Ethics: Basic Tenets and Logical Corollaries

Philip G. Ney, M.D., F.R.C.P.(C.)

June 1987

Introduction

At a time when committees and physicians are trying hard to make ethical decisions in medicine based upon human rights and new concepts,^{1 2} it may be worthwhile to re_consider ethics based on ancient tenets and immutable principles. A proper consideration of the sketchily described and insufficiently supported principles contained in this article would take a book, maybe two. However, those inclined may see in them valuable principles that can apply to their lives and practice.

Fifteen basic tenets and their logical corollaries

1. We cannot benefit at another's expense. If it is not good for one's neighbour, it is not good for oneself; if not good for black, then not for white; if not good for women, then not for men; if not good for infant, then not for parent.³ Although there may be some apparent quick gain, empires or medical procedures built by exploitation inevitably collapse. Partly because governments and families (for selfish reasons) are able to coerce patients into accepting painless "quick fixes" instead of supporting long_term gains, we must persistently resist the pressure to get rid of the "useless eaters"__handicapped, enfeebled and pre_born.

2. In this tight bundle of life, what we do to others we do to ourselves. We progressively lose our own humanity when we dehumanise and mistreat others__regardless of who or when. When we love others it is good for us.⁴ We all benefit when we meet another's real needs. Needs are definable and measurable.

3. Each person is tri_partite__body, soul and spirit. The natural tendency is to mature and heal in all these areas. There is always a possibility for growth, even when dying. Therefore physicians' intentions must be to understand their patient's⁵ deeper yearnings and always to treat their basic disease. Even when impoverished, weary, discouraged or prohibited, physicians must facilitate self_awareness and healing until the patient is better, dead or referred to someone more competent. Until a purported remedy has been demonstrated to be both safe and effective treatment for some illness, Primum non nocere must apply.

4. People are created equal. Therefore there should be equal resources expended on each person's health and welfare. In those instances where, because of limited resources, it is only possible to treat some and not others, triage applies. Those most likely to benefit regardless of their size, shape, sex, intelligence, race, creed, social status etcetera should receive treatment first. At the same time, the physician must demand more resources, more knowledge and better skills so there is less constraint and less need to triage. Those considered least worthy by society__the small, voiceless and voteless__should receive the greatest effort and most protection.

5. The human is a person as long as he/she has resident a human, God_given, ever_living spirit. Since it may not be possible to know precisely when this is, we must err on the side of life and love and assume this is from conception to death. Therefore, we must never kill a human__actively or passively. We must eschew any action that ends in a person's death, no matter how plausibly killing is supported.

6. A person's inalienable right is to be__to be here and to become the person they were designed to be. Every person is a necessary part of the great mosaic and may contribute to the benefit of others. "Wantedness" is not the first right of a child. A social system that determines who lives or dies upon their wantedness is dangerous for any civilisation and destructive for every individual.

7. The person behind any effort for good is God. To know him is to understand more clearly one's self, one's time and one's place. Truth is unitary and coherent. Good science coincides with good ethics, which coincides with good economy. Those who wish to know the truth must strive to have wisdom, especially when technology is so tempting.

8. Every person is unique and a property only of themselves and their Maker. A child is not a gift, but a loan. Thus we should welcome every child regardless of size, shape, sex, race, intelligence, completeness or occasion. A welcome in the name of Jesus and in our own name provides children with hospitality, protection and a sense of intrinsic value.

9. There is a force for and of evil whose aim is the confusion, enslavement and death of humanity. Because of its intent, evil is persistent and seductive, formidable but subtle. There is a slippery slope. Ignorance builds on ignorance, fear on fear. There are few who recognise the early signs of the demise of a civilisation. We usually scoff at those who do. Thus we should suspect anyone who, or any institution that, profits while others become trapped, unwell or die, no matter how popular the person or institution appears to be.

10. Humans inherit a penchant for the knowledge of good and evil. Many discoveries have been just as quickly put to destructive uses as to bettering humankind. Too often, wisdom is inversely proportional to technology. Wisdom is rare and ancient. Guided by wisdom, people understand they may not do everything that technology makes possible.

11. Humans are born into conflict. Thus they are ambivalent about everything almost all the time. While ostensibly pursuing truth, they ignore their own deep resistance to knowing and growing. We will not see, hear or feel in others what we refuse to understand in ourselves. Therefore, when we pursue truth we must uncover our resistance to understanding and maturing. When we avoid empathising with the gut_wrenching pain, confusion, terror and despair of our patients and too quickly prescribe affect_modifying medication, we add to their feelings of shame and inadequacy and truncate an opportunity to gain wisdom and freedom. We also lose a golden opportunity to know and grow.

