an open context, empty term. No attempt of clarification is given, but instead an appeal to culture, to religion, to a mentalistic “freedom of the will” [121]. In the discussion of ethics as rights it could have been pointed out that right is an open-context term and meaningless in itself [122]. There are no rights in themselves. In this case the authors did at least point out that rights need not be absolute and do depend upon consequences. Autonomy is appropriately but briefly criticized and it is pointed out that to be autonomous must rest on rationality and there may be higher order desires and even a life plan [123]. These are important points, but it would have been good to expand the higher order desires to conclude that autonomous decisions should be made holistically and in terms of one’s life plans. This would mean that to be autonomous would require philosophical and critical thinking. But it is part of a naturalistic theory of ethics to consider consequences on the highest level possible, something the enculturated and philosophically untrained person cannot do (See Chapter 12). Law is presented as required, but a critique and evaluation of law is not to be found [124]. The philosophy of law is an examination of the methods and concepts in law. Stare decisis Latin “to stand by which is decided” is the fundamental jurisprudential principal that the precedent decisions are to be followed by the courts even though the case, if considered anew, might be decided differently by the current justices. This commits the fallacy of appeal to tradition and precedent. Physicians are often treated extremely unfairly in the courts and it is negligence not to include such issues (See critique of the law in the Chapter 3). To be a lawyer or even Supreme Court member does not mean one is ethical or knows anything at all about ethics. Law and jurisprudence are not ethics. 5.10 Case Example: Medicine and Dysfunctional Culture (Made Available by Dr Wolf Michael Luetje, Head of the Women’s Hospital Viersee in Germany)S is one of the two daughters of D. (D who has several shops in the Katmandu Valley. Katmandu, capital of Nepal). The family is of royal origin and wealthy. S was age 20, married for 2 years and was attending a business school. She was pressured by both families to have a child. They thought it abnormal not to do so. As a woman without children is without honour and she may lose her husband. The woman was desperate. Her father then sent her to a fertility clinic in India where she underwent IVF (in vitro fertilization) because her Fallopian tubes were blocked due to an infection. In her sixth week she had a miscarriage. Her husband threatened to leave her. She had known for a long time that he was unfaithful to her. Her father then arranged a second IVF in Germany. This also failed. After her return to Katmandu she became an “untouchable,” meaning that she had to serve all family members and that her husband would not touch her also. She also had to stop her studies. As she was infertile and “untouchable” her husband had no use for her and had other women instead. Her father did not give up and 2 years later sent her and her husband to America for fertility treatment at a cost of $10,000, which is the sum of healthcare costs for 10,000 women in Nepal per year. He had lost his only son in an automobile accident and perhaps in the hopes of having a grandson to “replace” his lost son he had sent his daughter to America for fertilization. She was successful this time and delivered a son in America. A caesarean section was performed at an astrologically favourable date selected by the father. Upon her return she was welcomed as if she were a queen and her husband took especially good care of her and the child. She completely regained her original social position and was also allowed to continue her education. Reproductive technology saved this woman from being destroyed by her culture. Along with humanism and the naturalistic theory of ethics comes an ethical concern with global medicine and concern with all those who are in need of food and medicine. 5.11 Case Example: Military Medical Service as Contradictory to Medical PracticeThe editors of the volume containing the article by Sidel and Levy [125] felt compelled to give the following caveat regarding challenges of the very morality of physicians serving in the armed forces. “The following chapter is controversial. The field of ethics is a discipline of logical and philosophical analysis that requires debate. For true debate to occur, opposing viewpoints must be advanced forcefully and analyzed rigorously. The editors recognized that examining opposing viewpoints could challenge even our most basic presuppositions and that these challenges would cause discomfort. Were we not to include the challenges, we would fail to generate the required thoughtful analysis and debate.” “Conventional war has largely disappeared…replaced in recent years by fierce ethnic or religious rivalries” [126]. The requirements before going to war are not known or considered. All wars are in the philosophical and rational sense unjustifiable and crimes against humanity [127]. Now hundreds of thousands of children are used as soldiers and killing is in the millions. Gelfand says