Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 1 Brendan Shea, 2015, "The Medical Ethics of Miracle Max." In: R. Greene and R. Greene (eds.) The Princess Bride and Philosophy: Inconceivable!. (Chicago: Open Court), 193-203. The Medical Ethics of "Miracle Max" Miracle Max, it seems, is the only remaining miracle worker in all of Florin. Among other things, this means that he (unlike anyone else) can resurrect the recently dead, at least in certain circumstances. Max's peculiar talents come with significant perks (as Fezzik and Inigo discover, he can basically set his own prices!), but they also raise a number of ethical dilemmas that range from the merely amusing to the truly perplexing:  How much about Max's "methods" does he need to reveal to his patients? Is it really OK for Max to lie about Valerie's being a witch, even though she really isn't? Just how much of the "truth" does Max have to tell his patients?  Let's suppose that Humperdinck had offered Max his old job back. Would it have been OK for Max to accept this offer? What about if Humperdinck wanted him to do experiments at "the Zoo"?  Is Max obligated to offer his services to everyone who needs them, such as the (mostly) dead Westley and friends? Or is free to pick and choose? In this chapter, I'll consider how these questions might be addressed using concepts of medical ethics. As it turns out, Max's dilemmas are not too different from the sorts of dilemmas that many medical professionals encounter in their daily lives, and exploring how Max could (or should) respond to them can help us figure out what we can do here in the "real" world. 1 HEROES AND VILLAINS: WHAT IS ETHICS ALL ABOUT? In its broadest sense, ethics is simply the study of "right" and "wrong" behavior, and medical ethics is the study of ethical issues that arise in the context of medicine and biomedical research. The philosophical study of ethics goes (at least) all the way back to ancient Greek thinkers such as Socrates (469-399 BCE), Plato (429-347 BCE), and Aristotle (384-322 BCE). Their contemporary Hippocrates (460-370 BCE) even seems to have been interested in medical ethics in particular, and inspired the "Hippocratic Oath" still taken by medical professionals today. Before going on any further, though, it's important to make a distinction between two very different sorts of ethical questions: "How, as a matter of fact, Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 2 does a particular person or group actually think about right and wrong behavior?" and "Are these judgements correct or incorrect-that is, how ought this person or group to act?" The first sort of question is the domain of descriptive ethics, while the second belongs to normative ethics. So, for example, consider Prince Humperdink. Descriptively, it seems safe to say that "Humperdinkian ethics" allows things such as the kidnapping and murdering of spouses, the construction of giant torture machines, and the instigation of wars with neighboring countries, so long as such actions advance one's career goals. As a matter of normative ethics, however, Humperdink's actions are simply wrong-these are surely not the sort of things a decent person ought to do! The distinction between normative and descriptive ethics will prove valuable to us when we start to consider Miracle Max. It is, for example, a matter of simple economics that Max can get away with charging a very high price for his services-after all, the services he offers (such as raising the dead) are highly valuable ones, and he is the only person who is able to offer them (talk about a monopoly!). With this in mind, we could look at the prices Max actually charges and simply describe Max's ethics when it comes to pricing Does he charge rich people more than poor people? Pretty people more than ugly ones? Heroes more than villains? If we did this, we would be engaging in descriptive ethics. In general, however, we'll be more interested in answering questions about normative ethics: for example, how much should Max charge various people, and how should he determine this? In order to address these sorts of normative, ethical questions, we'll be adopting an influential view called "Principilism," which was defended by Tom Beauchamp and James Childress in their book Principles of Biomedical Ethics. On this view, medical professionals (such as Max) can improve their ability to make ethical decisions in particular cases by applying four fundamental principles: autonomy, nonmalfeasance, beneficence, and justice. Moreover, a working knowledge of these principles is valuable not just for medical professionals, but for anybody who wants to think clearly about what it means "to do the right thing" as patients, caregivers, voters, and citizens more generally. 