The Arete Medical Ethics Summer Seminar is a ministry of CMDA US. Thanks to networking by our Associate Staff Networker Jon Dykeman, Samantha was invited to attend. The cost of tuition and accommodations were provided by CMDA US.
During the last week of June, I had the opportunity to attend the Arete Medical Ethics Summer Seminar at Duke University in North Carolina; a five-day intensive course that was unforgettable and life-changing for me as a medical learner. The seminar was facilitated by Dr. Farr Curlin, a palliative care physician at Duke University, and Dr. Christopher Tollefsen, a philosophy professor at The University of South Carolina.
At the seminar, we were invited to examine central ethical questions that arise in medical practice and to interpret those questions through a moral framework drawing from both natural law and medicine’s traditional orientation toward patient health. Furthermore, we were tasked with considering what sort of practice medicine is and whether it has a rational end or goal. The seminar’s emphasis on natural law attracted a predominantly Christian group of learners. Nonetheless, nearly 20 medical learners from varying ethnocultural backgrounds, and with differing belief systems and levels of medical training, came together to engage in intimate, thought-provoking sessions guided by Dr. Curlin and Dr. Tollefsen. We represented schools from all across the USA and Canada, and even Europe!
The fruits of my week at Duke were manifold. Most fundamentally, the seminar served as a crash course in bioethics. We discussed the definition of health, and examined topics including the beginning of life, reproductive health, the end-of-life, and conscience/freedom of belief in medical practice. We were also introduced to a variety of moral frameworks, including principlism and consequentialism, as well as a natural law-informed approach coined The Way of Medicine by Curlin and Tollefsen. We used critical thinking to put the various ethical frameworks to the test in our discussions of bioethical issues.
As pre-meds, most of us are introduced to principlism through books like Hebert’s Doing Right, which has essentially become prerequisite reading for medical school interview preparation. The principlism framework is one that we, as medical learners in Canada, accept as the framework of choice even before our training begins, and which continues to be reinforced throughout medical school. Principlism calls us to make ethically challenging decisions according to four very noble principles loosely grounded in the Hippocratic tradition: autonomy, beneficence, nonmaleficence, and justice. In many cases, these principles serve as appropriate, sensible criteria for making ethically sound medical decisions. However, in cases where two or more principles are found to be at odds, we are often tasked with prioritizing which principle will take precedence over the other(s). And this is precisely where things get mucky.
Take end-of-life care, for example. It would be both just and beneficent for a physician to intervene in some way to help a suffering patient feel less pain, so to improve their quality of life. Should a patient want to end their own life because they are suffering immensely, respecting a person’s autonomy might see a physician participate in assisted suicide to help the patient fulfill their request. However, the principle of non-maleficence would suggest that euthanasia – intentionally ending the life of another person – is morally wrong, as it is an intrinsically maleficent act. Here we can see the clashing of principles, and a decision must be made to prioritize one over the other. Four years ago, Canadian law would have held that the principle of non-maleficence should outweigh autonomy, condemning euthanasia as a morally impermissible act of killing. However, with the introduction of Medical Aid in Dying (MAID) legislation in 2016, the ordering of the principles has been reversed such that autonomy trumps non-maleficence and even touts MAID as an act of beneficence by allowing someone the ‘right to die’.
Though principlism can and does help us to make decisions regarding ethical dilemmas by weighing all four of the principles when making a decision, in today’s post-Enlightenment individualistic society, it often gives the principle of autonomy veto power over the other three principles. As demonstrated above, principlism has the potential to introduce a slippery slope where virtually any patient request can be deemed morally acceptable if it is autonomous, and provided that the other principles are being respected (or at least can be portrayed in such a way that they seem to be respected.) This glorification of autonomy had led to what Curlin and Tollefsen have called the Provider of Services Model, wherein physicians are asked to respond to patient requests for “health” services that may or may not actually be oriented toward a patient’s health.
Throughout the week, Curlin and Tollefsen exposed us to The Way of Medicine as an alternative to the Provider of Services Model. In The Way of Medicine, all treatments a physician prescribes are oriented toward the basic human good of health and serve to restore the well-working of the human organism and lead to its flourishing. I could spend days applying this framework to various bioethical issues – and believe me, we did – but suffice it to say that the physician is not merely a provider of services under this framework, but an instrument of healing. From a Christian perspective, physicians under The Way of Medicine act to restore the patient back to their well-working state, in accordance with the natural law as God has designed it.