it is not a contradiction for a physician to develop bacterial weapons [128]. But the military has the job to kill, healthcare workers have the job to heal and keep alive. No two professions could be more contradictory. But is the physician’s helping to heal soldiers not contributing to killing again? War is totally contradictory to the physician’s profession. Also, military healthcare workers may well be tried for war crimes just as would be appropriate for anyone serving in the military. Thus, we may ask, “Should physicians serve in the military service and so contribute to war and killing?” This is a contradiction to the physicians’ oath to heal and save lives and is not justifiable. It contributes to more killing, injuries and death. Just as the physician has the duty not to support any criminal activity s/he has the duty not to support the military. This issue was addressed by Michael Gross who wrote that, every soldier is ruled by the military and state and has no rights to life or medical treatment except for the purpose of fighting for the military [129]. “War fundamentally abridges an individual’s right to life” [130]. “War…undermines each actor’s right to medical care” [130]. “Combatants lose their right to life as they gain the right to kill” [130]. They have no individual right to refuse medical treatment or to die. They can, however, daily be commanded to sacrifice their lives. Combatant risks of 50–100% casualties are usual even for minor military gains. Soldiers can also be required to take experimental and harmful investigational drugs [131]. Soldiers do not have identity except as part of a fighting force. They have no use, or patient rights except as military fighters. “Right of one’s own wounded soldiers to receive medical care is contingent upon their ‘salvage value’” [129]. Salvage value which is the likelihood of returning to battle, replaces the “quality of life” criterion. “Those beyond salvage…may not appeal to any right to life to secure medical treatment when resources are scarce” [129]. “The good of the self is not a concern of anyone in the military” [129]. “Utility allows military necessity to trump other military constraints on military action” [130]. War overrides civil liberties, autonomy and the individual, whether civilian or combatant. “Enemy soldiers have no intrinsic right to medical care” [129]. Healthcare workers may treat them only if they are no longer a threat. Civilian’s and non-combatant’s rights to life or treatment are secondary to military concern and may therefore be denied altogether. “During war the state rarely sacrifices a few lives to save many. Instead, it sacrifices the lives of many to save some intangible national asset.” (e.g., freedom, democracy, way of life, military interests, revenge, religion, culture, race and ethnicity reasons, power, economy, pride, legality, treaties, etc.) [129]. It is supposedly for the interests of the state, but the interests of the state may even be opposed by the majority of citizens [132]. “Non-care giving arise[s] as physicians are asked to contribute to the practice of war and the development of weapon systems (e.g., biological warfare) rather than healing the sick or injured” [126]. Physicians should not even help to develop non-lethal weapons. They are still weapons. Medical units and personnel are not respected by combatants and are directly attacked or killed. This happens also as a result of the inevitable collateral damage. Medical units are used for military disguise and so are military targets [133]. Military blockades also block medical help. Basically, at present members of the medical profession are treated as mindless collaborators of the military establishment. Medical ethics and practice is taken over by the military. There is no longer medical ethics and professional medical practice. It has become military medicine, which is a contradiction in terms, similar to saving life versus killing. “It is an inherent moral impossibility to be a physician-soldier” [134]. By killing, the military thinks it is saving lives, that the military is a kind of medical corps. The prevailing principles of military service are obedience and support of the fighting force. Sidel and Barry state, “In our view, the ethical principles of medicine make medical practice under military control fundamentally dysfunctional and unethical.” “We believe the role of the ‘physician-soldier’ to be an inherent moral impossibility” [135]. They argue that: 1. The best interests of the patient are subordinated to the goals of the military. But according to the Geneva Conventions the wounded must be cared for in war equally among civilians and the enemy. One cannot give priority to one’s own troops or deny care to others although that is the actual practice. In commenting on the authors’ objection here in a sense the obligation to provide medical treatment seems moot because the soldiers are sent into killing fields anyway. It is in some ways like sterilizing needles before executing prisoners. To be able to kill, but then treat with care makes war into a game. 2. Medical research is conducted on soldiers without their informed consent. FDA allows wavers for the military to use drugs on soldiers without requiring informed consent. 