2 LIES, LIES, LIES: SOME VIOLATIONS OF PATIENT AUTONOMY When Inigo and Fezzik first go to seek Max's aid, he isn't entirely honest. He begins by implying that he can't help (he can), states that his wife Valerie is a witch (she isn't), tells Valerie they've offered 20 gold pieces (they offered 65), claims that Westley is saying "to blove [bluff]" (he's saying "true love"), and assures them the miracle pill will last for 60 minutes (it will only last 40). He lies, in short, to both his patients and the other members of his medical team, and doesn't tell the heroes that (due to medical error) the miracle pill won't Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 3 last as long as he'd originally said. While many of these lapses are understandable, given Max's low self-esteem and rusty skills, they serve as examples on an all-too-common dilemma in medical ethics: just what sorts of information should a medical professional reveal to patients? These questions all pertain to the Principle of Autonomy, which states that medical professionals should respect and support the abilities of competent patients to make their own decisions about treatment. Among other things, this means that the medical professional needs to accurately describe the diagnosis, prognosis, and possible treatments to the patient. While everything turns out OK for Max in the end, he makes a few mistakes along the way. First, he exaggerates Valerie's skill (by saying she's a witch) and then radically downplays his chance of success because of his fear of failure. While Max's failings here are comic, his motivations for lying (a "harmless" exaggeration of a colleague's skill, a sense of risk aversion overly focused on preserving professional pride) are, unfortunately, all too realistic, and they can easily be the sorts of things that cause medical professionals to mislead patients. Ideally, of course, a medical professional could meet the demands of autonomy by sitting down with a patient, explaining the proposed treatment in detail, and having the patient give his or her verbal or written informed consent. In practice, however, this is often impossible. For one thing, patients are often unconscious, as Westley is when Fezzik and Inigo bring him in. In addition, patients who are conscious may be unable to understand the proposed treatment. By the time we encounter him in The Princess Bride, for example, it may well be that old King Lotharon (Max's old employer) is simply incapable of making autonomous choices about his own treatment. Finally, even if patients are both conscious and capable of understanding, there may be some other factor that prevents them from making their own choices. So, for example, it seems unlikely that Max really ought to go along with patients' requests if he suspected these requests were due to mental incapacitation (Fezzik's getting hit in head with a rock, Inigo's still being drunk) or because of external threats (perhaps Vizzini has tricked them, or Humperdink threatened them). In cases where a patient's autonomy is compromised by any of these factors, the medical professional will have to rely (as Max does) on the decisions of surrogates, and on what was known of the patient's wishes back when they were capable of making decisions. In the case of Westley, this is thankfully not too difficult-the treatment Fezzik and Inigo propose (saving Westley's life) seems to be clearly in the patient's best interest, a fact that Max is able to confirm by asking the (deceased) Westley what is worth living for. In many other cases, unfortunately, matters are not always so clear-cut, and medical professionals may need to carefully consider how to weigh seemingly conflicting evidence about what the patient "really wanted." Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 4 3 WHY WORKING FOR HUMPERDINK IS A BAD IDEA The idea that medical professionals should respect and promote the ability of patients to make their own, autonomous decisions is of a relatively recent vintage. By contrast, the idea that they should avoid harming patients is a very old, going back (at least) to the Hippocratic Oath, with its promise to "do no harm." In the language of Principilism, this is called the Principle of Nonmalfeasance. One can violate this principle either by directly harming others through one's actions (Count Rugen killing Inigo's father), or by negligently allowing a person to be harmed when it was your responsibility to prevent this (Yellin not doing anything when Humperdink reveals his plan to murder Buttercup). In the case of Westley, of course, Max is at little risk of directly causing harm (Westley is already dead, after all). However, it is worth exploring what exactly Max was morally required to do, once he recognizes that Westley has slipped from being "somewhat dead" to "mostly dead." Somewhat surprisingly, according to many traditional interpretations of "do no harm," Max was required to do almost nothing for Westley, even if he's already signed on as his physician. For example, one traditional view holds that while medical professionals should never "withdraw" life-saving treatment (no taking the miracle pill out of Westley's mouth), they are perfectly free to "withhold" it (not giving the miracle pill in the first place). Another common view states that while Max's killing Westley would be wrong, there would be nothing wrong with Max "letting him die," even if there were measures that could save him. A third proposal requires that Max provide Westley with "ordinary