This past summer, I had the opportunity to attend the Arete Medical Ethics Summer Seminar at Duke University. It was a five-day course facilitated by Dr. Farr Curlin, a palliative care physician at Duke, and Dr. Christopher Tollefsen, a philosophy professor at The University of South Carolina. The seminar invited us to examine central ethical questions in medicine and to interpret them through 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.
Furthermore, we considered 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 students from varying ethnocultural backgrounds, with differing belief systems and levels of medical training, came together to engage in intimate, thought-provoking sessions. We represented schools from all across the United States, Canada and Europe.
As pre-meds, most of us are introduced to principlism through books like Philip 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 noble principles: autonomy, beneficence, non-maleficence, and justice. These principles serve as appropriate, sensible criteria for making ethically sound medical decisions in most cases. However, in cases where two or more principles are at odds, we often must prioritize which principle will take precedence. 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 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 manipulated 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 make decisions regarding ethically complex scenarios by weighing all four of the principles, 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 respected (or at least can be portrayed in such a way that they seem to be respected.) This glorification of autonomy has 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 the patient’s health.
Curlin and Tollefsen exposed us to The Way of Medicine as an alternative to the Provider of Services Model and applied it to topics ranging from the beginning of life, reproductive health, the end of life and conscience in medical practice. 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 in accordance with the natural law as God has designed it. The physician is not merely a provider of services under this framework, but an instrument of healing and human flourishing.