3. Triage treatment favors soldiers who can return to duty rather to the exclusion of all others. The authors believe the demands of the military have an “inappropriate” priority [136]. 4. Poor medical records are kept, or not kept at all, e.g., of the 150,000 U.S. troops, which received controversial anthrax vaccine in the Persian Gulf War. Bad batches of vaccine and other adverse effects could therefore not be identified. The anthrax trials were 40 years old and more recent ones used in animals. Those refusing the vaccine were threatened with punishment. 5. The military physician has always absolute decision power over which patient is treated. 6. The military can require immunizations or medications or exposure to unknown hazards (e.g., Agent Orange), which have a short-term value for immediate battle plans, though the soldiers may be seriously harmed in the long run. 7. The healthcare worker’s concern for life should be in terms of helping everyone in the world. It does not stop at the nationalistic borders. Sidel and Barry recommend a global perspective of medicine [137]. 8. The killing of citizens by the military clearly opposes medical practice. 90% of deaths in recent wars were among civilians, including women, and children [134]. 9. Healthcare workers are theoretically given immunity from attack and should not be used as combatants, yet they are being used that way. 10. Physicians should always do no harm. They should therefore not engage in military biological, chemical, and nuclear weapons warfare research. There should be no involvement with torture. Medicine is used by the military and prisons as a weapon [138]. Therefore, physicians become combatants, torturers and poisoners. 11. The military does not allow physicians to exercise ethical judgments. Healthcare workers must first obey orders then act as healthcare workers. In 1967 Howard Levy a drafted U.S. Army Medical Corps dermatologist refused an order to train special combat forces in dermatology because it undermined physician-combatant role. He was given a dishonorable discharge and 3 years in military prison [138]. Military physicians are not allowed to protest unethical military actions, or an unjust war, e.g., the U.S. bombing of a North African pharmaceutical plant, which supplied half of the medicine needed for the region. Conscientious objection (CO) in the U.S. is based only on sincere religious training and belief [139]. The military is anti pacifists. Healthcare workers should be allowed as COs. Three hundred American medical students refused to serve in the Armed Forces in protest of the Vietnam War [137]. Yolanda Huet-Vaughn, captain and physician in the U.S. Army Medical Reserve refused to serve in Persian Gulf War in 1990, because she thought it was an immoral war and violated the goals of medicine, and her concern for humanity. She was convicted and imprisoned at Fort Leavenworth in Kansas. The authors recommend physicians not be required to serve in a doctor draft and furthermore help end war by their refusal to participate in it in any way [140]. They further recommend that healthcare workers should take the leadership in preventing and opposing war [137]. In sum, the military and belief-systems not objecting to war and even promoting it are contradictory to medicine and keeping people alive and the professional physician should not participate in the military in any way and take the leadership in doing all possible to oppose all military action. War is a cultural metaphor the populace has accepted and is held captive by. 5.12 Insensitivity to Killing: The Failure to be EmbarrassedWhere the intellect is absent it cannot be embarrassed. Unembarrassed goes together with terms such as defensive, apathetic, unquestioning, dull, uncritical, enculturated. However, we can at least show how one is embarrassing by examining the arguments and pointing out contradictions and fallacies in one’s thinking. People, including professionals, just follow commands and so perform the most horrible acts in war, business and in everyday life. Because there are commands they are not affected or embarrassed by the acts. Canetti wrote, “‘That’s not me. I could not have done that’…How undisturbed they remain…They feel no guilt and regret nothing. The [horrible] act did not get into them” (Translation of the author) [141]. They cannot evaluate their own actions without having insight into ethics. There is blindness to arguments, which is without guilt. Only the gracious have sensitivity and can be embarrassed. How can one possibly get an enculturated, insensitive, uncritical, and uncaring person to understand the fatal consequences of acts in war? Absolutists have failed to understand the very concept of consequences. They rationalize that they are doing good. So perverse is the understanding that they will say they are not killing, but preserving peace, neutralizing the enemy, saving lives, eliminating an evil force, or making the world safer. Citizens will be enraged to be told that they are killers. Nevertheless, they are by their votes. We possess no intelligible argument to conclude otherwise. To support war in any way is to participate in war. Insensitivity to human life is combined with irrationality and unethical behavior to the detriment of