Hastings Center Report

This essay is based on a plenary address at the 2005 annual meeting of the American Society for Bioethics and the Humanities, delivered upon acceptance of a Lifetime Achievement Award.

I do not consider myself primarily an ethicist, but I have spent most of my life as a physician thinking about what to do for sick people. Like many other internists, I have usually found the technical aspects of these problems easier to solve than the personal and moral issues. We are all unique individuals living in a world of others, and it is a sometimes uncomfortable fact that whatever is done for one person inevitably has implications for others, some of whom are so close to that person as to be almost one with him or her. Despite all the thought we in bioethics have devoted to these problems, and despite the considerable and continued growth of bioethics, some of our most difficult questions remain unanswered.

This realization is driven home for me when I recall my inaugural experience in bioethics. I was introduced to The Hastings Center (then the Institute for Society, Ethics, and the Life Sciences) at a meeting of the Task Force on Death and Dying in January 1971. Leon Kass, who went on to chair the President's Council on Bioethics, had read my essay "Death and the Physician," and Dan Callahan thought the perspective of a practicing internist might be useful. My presentation, "The Care of the Dying," responded to a chapter, "On (Only) Caring for the Dying," in Paul Ramsey's book The Patient as Person. The chapter broached many ethical issues concerning patients who are dying, but I restricted my comments to the most common problems. I included what some of my patients thought about the problems, in addition to the disparity between what patients mean by the term "dying" and what "dying" means to physicians.

Ramsey asked: "Must a terminal cancer patient be urged to undergo major surgery for the sake of a few months palliation?" "How much blood are we going to give a terminal patient . . . ?" "Should transfusions for the treatment of hemorrhage from gastrointestinal cancer be discontinued when an operation to relieve this condition is not contemplated or feasible?" "Is there no end to the doctor's vocation to maintain life until the matter is taken out of his hands?" Or, put another way, "[O]ught there be any relief for the dying from a physician's search for exquisite triumphs over death in a sort of salvation by works?"¹

The gist of the chapter is that physicians have no obligation to continue the lives of persons who had been "seized by their particular process of dying," and that a physician should "make room for the dispensability of extraordinary life-sustaining treatments because he as a man acknowledges that there may be sufficient moral and human reasons for this decision" (my italics). Ramsey gives an example of incompetent patients where further treatment would be of no avail and families are unable, because of guilt, to cease treatment. "[G]uilt ridden people in their grief may be unable to bear the additional burden of a decision to discontinue treatment, and they are often relieved if this decision is not wholly placed on them." "This means that the physician must exercise the authority he has acquired as a physician and as a man in relation to the relatives and take the lead in suggesting what should be done. In doing this the doctor acts more as a man than as a medical expert, acknowledging the preeminence of the human relations in which he with these and all other men stand" (italics mine).²

His emphasis on the central importance in medical relations of the person (the physician as well as the patient) and human relations was something I, a high-technology (for the times) internist, had not previously encountered. Many of his other ideas were also new to me. Even the style of the writing was very different from medical writing. As imposing as he was in print, Paul Ramsey was an even more impressive speaker. I had never before...