12. No one is ever independent. We all need each other and God, especially when we think we don't. When unwell, infirm, confused or handicapped, we naturally regress and become more dependant, especially upon any professional into whose hands we entrust our health, welfare or safety. Thus professionals, especially those in the medical field, must never take selfish advantage of a person's dependency. As professionals, we must guard, guide, instruct and correct each other. We all must carefully listen to unpopular and politically incorrect opinions, particularly those that are uncomfortable because they remind us of our duties.

13. People have a limited ability to choose. Constitutional, developmental and environmental factors limit choosing. "Free choice" is hypothetical at best. Some people clearly have a greater capability to choose than others. Thus we have a collective responsibility.⁶ Yet, each decision of every person is important. One cannot arbitrarily reverse an earlier decision, especially when it impinges on another, e.g. get pregnant and then get rid of it.

14. Human tragedies grow out of an implicit collusion between perpetrator, observer and victim.⁷ Almost everyone involved in a tragedy makes a partial contribution. The observer has a greater responsibility. There are no innocent bystanders. Those determined to appear innocent must scapegoat those who are easily alienated. The most likely scapegoat is small, innocent, voiceless and defenceless, i.e. pre_born people.

15. Tragedy will repeat until people learn.⁸ We must learn from the painful past in order to survive and progress. When people do not want to examine and learn from their personal family, tribal or national history because it is too discomfiting, tragedy is bound to be re_enacted. It would be tragic and costly, but easy to return to pre_Hippocratic precepts when patients distrusted and avoided their physicians.

Practical applications

If these tenets and their corollaries are correct, there must be practical applications and beneficial outcomes. Physicians should avoid being utilitarian, but they are forced to be pragmatic.⁹ There may be many who would delight in the opportunity to show that in a particular case of their patient these principles could not and should not apply. I welcome the challenge.

1. Harvesting tissue. Some argue that because the anencephalic, miscarried or aborted baby is doomed, their tissue may be used for research and treatment. This utilitarian argument is immediately suspect__partly because the powerful and privileged so frequently voice it. According to the fifteen tenets, we must err on the side of life and love and assume that all of these humans are people. We cannot benefit at their expense. We cannot own them, nor may we use them. They are on loan. We may benefit greatly by giving them care. Our gain in maturity from treating them with respect is proportional to their apparent unworthiness. The utilitarian argument greases the slippery slope of apparent gain at their expense. One could soon argue that if a mother does not want a particular child, but if she will go through the pregnancy, technology can make a baby anencephalic by aspirating her brains as in a partial_birth abortion. Allowing the body to live nine months in utero might then provide many organs for harvesting. On the other hand, if we truly benefit by loving others, then our capacity to love increases as we care for those most dehumanised. If we dehumanise the pre_born and anencephalic, we dehumanise ourselves. If we recognise their right to be, to be here and to become until natural death takes them, then we also benefit. One small benefit is that upon their death we are less likely to have a complicated grieving process.

2. Doctor_assisted suicide. Those utilitarian argue is that a competent person has the right to take his/her life when he/she chooses. Since some are incapable of doing it quietly, quickly and painlessly, physicians should be available to do the job. According to the fifteen basic tenets, dying is one of the most important events in one's life. There is the possibility of considerable psychological and spiritual maturing in the process. One must suspect selfish motives of government, physicians and family who quietly coerce individuals to consider easy death rather than deal with the despair and alienation felt by dying people. According to these principles, when we passively or actively kill another, we destroy something of ourselves. In a short time we cannot trust ourselves or our motives, nor should others trust us. Since everyone is essentially equal, we must spread medical resources evenly. Thus the needs for basic treatment of many now going without will curtail if not eliminate costly end of life efforts for others. Yet, we must always treat. There is always something we can do to lessen a person's desire for death. Since death is subtly seductive, we must counter it in its most incipient forms, for they eventually result in suicide, abortion and genocide.

Since there is so much diversity and disagreement regarding ethics among physicians, no one can assume they know what their physician believes. It is essentially unethical not to declare one's ethics.^{10 11}

The ethical statement I display reads as follows.

Almighty God, With You all life begins and ends.

I know my life entirely depends on You.

By You, all human life is loaned for a season.

I cannot give life to, or take life from anyone.

For You, I must hold in careful stewardship

My life, and the lives of all my neighbours.

You created mankind a little lower than the angels

And have given me Your life and love giving Spirit.