humanity. It is what is meant by ethical depravity. People are concerned with and sensitive to the immediate. If my pet dies I perceive that as a great tragedy. Ten thousand killed by a bombing raid is considered a great success. Even if it were not, it is just a number. There can hardly be a greater insensitivity than this. One reason for this is perceptual distance. We know what we can immediately relate to. We feed our pet, run with it, pet it. That millions are starving in the world is only a concept, if that. We sometimes become affected if we meet the child or see a picture or video of children starving. But that too we become used to. We have seen too much of it in the comfortable setting of our living rooms to think and feel it unacceptable. We become insensitive to killing. It is thought to be normal. It is even thought to be moral. But those who actually experience war, the soldiers who did not really know where they were going into may suffer from posttraumatic stress disorders. Their bodies know more than they do. But bodies can break down under the stress as well (See Chapter 13). Physicians may never be able to adjust to the immediate perception of continually seeing and treating people severely ill and dying. Each death can be experienced as a profound tragedy and occasion for grief. One has to sensitively experience it to understand the trauma daily observed and the responsibility for other people’s lives. The immediate holds us captive and prevents us from understanding even the tragedies in the lives of our own physicians. We remain relatively insensitive to anything beyond our direct experience. We are perceptually egoistic. Rather we may try to see the world as our family. We may approach the issue from the ordinary language philosophy perspective: What use does “kill” have? “Kill” objectively means to cause death. “Kill” as an ethical term means to destroy, devastate, damage, demolish, ruin, to cause a body to fail and a person to die. On this meaning, killing by definition is wrong. Killing another is not like killing oneself. Another’s death is not like mine. But do we know what death is? [142] (See also Chapter 21). We are unclear about death – the complete destruction of our thought? What does one think (say) here? When we kill can we genuinely know what we are doing? We use the word “killing” as we use other verbs. But is it like them? Our words are living words used in practical everyday life. Such words as killing people, dying and death go beyond the use of such conscious words. What are the naturalistic consequences of killing? Does killing reach beyond our living language uses? Does killing somehow take us beyond the limits of language – into death itself? What fallacy is this, death-in-itself? We speak of death as we speak of other things and so prevent ourselves from grasping its meaning. We remain insensitive to killing because we are unable to understand its meaning. To find out exactly what something is in a particular case, we must discover the actual assessments and actions relevant to it. Typically, we cannot imagine our own death and what it might mean to die. What we say about death is said – a metaphorical, linguistic construct. We constitute ourselves by language. We are linguistic constructs. Our grief is typically not because of the death, but because of one’s own losses or because of other self-talk (thinking). One of the main reasons for the incredible insensitivity to killing is that it is regarded as a common word like swimming, winning, running. But it is not. This exposes another reason why people cannot be embarrassed about his or her killing of others. The government may be shocking, but it truly represents the citizens who have voted for it. Roughly 90%, for example, supported the first Gulf War in 1991, most oppose universal health care, yet are religious, etc. Another ordinary language view is the observation that “life” is only a symbol and so not the sort of thing that can be meaningful [143]. “Life” only has meaning in various language games or contexts. Thus, we would not look for the meaning, purpose, or value of life as such. “It’s a good life” can mean something like “I am happy,” with no actual assertion about life or what it may be. “Meaningful” in “Life is meaningful” can indicate, “Life is good.” “Meaningful” functions as an open-context value term here. The synonym, “significant,” especially connotes value. That is, each term has no literal meaning, but gains meaning by its use in a language-game. Additionally, there is no life, meaning, value as such but only linguistic usages. They are language constructs not mentalistic ideas or “objects” independent of language. Language, not perception or objects, has epistemological primacy. Medicine uses the scientific method, but the scientific method presupposes and is a linguistic construct. Every theory in science is a linguistic construct. 