treatment" (perhaps CPR?), but not that he undertake "extraordinary treatment" (a category that surely includes miracle pills). While these sorts of guidelines may provide certain psychological benefits for physicians by making things "simple", Max's experience suggests that they may be bad ways of thinking about nonmalfeasance, and on what it means to avoid harming patients. Instead, it seems that, if we have good reasons (as Max does), to think that a treatment could work for a patient (and that the patient would consent to it), then the treatment ought to be attempted. Conversely, if a treatment will not help (or if a patient does not or would not consent to it), it should be stopped or withdrawn. Another application of the Principle of Nonmalfeasance concerns its application to medical research. What should Max say, for instance, if Humperdink were to offer his old job back, but on the condition that he carry out experiments at the Zoo of Death? This would surely involve harming both humans and animals, and so it would clearly violate the principle. However, this does not (by itself) entail that Max ought to refuse. After all, he would need to consider the possibility that the violation of nonmalfeasance was outweighed by patient autonomy (if human research subjects gave informed consent) or by the goal of beneficence (if animal experimentation promised some great Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 5 benefit). In the case of the Zoo, of course, neither of these criteria are met, since Humperdink's and Rugen's main interest seems to be in inflicting as much pain as possible. In the real world, however, these three principles would need to be carefully weighed against each other, both by individual professionals such as Max and by the Institutional Review Boards (IRBs) commonly called upon to determine the ethics of proposed research. 4 MAX THE BENEFICENT When Inigo and Fezzik go to seek Max's aid, they are able to offer Max a hefty sum of gold for his services, a fact that goes a long way toward overcoming Max's initial reluctance to help. Unfortunately, it seems unlikely that the average resident of Florin could afford this price, even though they could definitely make use of Max's services. So, what should Max do when these people show up at his door, asking for help, but with no way to pay? Or what about when he is out for a walk, and he encounters a mostly dead person on the side of the road? Is he required to stop and help, or is this going above and beyond the call of duty? In Principilism, questions such as this fall under the Principle of Beneficence, which requires medical professionals to take positive action to benefit others, or to prevent them from being harmed. In very general terms, the principle says that we are obligated to help people when (1) we notice they are at risk of major harm, (2) we think it is likely we can help them without too much cost or risk to ourselves, and (3) all things considered, it seems that our actions will do more good than harm. This principle would imply, for example, that Max ought to help a recently dead person he finds by the side of the road, should he have a soon-to-expire miracle pill in his pocket, and no particular plans for it. By contrast, Inigo and Fezzik are clearly going above and beyond the Principle of Beneficence when they put themselves in danger by rescuing Westley from the Zoo. Similarly, Westley's "as you wish" agreement to all of Buttercup's demands at the beginning of the book goes well beyond the sort of beneficence he would owe to a random stranger (though perhaps not to the love of his life). Beneficence becomes even trickier when it conflicts with other principles, or when actions that have good consequences for some people have bad effects for others. So, let's say that Valerie has developed a new miracle pill that she would like Max to test. When people hear about this (even more miraculous!) pill, they will surely be eager to try it. However, in order for Valerie and Max to figure out whether or not this pill works, they will have to test it rigorously. And in order to do this, it may be that they can't give it to everyone-instead, they'll have to give it to some people (the "experimental group"), while denying it to others (the "control group") in order to compare the outcomes and see what happens. In this case, it seems like beneficence toward the large number of future patients who would benefit from the new pill will sometimes trump beneficence toward the one or two particular patients who might benefit now. Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 6 In other cases, beneficence may conflict with respect for autonomy, nonmalfeasance, or both; as when a patient refuses to undergo a painful procedure that could save their life. So, for example, suppose the King refused to take a life-saving miracle pill on the grounds that it "gave him a stomachache." In this scenario, it seems like Max should at least consider tricking the King into taking into it (perhaps by sticking it in ice cream?). As with many "tough" cases in medical ethics, there may simply be no hard-and-fast "rule" about how such cases ought to be decided. 