The Moral Authority of the Standard of Care: Contrasting Cases from Adult and Pediatric Clinical Ethics
Yael Shinar, M.Div., Medical Student, University of Michigan Medical School
The contemporary practice of medicine in our pluralistic society lacks a content-full morality to provide definitive guidance in ethical dilemmas.(1) Hence clinical ethics committees seek to preserve negative liberties (2) and rely on the principle of respect for autonomy, in order to determine ethically permissible courses of action in any given case.
Challenges to pluralist ethics arise in various ways. One challenge arises when the content of a particular belief cannot be reconciled with current medical practice, as when Jehovah’s Witnesses refuse blood transfusions at times when transfusions are medically indicated. Other challenges to such pluralist clinical ethics arise when autonomy is compromised, i.e. when the individual whose freedoms are to be protected is cognitively or legally vulnerable. This occurs in cases of adult patients whose illnesses compromise decisional capacities, and it occurs in pediatric cases, where patients have yet to develop legal autonomy. In such cases, substituted judgment and beneficence seek to approximate the situation that would be were autonomy intact.
This paper contrasts two cases brought to our ethics committees, one adult and one pediatric, in order to analyze the medical context in which the pluralist impulse to protect negative liberties may become the prescriptive assertion of positive obligation to receive medical treatment. In the adult case, a patient’s autonomy to refuse medical intervention was respected as a decision within the proper purview of his decisional capacity. In the pediatric case, parents of an ill child were prevented from refusing medical treatment for their child.
In analyzing these cases, we ask, What is the moral foundation for the imposition of medical intervention? What belief do we impose, when we impose the standard of care? By what authority do we insist on the righteousness such imposition? Is it a secular impulse, derivable from behind a Rawlsian veil of ignorance,(3) or is it a religious attitude?
Analyses of the cases in the language of religious experience(4) will augment our understanding of the relationships among medical practice, scientific evidence, and clinical ethics. These cases may illuminate how the standard of care, as a scientifically informed standard in a pluralistic society, comes to carry the weight of moral authority, especially for children.
The contemporary practice of medicine in our pluralistic society lacks a content-full morality to provide definitive guidance in ethical dilemmas.(1) Hence clinical ethics committees seek to preserve negative liberties (2) and rely on the principle of respect for autonomy, in order to determine ethically permissible courses of action in any given case.
Challenges to pluralist ethics arise in various ways. One challenge arises when the content of a particular belief cannot be reconciled with current medical practice, as when Jehovah’s Witnesses refuse blood transfusions at times when transfusions are medically indicated. Other challenges to such pluralist clinical ethics arise when autonomy is compromised, i.e. when the individual whose freedoms are to be protected is cognitively or legally vulnerable. This occurs in cases of adult patients whose illnesses compromise decisional capacities, and it occurs in pediatric cases, where patients have yet to develop legal autonomy. In such cases, substituted judgment and beneficence seek to approximate the situation that would be were autonomy intact.
This paper contrasts two cases brought to our ethics committees, one adult and one pediatric, in order to analyze the medical context in which the pluralist impulse to protect negative liberties may become the prescriptive assertion of positive obligation to receive medical treatment. In the adult case, a patient’s autonomy to refuse medical intervention was respected as a decision within the proper purview of his decisional capacity. In the pediatric case, parents of an ill child were prevented from refusing medical treatment for their child.
In analyzing these cases, we ask, What is the moral foundation for the imposition of medical intervention? What belief do we impose, when we impose the standard of care? By what authority do we insist on the righteousness such imposition? Is it a secular impulse, derivable from behind a Rawlsian veil of ignorance,(3) or is it a religious attitude?
Analyses of the cases in the language of religious experience(4) will augment our understanding of the relationships among medical practice, scientific evidence, and clinical ethics. These cases may illuminate how the standard of care, as a scientifically informed standard in a pluralistic society, comes to carry the weight of moral authority, especially for children.