5.13 Case Example: On SensitivityThe following is a narrative of what it meant and means to me, the author of this book to be a physician. What is it to experience genuine sensitivity for others? It is part of my profession and to a large extent defines it. Having devoted my life to helping people, much of it voluntary, their death can become a threat almost as overwhelming and intense to me as if it were my own, if I would know what my death will be like. Having witnessed someone whose death could perhaps have been prevented or been even remotely involved in such a case is a challenge to all of my professional thinking and personal emotions. What such sensitivity does to me is that it shows the great value of life and tragedy of death. Every death of a person is the death of a world – including my own. The confrontation with death stops life. My life becomes paralyzed. How could I ever love, enjoy, have fun, knowing how those must feel who have lost their beloved. Death is what the physician must prevent. If I could not prevent a person from dying I would feel it as a failure as a physician. I ask why I am still alive after the death of a patient whom I have taken care of and felt responsible for when this other person is not? This experience tares me into a sort of life in death, a living death. Life’s fragility and borderline struggle is more evident than ever. It is almost impossible to find my way back into my everyday life or let myself be concerned with the little or large sorrows of those around me. They cannot understand I am in pieces. As a physician one always has to be aware, one little mistake and someone’s life is gone. You strive to get back to your normal life before, but there is no way back. Why did I become a physician? To find out about that? No. You kind of knew, you might have to, but you hoped, you might not. My motivation for becoming a physician is similar to that of A Schweitzer [144]. I have to decide what from my life, I have to sacrifice, how much I can keep for myself in all the areas of my life as a human being. This is my very personal decision. It depends upon my understanding and care. Common morals and societal guidelines would not work for that. They are too superficial, not sensitive enough for specific contexts (See also the Chapter 9). Schweitzer takes an existentialist position. The genuine ethical challenge can only be reduced to a personal subjectivity and sensitivity, not to moral or societal imperatives. “My personal ethics is basically subjective, because of acknowledging for every one of us the liability to decide how far s/he wants to go with sacrifice” [145]. The humanistic point is that we can do all we can for others, as a person and physician, but each one of us has to guard that we do not destroy ourselves and our lives in the process. Altruism should not exclude the life of the altruist (See also Chapter 10). 5.14 Case Example: Tsunami Disaster and Cultural Irresponsibility“Tsunami” is a Japanese word from the 1960s used to refer to large and devastating tidal waves. On December 26, 2004, the catastrophic tidal wave took the lives of eventually around 200,000 people in 12 countries bordering on the Indian Ocean. Additional millions are left hopelessly without shelter, jobs, income, health care, food or water causing thousands of additional deaths. The initial reaction of the U.S. President G W Bush was none. He waited 3–4 days before responding. When he did make a statement to contribute to one of the largest natural disasters of this sort in known history, the U.S. government initially offered to contribute only $15 million, considerably less than even the tiny country of Austria gave (100 million). The Pfizer company alone pledged $35 million. Around 3,000 lives were lost in the New York 9/11 attack, not 200,000, yet the U.S. reacted to the attack as if it were the greatest disaster in the world, totally revised its entire government into an armed camp called “Homeland Security,” and mourned as if it were the greatest victim known to humankind. However, every life lost is a tragedy, here but also everywhere. Not only here. Hundreds of billions were given for the 9/11 attack, and the average payment from the 9/11 Fund to affected families was over seven billion dollars. The tsunami funds are measured in millions not billions and the families for the most part will receive virtually no payment at all and return to starvation conditions. Noam Chomsky in his book, 9/11, wrote that our anti-humanistic and aggressive militant policy caused the attack on the U.S. He said, to find out who caused the attack, look in the mirror [146]. By Bush failing to act immediately to the tsunami news he should have washed out all of the compassion he seemed to have regarding 9/11. Suppose the Bush administration reacted as slowly to 9/11 as it did to the southeast Asia disaster? It was only after Bush returned to Washington from his vacation the donation the U.S. pledged eventually raised to 35 million and then later to 350 million toward the tsunami disaster. This was presumably because of national and international criticism that the U.S. was giving too little. Compare: A 6 year old in China gave 22 Euro, all of his earnings, and Michael Schumacher, a private person gave 10 million. The U.S. gives a miserly .1% of its GNP instead of the .7% recommended by the U.N. Even if it were to give generously to help with the tsunami crisis, it still will have an un-humanistic reputation because it does not do its share to deal with the more major problem of all the dying people of the world. Millions die each year from preventable diseases. One billion people in the world are starving, seven million in Zimbabwe alone. Sub-Saharan Africa has the highest number of starving, about 50%. Two million children under the age of five needlessly die of pneumonia each year. One million people contract malaria each year. 240,000 die of AIDS each month. 