What did become clear to me is that physicians today have a profound deficit in knowledge and understanding regarding the historical and philosophical underpinnings of modern-day medical practice and the implications of this on medical practice are critical. In the wise words of Dr. Curlin, how can we (physicians) practice medicine well when we are unaware of what sort of practice medicine is and whether it has a rational end or goal? When the aims of medicine are unclear, physicians are reduced to acting as mere service providers and effectively lose their identities as practitioners dedicated to the ministry of healing and human flourishing.
Applying what I learned at Arete on a practical level, I am particularly concerned about what is happening in my home province of Ontario. We are the first and only jurisdiction in the world that has done away with the right to conscientious objection for physicians. In fact, Ontario was the subject of much discussion and utter shock for participants at the seminar! We have allowed the pendulum to swing so extremely towards honouring patient preferences that we have done away with physicians’ conscientiously-informed professional and personal opinions. I will certainly concede that absolute paternalism poses problems for the quality of medical care provided to patients, but what makes us think that the extreme opposite – favouring patient autonomy above everything – is not also a problem?
Conscience is the only faculty we have to make reasonable decisions about what is right and wrong. When governing bodies strip physicians of the ability to think and act conscientiously, then moral decline in practice is inevitable. Not only that, but Curlin argues that when we leave our consciences at the door and become cogs in a machine, burn out is inevitable. And it is no secret that burnout in the health care sector has become endemic. We all yearn to live out our vocations purposefully and to find meaning in what we do. Stripping conscience away leads to profound meaninglessness and is ultimately not a sustainable way to go on working. This seminar has certainly piqued my interest in this area, and has prompted me to stay up-to-date with the news on the conscience rights battle here in Ontario through Concerned Ontario Doctors (COD) and CMDA Canada news.
The seminar was a joy to take part in. I was blown away by the integrity, intelligence and open-mindedness of the people I can now call my friends. The connections and friendships we formed, the authenticity and honesty with which we discussed difficult issues, the mutual support we offered one another when grappling with doubts and difficult questions. It was all incredibly life-giving. There were days when the content seemed too dense, and when our minds grew tired and foggy. Gallons of coffee (and orange juice) were consumed. I’ll never forget how emotionally and mentally exhausted we all felt by the end of the Wednesday session on abortion, when we had reached our wits’ end arguing our ideas and beliefs. Through it all, we remained united in our genuine pursuit of truth and concern for our fellow person. No one ever left a difficult conversation with hard feelings, but instead with a thirst to keep learning more and to challenge pre-conceived ways of thinking.
I did also leave that week with a recognition of the limits of reason. As G.K. Chesterton points out in his work Orthodoxy, “reason seeks to cross the infinite sea, and so make it finite. The results is mental exhaustion[…]. The logician seeks to get the heavens into his head. And it is his head that splits.” Having experienced this head-splitting mental exhaustion, I returned truly thankful for the gifts of faith and leisure. There’s nothing like going for a long hike and getting to know new friends, sharing a drink or two, or talking and laughing until the wee hours of the night. There’s nothing like exposing your most deeply held beliefs with a group of people that you’ve known for only a few short days, but know with every fiber of your being that you can trust. There’s nothing like the genuine human connection that comes about when you’ve found people who share the same vocation and are striving to live it out with the same zeal and integrity as you are.
Course material aside, the seminar helped us to create a network of like-minded medical trainees, to develop lasting friendships, and to grow in faith. Throughout the week, some of us Christian medical students in the group went out to worship events on campus, and even some of the non-Christian friends came along for the experience. Weeks after the conference ended, I continued to engage in long phone conversations and email threads with members of my ‘Arete Fam’ to grapple with difficult issues, both professional and personal. One of my new friends has even decided to give Christianity a try and has started going to weekly Bible study. Praise God!
As Christians, we are often ignored because of the notion that our values are extreme and irrationally held. After this conference, I have become even more fully convinced that a bioethical perspective consistent with Christian values is grounded in sound, logical arguments that aren’t easily deflected, and I am willing and ready to defend them. In a conversation at the end of the conference, Dr. Curlin left me with a nugget of hope – don’t believe for one second that speaking up with an unpopular opinion is futile. There are many luke-warm people out there just waiting to hear a message that resonates with them. As St. Augustine of Hippo said, “The truth is like a lion; you don’t have to defend it. Let it loose; it will defend itself.”