REVIEWED BY THOMAS A. SHANNON, Ph.D.
Hippocratic, Religious, And Secular Medical Ethics: The Points Of Conflict
Georgetown University Press, 2012 256 pages; $29.95
BY ROBERT M. VEATCH
In this book, a revision and development of his 2008 Gifford Lecture at the University of Edinburgh, Robert M. Veatch, Ph.D., provides a useful framework for helping us to engage in a critical discussion of professional ethics.
Veatch, professor of medical ethics at Georgetown University in Washington, D.C., presents a sustained argument against professional groups developing an ethic that they then impose on themselves and others. Within this overarching argument are three other thematic arguments: First, the Hippocratic Oath has seen its day and can no longer function either as a code of ethics or as the basis for a professional code. Second, people have a variety of sources of both values and moral authorities that conflict with the principles of professional codes. Third, there is enough consensus in what Veatch calls the common morality to serve as the basis for a negotiated code of ethics between laity and professionals.
As a conclusion, he argues that UNESCO's 2005 Universal Declaration on Bioethics and Human Rights can serve as an appropriate first draft of a professional ethics model.
Running through the development of these positions is an exceptionally strong rejection of the Hippocratic Oath, which he deems "… unacceptable to any thinking person" because it is rooted in a religious cult that requires allegiance to its gods. But more central to its rejection is Veatch's focus on the paternalism in the oath — the physician determines what benefits the patient — as well as other such problematic provisions as violations of confidentiality "for strictly paternalistic reasons" and a prohibition on surgery.
But Veatch then argues against the acceptability of any professional code. The problem he identifies is that while professional codes generate norms for their members, they also often impose obligations on the clients of these professions. Although Veatch does not reject role-generated duties or obligations, his larger point is that such duties must be grounded in ethical norms outside the profession and comprehensible to those not in the profession. Thus ethical norms for a profession cannot adequately be generated from within the profession itself.
In many ways, the core argument of the book is what may be his most significant contribution to medical ethics: what Veatch describes as the problem of the generalization of expertise. Simply stated, this is the assumption that if one is a technical expert in one field, then one is also an expert in any value choices related to that — or other — fields. To avoid this problem, he says, both professionals and the laity should "turn for moral guidance to sources of moral knowledge that they respect."
This position leads Veatch to discussions of the use of the Hippocratic Oath tradition, its eventual falling into disfavor and the development of other medical oaths. He also raises the legitimacy of such oaths. Given the pluralism among medical students and the various competing ethical claims in the wide variety of oaths administered at graduation, as well as the other sources of moral authority that make claims on the new physicians, Veatch argues that "such oaths should be abandoned in favor of commitments of the professional grounded outside the profession."
Thus Veatch's quest to examine a variety of such commitments — secular and religious — to see whether they have sufficient principles in common to function as a common morality or whether there is sufficient convergence around these principles to serve as the basis for moral negotiations between professionals and laity. He carefully examines several religious traditions, as well as many of the main medical ethical theorists, and concludes that though each tradition or theorist proposes their own specific framework of principles, there is sufficient overlap between and among all of these to provide the basis for a common morality.
Veatch is careful to note that such a morality will not resolve all problems, particularly the most socially intractable, such as abortion and euthanasia. However this common morality provides a starting point for conversations between professionals and laity as well as between various religions and secular theories of ethics. If we respect the limits of reason and human fallibility, we can begin a conversation.
While Veatch is correct that expertise in one area does not confer expertise in another, I think his insistence on the somewhat stark separation of the physician-patient relationship might be somewhat overstated. It is generally true that a physician does not know a patient's values. Nonetheless, a professional code can suggest that the main ethical responsibility is to establish a fiduciary relation with the patient and use his or her professional expertise on behalf of the patient. Otherwise I think we might wind up having physicians simply present options to patients and telling them to choose because the physician does not know their values. Emphasizing the fiduciary nature of the relationship helps guarantee that professionals recognize their limits but also encourages them to help their clients evaluate and articulate what is in their best interest.
This caveat aside, Veatch provides a very helpful review of the status of and a thoughtful examination of the foundations of professional ethics.
THOMAS A. SHANNON is professor emeritus of religion and social ethics, Worcester Polytechnic Institute, Worcester, Mass.
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