13 million children die of diseases caused by malnutrition each year. From January to April more people will die in the eastern Congo than were killed in the tsunami. 12 million each year die of lack of water or polluted water. 20% of the world’s population lives on less than $1 per day. Statistically there is enough food to feed the world but the rich nations let the starving die. The real tragedies are not just the needless, fatal wars or the preventable natural disasters, but the societal and cultural opposition to humanism, ethics and critical thinking (speaking). There is a failure to be able to think of ourselves as global, world citizens. Those engaging in lethal war should be regarded as war criminals. War is terrorism. There is no justified war [127]. As stated in Der Spiegel, there is a lack of ethical sensitivities (ethische Empfindungen) [147]. On the other hand, private donations of people were extremely generous. This seems to indicate the contradiction we inevitably find on the level of normative morality. People sometimes respond to a well-publicized emergency, which involves their own people (tourists) but have no real awareness or concern about the fact that people are needlessly dying every day all over the world. A Peace and Humanitarian Corps is needed, which is as large as the Military consisting of volunteers from each discipline (agriculture, communication, ecology, economics, education, medicine, philosophy, philosophy of religion, politics, sociology, therapy, science, etc.) to prevent war and meet the physical and psychological needs of all people of the world. Organizations such as Doctors without Borders, the Red Cross, OXFAM, etc. are excellent examples of what a peace corps and genuine heros should look like. The tsunami was not a new phenomenon. In 1883 there was one from the explosion of Krakatau Volcano in Indonesia, which drowned 36,400. In 1992 there was a proposal in Jakarta, Indonesia to develop a high tide warning system for the Indian Ocean, which would cost two million dollars, but it was not adopted. This is a massive form of letting die. The members of the Peace Corps can be basically volunteers and each member of each society would be expected to participate for at least a year. Those receiving welfare can continue Peace Corps service until they are qualified for other work. This would help to guarantee total employment for each country and reduce welfare. The military should be as minimal as necessary and for defense alone, not for aggression as it is at present. Its weapons should be completely non-lethal and environment friendly. All nations could develop their own Peace and Humanitarian Corps, which coordinates with all others. The large nations, including the USA, could especially reverse their policies to become aggressive models for humanitarian aid and peace. Altruism, rational problem solving and helping all others is also in one’s own self-interest. There is a global ethics. We can learn from it how to save millions of other lives. The island we all live on is the earth. The healthcare profession could thus be part of and defined by taking a leadership in this humanistic goal-directed, universal medical philosophy. It is a universal Hippocratic Oath. 5.15 Case Example: Culture and Family as Anti-Medicine: Female CircumcisionSavulescu gives the example of the request of an African woman for infibulation – the excision of her clitoris and sewing together of her labia. He says there is no reason to comply with religious requests that are based on irrational beliefs [148]. The following is a review of the two books by Waris Dirie who details her cultural and familial life as a Somalian Nomad who was totally circumcised (infibulation) at age five [149, 150]. The circumcision was thought to be required by the Muslim religion as well as by the culture. All of the women she and her mother knew were circumcised. If a woman in Somalia (and typically in other Muslim countries) is not circumcised she is regarded as unmarriageable and “unclean” and “impure” [151]. Waris Dirie therefore also wanted the procedure and had the prevailing belief that she would thereby become a woman. In many countries, women traditionally are taught to think that they are more of a woman if they become a mother. A traveling Gypsy woman at high cost performed the circumcision. Sex and circumcision are basically taboo topics, so are virtually never discussed. Thus, no information about such things can be generally understood or evaluated [152]. The circumcision involves cutting out the clitoris, and lips of the vagina (labia maiora and/or minora) and then sewing it up so that only a scar will eventually remain where the entrance to the vagina once was. A small opening the size of a matchstick is left so that fluids can come out. As a result urination for Dirie was painful as only one drop at a time could come out. Every step of the procedure was unbearably painful and