A MATTER OF ETHICS

I was in the car a few Sundays ago, looking for a football game on the radio, and I happened upon one of those call-in medical shows that fill out the right-wing radio schedule when Rush and Sean and Michael and Laura are all hunkered down somewhere with a box of cigars, a case of single-malt scotch and a 57-inch plasma TV tuned to the NFL package.

Normally, a medical show would hold my attention for exactly the length of time it would take me to recognize it was a medical show and hit the dial. I disapprove of these things under the best of circumstances, but on a Sunday afternoon in the Fall, I find it positively frightening to discover there are people (Americans!) who would rather talk about ginkgo and bowel movements than watch Peyton Manning dissect the Seahawks’ secondary. The shock of this realization invariably makes me wonder, briefly, whether al-Qaeda might someday win.

But at the moment I tuned in, as luck would have it, the “doctor” was not talking about ginkgo or bowel movements. He wasn’t even talking about cholesterol. Instead, he was launching into a problem in medical ethics.

And here it is.

A married couple goes to a doctor’s office to inquire about their fertility problems. The doctor examines each of them, administers some tests, and tells them to return on Thursday for the results. As they are leaving, the wife says, “Thanks, doctor. This is very important to us. We’ve been trying to have another child for seven years now.”

Before the second appointment, the doctor learns the husband is sterile. There is no other conclusion. It is a congenital condition, and while it might be corrected with surgery, the husband is not the father of their seven-year-old child.

Thursday comes. You’re the doctor. What do you tell the couple?

There’s no right answer, of course. Or rather, there is a right answer, but considerable disagreement about what it is. All us mortals can do is argue about it, and it turns out to be a great question to argue about. I brought it up, over the pie and cheesecake and coffee, at our Thanksgiving dinner, and the discussion went on for quite a while. One thing I can report at the outset is that even those with positions on the two extremes---1) tell the hard truth or 2) lie like a dog---tend not to get adamant about it. Almost everyone, it seems, can see the other side of the coin.

While you are considering your answer, and before I tell you mine, let me specify one rule: you can’t duck the question. One guy (a lawyer, of course), said the solution was to call the ethics board at the AMA and get a ruling. OK, I said, then the question is: what answer should they give you? Another guy (a doctor) avoided the question by claiming there was no such thing as medical certainty, and thus, nothing he might tell the couple could be characterized as “true” or “false.” In a nutshell, he was arguing it was impossible for him to lie when he was offering a medical opinion. (A convenient position for a doctor, n’est-ce pas?) He never did give me an answer.

The hypothetical is designed to engage our view of right and wrong---that’s the purpose of it. Don’t fight it.

On one extreme is the view of the doctor on the radio show. He said he would sit the couple down and tell them the truth, the whole truth and nothing but the truth. This was his obligation as a doctor, he said. The couple came to him seeking a medical opinion and he would betray his oath if he were less than completely frank, no matter the consequences. As a policy matter, he noted that with DNA and genetic testing for diseases, this sort of issue was arising with increasing frequency, and it was essential to have an ironclad rule for the situation. Doctors could not be expected to “play God” with their patients, he suggested.

It’s a reasoned point of view, and I can see why a doctor, in particular, would feel that way. Among my unscientific sample, however, this is an extreme and unusual position. Only two people thought “the truth” trumped everything, and one of them was the lawyer whose first impulse was to duck the question.

The most common response, the middle road, is: “Well, he has to tell them the truth, right?” Then there is a pause of five or ten seconds. Then the person says, “Well, maybe I wouldn’t do that, exactly.” Following this, any number of creative lies emerge:

• “He’s been riding his bike too much.”
• “Maybe I check his medical records for the last seven years, and whatever happened to him is the reason he’s sterile."
• “I tell the wife the truth and ask her what she wants me to tell him.”
• “I tell them their first child was close to a miracle and he needs surgery to have another.”

My own view is at the other extreme---it would never occur to me to tell them the truth. I’m not sure what lie I would tell, but if I were a doctor, I’m sure I could invent something convincing, and I would. I would do so in spite of whatever ethical rules I learned in medical school and whatever legal liability I would be risking. I would falsify lab reports, if necessary. I would probably continue to lie even if they got a second opinion from another doctor and accused me of lying to them. I would tell them the second doctor was wrong, and subtly suggest he was well known to the police. Only when faced with threats of violence from the husband and service of a subpoena would I admit the truth.

