Questions involving ethical positions are often intensely felt by those involved. These are not just armchair discussion but reach to the very heart of our perceptions of ourselves as individuals. Practitioners quickly become aware that the value given to their opinions is directly linked to the quality of reasoning and rationales that they can provide for them. Specialists who know that something is wrong but cannot articulate their reasons or the methods by which they derived their beliefs are at a real disadvantage. Not only do they fail to provide appropriate advocacy for their ideas or the patients they serve, but also inflict upon themselves and their colleagues an incredible level of stress and discomfort.
One of the frustrating aspects of reasoning through those questions is that the people who you know and respect will often come to different opinions regarding the best answer. In that, values are not subject to scientific analysis or deal with areas that are easily quantifiable, value arguments are deeply felt and rarely won. Because of their personal nature, those who disagree with your personal value system are often not only classified as being wrong but are also somehow evil in their wrongness. Consider the two sides currently involved in the abortion debate.
Yet, we are entering professions where there is an abundance of value questions that must be dealt with on a daily basis. As professionals, even in out opposition our standing up for our position–and if necessary our becoming a majority of one–it is important that we remain constructive and appropriate in our actions.
To acknowledge that individuals can come to different opinions in regard to ethical issues is not the same as saying that all opinions are equal and have the same worth and credibility. In health care, there are decisions that must not be made. Whereas tolerance is generally considered a virtue, there are actions that must not be tolerated.
There are some in our society that subscribe to a philosophy of moral nihilism. Adherents to this philosophical position believe that there are no moral truths, no moral facts, no moral knowledge or responsibilities. For those that hold this position, nothing can truly be be wrong or right in a moral sense. For the moral nihilist, morality, like religion is a mere illusion. If you followed this reasoning to its conclusion, heinous acts such as the rape and torture of children would not necessarily be wrong. This is, fortunately, a position that most would feel uncomfortable in accepting.
A moderate form of nihilism is ethical relativism, which holds that morality is relative to the society in which one is is brought up. In this sense nothing can truly be right or wrong without a consideration of the culture and social context. Ethical relativists go beyond just recognizing differences between cultures, and hold that in questions of mortality rightness or wrongness is always relative to and determined by culture.
Others in our society ground their personal philosophy solely in a hedonistic worldview. For such an individual the major guidepost for decision making are desire and aversion, and nothing can be right or wrong apart from them. This attitude of self-absorption was captured in the slogan, “He who dies with the most toys wins”. Gross, personal self-interest provides an inadequate framework for ethical decision making in health care. In health care provision an attitude of “any thing goes” is unacceptable.
To involved ourselves in unethical practice harms the patients we serve; by association it harms all fellow practitioners; and in that it lowers the level of rust and esteem in which health care providers are held, it harms the community at large. An oft-used analogy is that health care practice can be considered an community commons. All practitioners in the community use the field and are responsible for its continued upkeep. It is unthinkable and unwise to believe that the maintenance of health care commons is the responsibility of some other group practitioners.
The obligation to provide ethical care, refine the quality of practice, and provide community service are not the obligations of few but of the many. it is our privilege to labor in the community commons; it is our obligation to maintain the space so that we can come again, and when we finally leave, leave the commons healthy so that others can replace us in labor. Nothing damages the health care commons more than unethical practice.