life threatening. The legs were bound together for over a month and the child left alone in a separate place until she either died or was healed. The cutting was done without anesthesia and in unsterile conditions. The cutting itself was done with a regular or jagged razor blade, broken glass, sharp rock, scissors, or one’s teeth to bite out the genitals [153]. The sewing up of the wound was done by making holes with thorns and then threaded. Dirie’s operation was done on a stone, which was afterward drenched with blood with her genitals lying on top of the rock, and would be most likely eaten by animals. Girls often die from the procedure, as did her sister, with no one speaking about it or saying why they disappeared. The result of infibulation is that the woman is deprived of virtually any usual sexual feelings [154]. Ironically, the procedure, which was culturally thought to make her into a woman, was the very procedure which deprived her physically and erotically from becoming one. When years later extremely painful menstruation began, she had to be cut open although it was a violation of her culture, to allow the fluids to pass through [155]. The pain of menstruation was so great that Dirie, usually extraordinarily courageous and uncomplaining, reported that she wanted to die [156]. The results of female circumcision are: bleeding to death due to the operation, infections, fever, extensive scar formation, tetanus, hepatitis B, chronic urinary and bladder infections, pelvic infection, cysts, abscesses, neuronomas (tumor of the nerves), dysmenorrhea, frigidity, depression, death. One could add to her account that massive keloid scarring can interfere with walking during one’s whole life. One cannot usually give birth vaginally in these cases without disruption of the scarred tissue, or even bleeding to death [151]. The smallness of the opening and the scar tissue prevents normal birth. Birth is often self-birth and there is no possibility of cesarean section. On the wedding night as before giving birth she must be cut open [157]. In the hospital such women must typically be given cesarean section deliveries. But in their countries this is often not available. The United Nations estimates that 130 million girls were circumcised, two million a year, most in Moslem areas, including Somalia (80% of the women), Egypt (84% between age 3–13 [158]), Sudan; and one could add to their list: Ethiopia, rural Saudi-Arabia, Kenya, Chad, Malaysia, Indonesia, and United Arab Republic. (80% of the female population in 28 countries in Africa.) 27,000 New York State women were or will be circumcised [159]. Admittedly, statistics of these sorts can only be estimates. Many years later Dirie tried to explain her circumcision to a friend in New York, but as she was unsuccessful she simply showed her the scar where once her genitals had been. She wrote, “Tears poured down her cheeks as she turned away.” The friend said, “Its horrible, Waris. I can’t believe that anyone would do this to you” [160]. What were the forces, which caused the circumcision? Most immediately was the family and, in general, the culture. Dirie’s mother ruled her own life by the Koran and thought her religion required circumcision. Her father required total obedience, ruled the household strictly, beat both wife and children, and he thought circumcision was a necessary condition for her to get married. When she was 13, Dirie’s father demanded that she marry an elderly, crippled man in exchange for which he would be given a few camels. Dirie escaped from having to submit to this arranged marriage by running away without food or water across a burning desert and not knowing which was the right direction to Mogadishu where relatives lived. She carried nothing with her. Without shoes she walked over burning sand, sharp rocks, thorns, scorpions, snakes, and in the dark as well as heat of the day with cut and bleeding feet until she was exhausted. She loved her family, but it was also the source of great harm to her both physically and psychologically. She stated, “My parents were both victims of their own upbringing, cultural practices that have continued for 1,000 of years” [161]. In spite of her courageous, rational and humanistic opposition to female genital mutilation (FGM), she nevertheless had her own son circumcised as a baby, though there were no medical reasons to do so. She said it was for medical cleanliness, which ironically was one of the reasons people gave for female circumcision, but the latter involved religious “cleanliness” [162]. Religion, often almost identical with the culture, was also a cause of circumcision and dysfunction. “In’shallah” is said to mean that everything that happens is a decision of Allah. If so, then female genital mutilation must also be a decision of Allah. Dirie is a believer, yet does not think Allah decided for female circumcision otherwise he would not have given women genitals in the first place. She believes that Allah’s plan for her, her destiny, was to campaign against female circumcision and help the Somalian people change their dysfunctional cultural ways. Still she believes that Allah will take care of her mother and father who were in the most desperate conditions when she visited them after being gone