Certainly, the truth is important, in an abstract sort of way. And yes, there is a contractual obligation on the doctor’s part to provide the service he has been engaged to perform. To see no further than these (perfectly legitimate) concerns, however, is to reduce the doctor’s role to that of the guy who sells you a new set of radial tires. A professional has an obligation to go a bit further, partly because he is in possession of specialized knowledge and the client is not. The client may not know what facts are important. He may not even know what the problem is. That’s why a professional has to acquaint himself with the entire picture, and has to use his judgment in identifying the problem and then deciding how to solve it.

How much further? Well, I admit my answer pushes professional responsibility to its limits, but once you acknowledge that the obligation to a patient or client extends further than that of the tire-monger, aren’t you forced to consider the interests of the seven-year-old child you have never met? And if, as a professional, you take that first little step toward an expanded view of your obligation---well, personally, I quickly come to the conclusion that the kid’s interests are the only ones that matter.

Morally, he trumps everybody. I’m an outsider here, but the one thing I know is that the kid is a completely innocent party. To my way of thinking, if that kid isn’t asking what happened nine months before he was born, I’m not going to tell him. I’m not going to tell anybody. And the kid isn’t asking. Why should he? He has a Momma and a Dada, and they all live together, and love each other, and whatever happened ninety-three months ago is ancient history.

It’s apparently ancient history to the husband and wife too, by the way. Remember---I’m just their doctor. I have no particular interest, professional or otherwise, in what happened way back when. All I see is a married couple that wants to have another kid. Maybe the husband had suspicions. If so, they’re gone now. The wife knew there was a possibility, but after seven years, she has persuaded herself her husband was the father. Maybe it was a two-week fling. Maybe it was a drunken Christmas party. Maybe, in her mind, it “didn’t matter.” What do I care? I’m only concerned with the kid, and what good can come to that seven-year-old by me telling the truth?

I have presented this argument to “truth-tellers” and have received the following response: “But it might be good for them to learn the truth. Maybe they will finally deal with the underlying issues in their relationship. Maybe they will reach a new understanding and a new level of partnership and love.”

“Yes,” I respond cordially. “And maybe monkeys will fly out of my butt.”

Speaking simply as a guy, qua guy, knowledge of a wife’s infidelity and a husband’s non-paternity is not going to catapult anybody to a new level of partnership and love. I don’t even know a guy who is that “evolved,” though I know some who probably think they are. A few guys would kill. More would divorce. About the best outcome would be a long series of therapy sessions and hot tubs and long, meaningful chats and crap like that. Meanwhile, the kid (remember the kid???) is wondering what the hell is wrong with his Momma and Dada. In my limited experience, kids don’t want Momma and Dada to have long, meaningful chats and deal with the underlying issues in their relationship. They prefer it when their parents are sitting on the patio drinking beer and talking about Britney Spears and Hillary Clinton. Kids want Momma to make cookies sometimes, and they want Dada to take them to a ballgame and buy them a hotdog and tell them a stupid joke. Kids HATE underlying issues. Nobody hates underlying issues more than kids do. Not even me.

What is interesting about this problem is that all of us can sympathize with the doctor. He is simply doing his job to the best of his ability, and suddenly he is confronted with a moral and ethical dilemma. He did not choose to be placed in the position he finds himself. Nobody would. Nevertheless, there it is. He holds the fate of this family in his hands and he has to decide what to do. He can consult other doctors or call the AMA Ethics Board or ask his priest, but the final decision is his. He’s stuck with it.

What engages us is that we are all placed in this position from time to time, typically when we least expect it. Moral issues are part of the human condition, as much as we may try to avoid them. But it’s not really an answer, is it, to “call the Ethics Board” or dismiss the issue with some bromide about “the truth” or “medical certainty” or “playing God.” Not that “the truth” is a concept without value, but why should it triumph here, in this situation, with this family? As my criminal law professor used to say, “Justify your answer!” Perhaps it can be justified, but if the parents get divorced and the kid starts selling dope on the corner, you will need a better answer for yourself than, “Well, that’s what the Ethics Board told me to do,” or “In medical school, they told us not to play God.” Because you were playing God. You were put in a position where you were forced to play God. You just made the wrong decision because you wanted to pretend you weren’t making a decision at all. This is the worst possible strategy when faced with a moral dilemma.

One way to approach these questions is to ask yourself, “If I choose Option A, and there are terrible consequences, can I still defend my decision?” Then ask yourself the same question about Option B. In this case, the first question becomes, “If I tell the truth and the family disintegrates, will I still feel I did the right thing?” Then ask, “If I lie, and I face discipline for an ethical violation (or get a punch in the nose), will I still believe my lie was justified?”

I remain curious about this question. If you disagree with me (and most people do), send me an email and tell me what you think.

Copyright 2006 Michael Kubacki