Medical Ethics Is All Political Economy!

Heather Chi is a 2nd year Geography major at NUS. She is a freelance writer, a researcher with a keen interest in the issues of food security, uneven development and social entrepreneurship,  she is currently director of an anti-hunger initiative, Food for All, as well as a socially-oriented undergraduate research initiative, WeSearch! She brings a story to Kent Ridge Common about one of her more interesting experiences in London.

Attending a pub debate is one of the must-do’s for anyone on exchange in an English-speaking country. In London, the world’s cultural capital, that goes without saying. Having just returned from a very interesting and intense Big Ideas (http://www.bigi.org.uk/) debate on medical ethics at The Wheatsheaf (and expecting another narrow-minded, issues-based discussion full of drunken talk and polarized views), I was pleasantly surprised when speaker Miran Epstein – a Senior Lecturer in Medical Ethics and Law at The London School of Medicine – provoked much ire right at the start when he proclaimed: “Medical ethics is all political economy.”

He went on, stoking the flames: “There is nothing wrong with the ethics we have, the Hippocrates Oath, whatever…the issue is the social and political context within which this ethics is applied. There is no point having this debate about ‘who to save?’ ‘should abortion be legalized?’ or whatever when, as we speak, huge sums of money are diverted from health-care to fund big banks everyday and governments speak of fictional resource constraints and the need for an ‘ethics’ to allocate life and death!”

Here someone said, “Alright, can we step back from politics a bit and focus on medical issues…” To which he erupted: “The very fact that we separate bioethics and politics is itself a reflection of the perversity of the society we live in!”

By this point (barely five minutes into the evening), almost the entire (English, medical) crowd was up in arms while I was merely extremely excited. As a social science student interested in social ethics and its implications, I found Miran’s points extremely refreshing. Although his attack on an entire tradition of ethical theorizing was rather brazen, I was very heartened to hear a bioethicist questioning the need for a ‘better, more relevant’ ethics and the politics of ethical practice itself.

To Miran, ethics functioned as an ‘ideological smokescreen’ behind which medical professionals could be absolved of the need to have a conscience; with clear ethical guidelines grounded in a legal framework, medical practitioners need no longer think critically about their own discipline: who was funding drugs research? who had vested interest to ‘prolong death’ in palliative care institutions? who ultimately benefited from opt in/opt out organ donation arrangements? Who to give this one kidney to?

The patient checked all the boxes, I can proceed.
Guantanamo Bay has myself and two colleagues “supervising”, this torture is legal.

Another issue that was thrown into the open was that of the extensive ‘medicalization’ of life. Miran stated, rather controversially, that he had no issues at all with euthanasia and assisted suicide. Some people want to die, let them die, and by all means help them – just don’t get a doctor to do it. At this point, the audience absolutely erupted; assuming (wrongly) that Miran had just washed his bloody hands in front of them, stating that euthanasia and assisted suicide were outside the realm of ethics, or at least medical ethics, and that as long as someone else did the dirty work, everything would be fine. This was not what Miran was saying at all (the French accent didn’t help).

In fact, Miran was questioning (though not directly) the very scope of medicine itself and the extent to which professional medicine should intervene in the autonomous lives of individuals:

He raised the example of reproduction. Historically, reproduction was firmly grounded in the family and the community; pregnant women were cared for their mothers and grandmothers; midwives assisted in birth; wet nurses assisted in breastfeeding. However, over the centuries, the entire process of reproduction began increasingly to come within the scope of biomedicine and women increasingly surrendered themselves to a whole range of specialist advice and medical technologies. No longer was it acceptable for a woman to give birth on her own… and no longer acceptable for her to abort an unwanted child.

In Miran’s opinion, the excessive medicalization of life (‘which paradoxically denies the right to death but also the right to live – thanks to prohibitive consultation and treatment fees for the poor!’), and the ideological smokescreen of professional ethics, has resulted in doctors who increasingly turn to deception to reconcile their conscience with their practice:

(1) Euthanasia: Alluding to the ‘law of double effects’, doctors can always ‘justify’ an untimely death by saying that they merely wished to reduce the level of pain by prescribing higher and higher doses of morphine which, unfortunately, killed the patient in the end. This effectively bypasses the law, but makes the doctor essentially a deceiving murderer. Wouldn’t it be more ethical to legalize euthanasia but take it out of the medical practice entirely? So the children want their parent to rest in peace? Why then let them pull the plug.

(2) Opt-out schemes for organ donations: Essentially a scheme to capitalize on the ignorance of a segment of the population who would have said ‘no’ had they been offered a choice, medical professionals choose not to ask at all and assume that everyone who did not say ‘no’ would have said ‘yes’ had they been asked, and thus find an easy way to obtain large numbers of organs for surgery and research…essentially by deception. (Miran did qualify, however, that in his ideal world, all dead bodies and their organs would be public property solely by virtue of their value to the living.)

At this point, most of the audience was either too angry or too exhausted to comment and the facilitator called for a ten minute break and another round of drinks. Although I left the discussion at this point, many questions remained unanswered, awaiting further research, reflection and discussion:

In what direction should the debate on ethics proceed? Should we accept Miran’s challenge to question the need for an ‘ethics’ in the first place and use this as a basis to critically examine the society that we live in – a society that ‘needs’ such an ethics at all? Should we accept his view that there is nothing fundamentally ‘wrong’ with our present medical ethics and that the issue is the political economy within which this ethics is embedded? If this is so, perhaps we should shift our focus from attempting to formulate a ‘purer’, more relevant ethics to simply eliminating ethics completely from the field of medicine altogether and calling ‘ethical dilemmas’ by their real name – social and political controversies.