for 20 years [163, 164]. In addition to superstition, and fate, she believes in prayer for rain and for other things [165]. Nevertheless, she says she opposes superstition [166]. It is hard to know that one still has superstitions when they are still bound up with enculturation. She believes in devils that inhabit the sick and stand at crossroads to confuse travelers [167]. Religion thus permeates the culture preventing rational education, thinking and medical care. It may be noted that in 1997, due to Islamic pressure, the Egyptian court overturned the ban on female genital circumcision and earlier Muslim Fatwas (e.g., Jan. 29, 1981) through Sheik of Al-Azahar who defended female circumcision as being necessary. Medicine is largely folk medicine and based on religion. Dirie mentions the word “ummi” meaning untouched by knowledge from any source other than Allah [168]. Here is pride in ignorance. It may be noted that the Islamic denial of sexuality and information about it in the Moslem world is similar to the Western Catholic, and some other Christian religions, which deny and undermine human sexuality and may be viewed as a form of psychological circumcision. Dirie wrote, “Families will claim it is their ‘religious right to mutilate their daughters’” [169]. With continued love of family, her culture and religion she found she simply had to object to some of their practices. She states, “Stand up for yourself and not let people push you around for no reason” [170]. By both her enmeshment with and yet opposition to her cultural practices, she was caught in a double bind leading her to be confused due to the contradiction in values [171]. She felt guilty because of her opposition as she says, “I could imagine them [Somali people] saying, ‘How dare you to criticize our ancient tradition!’” [170]. She thought she would be attacked or killed if she returned to Somalia [172]. She wrote, “I denounced my family and a tradition…. It made me an enemy in the country!” [173]. Her own religion opposes her speaking about and opposing female circumcision, and her occupational career in modeling is against Moslem beliefs. She faced the experience philosophers and other critical thinkers have when they inquire into the customs of culture and religion or try to establish a more humanistic society. The process of her breaking out of society to become a more humanistic and critical thinker was courageous, painful and slow. She wrote, “My visit showed me how difficult it will be for people to change” [174]. Physicians, like philosophers, must similarly have the courage to critique society, religion, and family beliefs in order to provide sound medical treatment in spite of the criticism or rejection they will inevitably experience. The U.N. organization in Bosasso tried for over 6 years to lessen female genital mutilation, but without success. They tried to teach mothers to use circumcision as occasionally practiced in Saudi Arabia which is just a ritual without cutting [175]. Perhaps because of the failure to be able to change adult thinking as proposed in her first book (1998) in her second book Dirie set her task to influence the Somalia children by improving their health and education. Dirie’s books about her experiences show the gradual development of critical and humanistic thinking and that to do so one is required to go beyond and critique one’s family, culture and religion possibly even at the expense of one’s life. This is true of philosophers as well as of scientists, as was the basis of the scientific revolution which freed physicians to gain medical knowledge. Medicine cannot just be based on family values, culture and religion and have it be scientific and successful. It must go beyond them. By critiquing society, people will suffer rejection by the indoctrinated and uncritical members of society. The questioner must be like a “desert flower” which can endure adverse conditions for long periods of time. Dirie’s first name is Waris, meaning “desert flower” in Somali. Dirie had to try to survive the dysfunctions of her family, culture and religion in order to become a more humanistic and critical person. References
Download references Author informationAuthors and Affiliations
Authors
Corresponding authorCorrespondence to Barbara Maier . Rights and permissionsCopyright information© 2011 Springer Science+Business Media B.V. About this chapterCite this chapterMaier, B., Shibles†, W.A. (2011). Ethics and Non-ethics. In: The Philosophy and Practice of Medicine and Bioethics. International Library of Ethics, Law, and the New Medicine, vol 47. Springer, Dordrecht. https://doi.org/10.1007/978-90-481-8867-3_5 Download citation
What is ethical but not moral?Ethics are distinct from morals in that they're much more practical. A moral precept is an idea or opinion that's driven by a desire to be good. An ethical code is a set of rules that defines allowable actions or correct behavior. An ethical code doesn't have to be moral. It's just a set of rules for people to follow.
What is a simple definition of ethics?What are ethics? Derived from the Greek word “ethos”, which means “way of living”, ethics is a branch of philosophy that is concerned with human conduct, more specifically the behaviour of individuals in society.
|