Through Jesus Christ You have made me Your child,

Now my first priority is to show people their hope is in You.

You have honoured me with Your challenging friendship

Thus, what I am becoming is more important than what I achieve.

You have conquered death and will soon destroy it.

Since I am Your servant, Your enemy is my enemy.

It is Your creation but death is seeking to ruin it.

I must fight death on its doorstep or it will attack me on mine.

There are no innocent bystanders in matters of life and death.

Unless I am fighting death, I am aiding and abetting its terror.

Without forgiveness and reconciliation between those who injure and are injured,

The triangles of tragedy must be re_enacted from generation to generation.

Unresolved bitterness will kill us and those we hate.

Unless forgiving and forgiven, our sins and illness will remain.

With love, You are always healing the weak and wounded,

By helping the smallest and weakest I learn to love like You.

Every person was wonderfully made in Your image,

So how could I ever benefit at the expense of another.

No, I benefit when I give my neighbours what they need,

For we are intrinsically bound together in the bundle of life.

I will love You more than my life; as long as I live

I will always promote and enhance life for everyone

Not regarding their wealth or rank, sex or race, ability or disability,

Their size or completeness, I will love them as myself.

I will seek my neighbours' physical, mental and spiritual wholeness.

Treating them equally, I will help distribute

Health and life maintaining resources fairly throughout the world.

I will help each one to the limit of my abilities and resources.

If because of circumstances I must choose who I will treat first

I will treat those who most likely will benefit from what I can offer.

I will seek to know all the needs of all my neighbours

And help find and apply new remedies.

I will try to untangle the tragic triangles that injure and kill.

Starting with myself I will exemplify and promote reconciliation.

I will not kill or hasten death or just let anyone die

But will seek to remedy all factors that lead to the destruction of life.

I will oppose abortion, euthanasia, murder and genocide

And help heal all those affected by these tragedies.

I will fight death in all its guises

And avoid compromise with any form of evil.

Please Lord, help me to do what I say I believe.

Give me the courage to love life and live it fully.

Remind me that my struggle is but for a short time.

Forgive me for vanity and pride in my accomplishments.

Remind me You alone heal and I am privileged to be your helper.

Keep me from fearing death or the consequences of serving You.

Grant me sufficient strength to bring hope, healing and joy to others.

Make me determined to loan my life without interest for

The most complete life of each and all of my neighbours.

When patients read this, some shake their heads in bewilderment or dismay. For others, it raises questions we must discuss. Most are glad to know my essential ethics, even if they cannot agree.

Conclusion

There are many practical applications of these ancient tenets to medicine, law, business, research and teaching. Hippocrates and colleagues were wise enough to recognise that if physicians euthanised, aborted or had sex with their patients, patients would never trust them.¹² When people do not trust physicians, the expense of time and money for medicine escalates. Maybe, if nothing else, medical economics will impel physicians to reconsider the wisdom of these ancient tenets.

¹ Flagler E, Baylis F & Rodgers S. Bioethics for clinicians: 12. Ethical dilemmas that arise in the care of pregnant women: rethinking "maternal_fetal conflicts." Can Med Assoc J 1997; (12): 1729_32.

² Lavery JV, Dickens BM, Boyle JM & Singer PA. Bioethics for clinicians: 11. Euthanasia and assisted suicide. Can Med Assoc J 1997; 156(10): 1405_1408.

³ Ney PG. The universal ethic of mutual benefit. T Klin Tibbi Etik 1994; 2: 53_56.

⁴ Ney PG. The Law and the Essence of Love 1974; Pioneer Publishing: Victoria, Canada.

⁵ Ney PG & Ney PM. Our patients' seven unspoken questions. Can Med Assoc J 1986; 135: 879_880.

⁶ Ney PG. Deeply Damaged 1997; Pioneer Publishing: Victoria, Canada.

⁷ Ney PG. Triangles of abuse: A model of maltreatment. Child Abuse & Neglect 1988; 12: 363_373.

⁸ Ney PG. Child mistreatment: Possible reasons for its transgenerational transmission. Can J Psychiatry 1989; 34: 594_601.

⁹ Ney PG & Ney PM. To treat, not to define. Can Med Assoc J 1987; 136: 814_815.

¹⁰ Ney PG. Letting patients know where you stand. Can Med Assoc J 1989; 140: 586.

¹¹ Ney PG. Putting your ethics on display. Can Med Assoc J 1990; 142: 752.

¹² Ney PG. Ethical dilemmas in psychiatry. NZ Med J 1983; 96(743): 939_41.