Ethical Philosophies and the Hippocratic Physician
By Jason Elwell
Twenty four centuries ago, Hippocrates created the profession of medicine, for the first time in human history separating and refining the art of healing from primitive superstitions and religious rituals. His famous Oath forged medicine into what the Greeks called a technik, a craft requiring the entire person of the craftsman, an art that, according to Socrates in his dialogue Gorgias, involved virtue in the soul and spirit as well as the hands and brain. Yet Hippocrates made medicine more than a craft; he infused it with an intrinsic moral quality, creating a “union of medical skill and the integrity of the person [physician]” (Cameron, 2001).
So, how do we who are aspire to be Hippocratic physicians achieve this goal? First we must look at the foundations for our personal ethical frameworks through meta-ethics. Meta-ethics refers to the systems by which we establish morals and ethical principles. Today there are many philosophies of meta-ethics, divided into two basic categories, moral absolutivism and moral relativism (Lawhead, 2000). The difference between these is in the nature of ethical principles, whether subjective or objective. Say something exists objectively, like a vase on a table. The subject’s perception of the vase must conform to the true vase. If, however, the subject is simply thinking about a vase, that vase exists subjectively, and its properties are contingent to the subject’s contemplations. So, how do these differing systems affect the physician in attaining the Hippocratic ideal? Let us first consider relativism.
To the Moral Relativist, moral principles are created within cultures and communities, coming from cultural folkways and mores (Gerson Moreno-Riaño, personal communication). These principles are normative only in the culture which created them. Already, the Hippocratic Oath loses its moral weight. For example, in the 1973 Roe v. Wade abortion, Justice Blackmun dismissed the centuries-long Hippocratic tradition as merely a “Pythagorean manifesto,” relegating it to minority status (Cameron, 2001). However, relativism does not end here.
If moral principles are defined by cultures, how does one define a culture? If a social scientist were to dissect cultures into subcultures, and then divide those as well, he could logically continue making “cultural distinctions” until he comes to individuals as separate cultures. As a culture of one, each individual by relativism’s definition creates his own moral principles. This could be called ethical egoism (David Mills, personal communication). As logical conclusion extension of relativism, ethical egoism creates a world of moral lone rangers, with no one responsible to answer to any other.
However, in the practice of medicine, this prepares the way for an even further regress from the Hippocratic Oath. Medical scientists often find the intellectual answer to the moral anarchy of ethical egoism in noncognitivism (IEP, 2001). Noncognitivism is the stance that any ethical principles, if they exist, are unknowable to humanity. This idea is a compromise epistemologically, for the scientist rejects the pursuit of value judgments for the sake of empirical knowledge, that being knowledge attainable through the scientific method of observation and experimentation. According to Moreno-Riaño, noncognitivists disclaim the three most prevalent methods by which humanity attempts to know truth: reason, intuition and Divine Revelation. Reason, they say, produces different conclusions in different cultures over the same dilemmas. If two rational, reasoning thinkers come to disagree, what is there that can adjucate between them? As far as intuition goes, noncognivists point out that there is no standard by which intuition can be judged. Can we assume, they would ask, that every culture and every human has a common internal moral awarness and intuition? Regarding Divine Revelation, they dismiss it as totally separate from legitimate study, and beyond investigation and verification.
It is easy, then, for the noncognitivist thinker to take a further step, embracing what is known as positivism. Positivism is brute empiricism; it is an attempt to “provide a value-free system to connect value-free facts” (Strauss, 1959). Positivists hold that while science is be able to mirror empirical facts in a man’s mind, when values are seen in the mind’s eye, they are hopelessly distorted by prejudice, preference, and worldview. Therefore, every effort is made to reduce reality to what science can tell us. Positivism is always descriptive, never prescriptive.
So, where is the positivist physician left, bioethically? He is left with a dilemma. While he attempts to keep his thinking strictly empirical and value-free, the “fact” remains that values are absolutely necessary in any bioethical decision. After all, weighing the relative values of various alternatives is the very foundation of any decision. The answer to this logical flaw for the positivist physician is found in consequentialism.
Consequentialism looks at the final outsome of various alternatives when choosing between them. Instead of looking at the deontological “rightness” or “wrongness” of the act itself, it looks at the “goodness” or “badness” of the effects that the act has on people. This can boil down to utilitarianism, which strives for the greatest good for the greatest many. This allows the positivist physician to make “moral” decisions while being guided only by the sum total of good and bad effects on alternatives.
So, does this resonate with the Hippocratic Oath? Unfortunately, it falls short. First, there is nothing left by which the physician can swear the Oath to; the essence of the technik of medicine is thus lost. We see that the physician is no longer bound to his duty towards patients, but to the majority. That aside, the impersonal, brutally pragmatic nature of consequencialism grates against the spirit of the Oath. Even the idea of “good” consequences guiding the physician is self-defeating. How does one discern what constitutes a good consequence? What makes a good consequence “good?” The consequentialist bioethicist has not escaped the need for objective moral principles. In fact, consequentialism is just like any moral system; it cannot operate strictly under relativism and positivism.