5 FIXING FLORIN'S HEALTHCARE PROBLEMS As the only remaining miracle worker in Florin, Max is in a peculiar position: his decisions to treat (or not treat) patients are (quite literally) matters life or death. So, for example, if he had not agreed to treat Westley, then Westley would have remained dead-the heroes simply had no other options. Given this monopoly on health care, how should Max distribute his efforts? Should he simply treat whoever pays the best? Charge a set price and do "first-come first-serve?" Or something else? These sorts of "who gets medical care?" dilemmas fall under the auspices of the Principle of Justice, which says that people should "get what they deserve." Among other things, this means that people should not be denied medical care because they happen to have certain disadvantageous properties (such as being born a giant, or having your father killed by an evil count) that they had no control over. Conversely, it says that people with undeserved advantageous properties (such as being born a prince) do not deserve privileged access to medical care. Just as with the other principles, it is highly unlikely that we could ever be "perfectly" just, since doing so would almost certainly involve substantial violations autonomy, nonmalfeasance, or beneficence. Nevertheless, the principle requires that we "aspire" toward justice, even if this (sometimes) means making sacrifices in other areas. So what does this mean for Max? Depending on one's theory of justice, one might hold that Max is free to sell his services to the highest bidder (libertarianism) or, conversely, that is he is required to provide his service (perhaps free of charge) solely on what he thinks would be most "health-promoting" (utilitarianism). However, there are problems with these extreme views, since the first option would say Max has no duties to anyone in Florin, while the second option would say he has no right to a spend any time on anything else. A more palatable proposal might involve Max balancing a commitment to doing something for the poorer citizens of Florin, while also reserving some of his time and resources for higher-paying clients (and for spending time with Valerie!). In the real world, of course, ensuring "justice" is largely a matter for large governmental or health-care institutions, and not for individual providers such as Max. However, Max's simplified case brings out a number of issues Brendan Shea, "The Medical Ethics of Miracle Max" (DRAFT) 7 relevant to debates about justice in health care. For example, the Principle of Justice seems to imply that people do have a right to a basic level of health care, even if this requires others to make sacrifices. However, because resources are limited (and because citizens have priorities besides health care), it seems implausible that people have a right to unlimited health care. Ideally, then, Max might recommend to Humperdink that he finance the training of some new miracle-workers, and that he put some money aside toward manufacturing miracle pills for those in need of them. Florinese politics being what they are, however, it seems likely that Max may well have to content himself with treating the occasional wounded adventurer. 6 TOO MUCH OR NOT ENOUGH? So, what would Max think of our four rules? Given the (sometimes questionable) state of his memory, he might ask if we could somehow simplify things-maybe just include three rules, or two rules, or even just one? Conversely, he might ask why we needed principles at all-why not just figure things out on a case-by-case basis? While these objections both have long philosophical pedigrees, there are real advantages to adopting Principilism. First, in allowing for a larger number of principles (as opposed to just one), we can account for the fact that questions in medical ethics problems are often complex (they can't be solved by "mechanically" applying a single rule), and they may be genuine dilemmas (with no clearly correct answer). Second, in positing there are some general principles that stay the same between cases, we can actually "learn from experience" by identifying specific commonalities between cases. So, while Max's experiences in Florin differ wildly from those of most real-world medical professionals, the principles used to assess them are the same, a fact that allows us to learn from Max's failures and success. In the end, the value of Principilism (as with any theory of normative ethics) lies in what it allows us to do with it, and in what problems it enables us to solve. In this respect, it is precisely the fact that Principilism allows us to learn something relevant to solving new moral problems by considering the outcome of previous or hypothetical cases that makes it so valuable. And this is possible only because Principilism attempts neither to reduce morality to a single, mechanical rule nor to throw out rule-based reasoning altogether. So, while Florin is (unfortunately, and despite my childhood confusion about this point) a fictional place, this doesn't mean that The Princess Bride has nothing "real" to offer us.