We see then the downward spiral that relativism takes away from the Hippocratic ideal of medicine. So, what of absolutivism? I suspect that our preexisting absolutist views are what attract us to the Oath in the first place. With a system of objective, deontological ethical principles that are universally binding, the Hippocratic Oath has its true weight. However, even here we must refine our thinking to truly hold to the Oath. For bioethics, we need to consider what happens with ethical dilemmas, when ethical principles seem to conflict and the ethicist is left with no alternative that does not involve breaking principle.
The pure absolutist would state that moral principles are absolutely valid and absolutely applicable; therefore, there is no “choosing the lesser of two evils”. If lying is ontologically “wrong,” then any “goodness” that may come out of it is morally unjustified. If truth-telling is ontologically “right” then any resultant “badness” is simply necessary. “Rightness” and “wrongness” are properties totally independent of consequences.
While this does give a covenantal sense of moral duty, it still does not match up with the spirit of the Hippocratic Oath. The physician ends up with an ethical system just as unfeeling as that of the consequentialist. To the absolutist physician, principles are superior to people, and this becomes as sterile as the positivist’s empiricism. Also, his motivation for doing right shifts away from the benefit of others, and towards constant, self-centered moral handwashing. “Doing right” can actually hinder sincere “doing good”. While the Oath does command duty, it does so in the context of relationships: doctor and peer, doctor and patient. This human element must be factored into the absolutist’s ethics.
This comes in the form of hierarchical absolutivism, or simply hierarchicalism. Hierarchicalism is the idea that while moral principles are universally objective, they are not absolute in their application (Feinberg and Feinberg, 1993). This accounts for that which pure absolutivism shrugs aside, the context. Moral decisions, hierarchicalists would say, are never made in a vacuum, and thus moral principles should never be treated as if they exist alone. In this light, the hierarchicalist distinguishes between an “act” and an “action” (Ross, 1932). An act exists in the realm of principles and ideals, such as “the act of lying”. An action, however, exists in the world of doing and interacting: it is the actual doing of an act in a specific context, such as Rehab lying to the soldiers in Joshua 2:3-21. Acts are a major component of actions, but not alone. Motive, intent, and human relationships are factored in as well. Hierarchialists believe that there is always one right action for every dilemma, but only after the context has qualified and applied principles (e.g., deception can be used to prevent unjustified murder). William Ross, a hierarchicalist, believes that human relationships play a tremendous role in applying moral principles (Lawhead, 2000).
This resonates with the Hippocratic Oath, both in moral command and in spirit. Never denying objective, absolute ethical principles that are independent of our thinking, hierarchicalism maintains the primary motivation which first inspired the Oath — an open eye towards the fellow men to be benefited by the healing arts.
Some absolutists object to hierarchicalism as a compromise, and a slide towards relativism. However, how should the Hippocratic physician, or better yet the Christian physician, view absolutes? I Corinthians 2:16 states that the Christian physician has “the mind of Christ,” but what is the nature of this gift? Is it a “once for all,” or is it a steady continuum of receiving, as we continue to pray and ask for wisdom?
Non-hierarchical absolutists are tempted to figure out everything according to a “cookie-cutter” set of absolutes, but is this not just a self-focused attempt to keep ourselves morally spotless? Would it not be better to depend on God’s direction, as we muddle through in our earthly context, and to be lovingly aware of the people whom our high-minded principles benefit?
There are clear dangers of relativism to the physician who aspires towards the Hippocratic ideal. A solid, unchanging moral system is needed. However, there are also dangers in insisting on a system of pure principles. Hierarchicalism provides the best framework by which the ideal of the Oath composed long ago can be worked out in today’s healers.
Works Cited:
Cameron, Nigel M. (2001). The New Medicine: Life and Death after Hippocrates, New Ed. Bioethics Press. Chicago & London .
Feinberg, John S., and Feinberg, Paul D. (1993). Ethics for a Brave New World, Crossway Books. Wheaton .
IEP: The Internet Encyclopedia of Philosophy (2001). Retrieved 12/18/2002 , from http://www.utm.edu/research/iep/n/noncogni.htm
Lawhead, William F. (2000). The Philosophical Journey, An Interactive Approach, 2nd Ed. McGraw-Hill. New York .
Plato. (1994). Gorgias. Oxford University Press. Oxford .
Ross, William D. (1932). The Right and the Good. Oxford University Press. Oxford .
Strauss, Leo. (1959). What is Political Philosophy? University of Chicago Press. Chicago .