This article appears in the August 2001edition of the Catholic Medical Quarterly
Can there be a moral dialogue between Doctor and Patient?
I want to use the familiar model of a consultation between a British general practitioner and a patient requesting a termination as a model for the wider category of consultations where a moral dialogue might occur. Some general practitioners hold that the fetus is an entity to whom they owe a moral obligation. For such general practitioners the request for a termination poses two moral dilemmas. The dilemma I want to discuss is not that between the rights of the fetus and those of the mother. That dilemma has been well covered from various points of view in the literature on medical ethics (Gillon 1994) and in popular books (Donellan 1997; Lloyd 1996; Wyatt 1998). The dilemma I want to discuss is; "To what extent and in what way should the practitioner engage with the mother in moral dialogue? Can it indeed be done at all?" By moral dialogue I mean a conversation between the two parties, in terms of concepts they share, that helps to form the moral decision of one party. While this dilemma has not been much discussed in England, debate about it has divided the Roman Catholic church in Germany (The Independent 2000). Moreover the disability rights lobby has usefully reminded us that the abortion consultation is not purely a private matter, but is one that sends a message to the wider society about how we value disabled people (Shakespeare 1998).
I want to address this question from the perspective of the doctor who feels that his obligation to the fetus is so strong it is not a private matter but rather a universal obligation. By a universal obligation I mean one like the rule "do not kill" which most people feel applies not just to them but to all citizens whatever their other beliefs. Such a doctor feels on the one hand that he should protect the fetus while on the other hand he wishes to respect the autonomy of the mother. This perspective is that of most Roman Catholics, some Protestants, and most Jews and Muslims. Moreover, it is but one of many such dilemmas that arise in our multicultural society in which minority beliefs are often pitted against the quite different norms of wider society.
Historically there are at least three ways that minority groups respond to this challenge: these are mirrored by the range of responses such doctors can give in this situation. Firstly the group can cut itself off from society into an internal ghetto. This would correspond to the doctor who put a sign in his waiting-room saying he did not see patients for termination. This is the attitude recommended by some Roman Catholic moralists (Finnis & Fisher 1994). Secondly groups can assimilate fully into society, keeping their beliefs, if at all, a private matter. This would correspond to a doctor who behaved as he thought other doctors in the host society behaved, keeping his beliefs for himself. Thirdly the group can engage the host society in a dialogue in various ways. This is the option for the doctor that I want to explore at greater length. I will ask;
Is moral dialogue between a doctor and a patient possible in our society?
Ought we to engage in it?
How can it be done?
The scope of moral obligations
Although I will focus on the dilemma for the doctor I will briefly consider the scope of moral obligations, and whether the fetus is included in them. This is because our attitude to abortion seems to depend principally on this question and much less on which moral theory we follow (Gillon 1986).
Historically over the centuries there has been much fluctuation in opinions about the stage of its development at which the fetus entered the scope of such obligations (Mori 1994). The language used was that of ensoulment; once the fetus had a soul we had obligations to it. Such a debate has not yet died in Roman Catholicism (Mon 1994).
The argument from uncertainty. Because the status of the fetus is uncertain it can be argued that it should be treated as if it had the same rights as a baby. In an analogous way, if you were a hunter shooting at an object behind a bush which could be a man or a rabbit, you would be bound to treat it as if it was a man.
The argument from potential. This is well treated by Anne Fagot-Largeau (Fagot-Largeau 1996). In her view it is a weak argument because an entity with many different potentials is quite different from an entity which has actualised just one of many potentials (as an acorn is from a tree). Moreover this argument can be used by anti-abortionists to argue for the rights of the fetus but also pro-abortionist to argue that a fetus may develop a disease and so should be aborted.
The argument from relationship. Many mothers will feel a fetus has moral rights in so far as they develop a relationship to it. For example, after quickening the mother forms more of a relationship and is often more reluctant to proceed to termination. Whereas contemporary Roman Catholic theologians dismiss ensoulment and the argument from potential, the argument from relationship is a key point for them. For they would argue that God forms a relationship at conception; as for example in Isaiah 44:2 "thus says God who made you, who formed you from the womb". While this is clearly an argument whose premise will not be shared by an atheist, its logic can, I hope, be understood.
The three possible positions for the doctor
I would like to look again at the three possible positions for the doctor, and consider what effect they might have on the patient.
Rejection of dialogue. This is the option in which the doctor makes it known, say by a notice in the waiting room, that he will not see patients for termination. This position is strong on respect for the doctor s integrity. It gives a clear message to the patient. It gives the patient an example to model which is perhaps to stick up for her beliefs against the pressures of society, but it also models a refusal to engage in dialogue.
Private judgement. By this I mean a doctor who keeps his own moral judgement private and does not share it with the patient. As mentioned above, we all divide the rules we obey into those that apply to us and those we feel are universal. What happens to the doctor who perceives such a universal rule and fails to obey it? Firstly he acts against the principle of respect for his own autonomy. Secondly, if we follow Aristotle, it will corrupt his moral character. Because, for Aristotle, the virtues are, as it were, the habits of doing good things, so that by doing good acts we become good. Conversely, by doing acts we believe are bad we will become bad. Thirdly, from a Kantian perspective, he would be dealing with the patient as a means and not an end. For to treat her as an end-in-herself is to share a rational moral argument with her and trust her judgement as a fellow rational human being. To refuse to share a rational argument with her is to fail to respect her capacity for reason and judgement, hence to treat her as a means (Maclntyre 1985). If the doctor refuses to share his ideas, he might be perceived by the patient as a doctor who thought himself so superior to, or so different from, her that he could not communicate with her.
Moral dialogue. So we come back to the third position: entering a dialogue with the patient.
A: Is moral dialogue possible in our society?
For a moral dialogue to be possible there are two requirements:
Shared words and concepts that form a more of less coherent framework and
Some means of using these words and concepts not only to describe moral choices but also to arrive at them.
Many would argue that moral dialogue is not possible in contemporary society because we do not share basic premises such as the existence of God or natural law. Nor do we share a common moral theory such as utilitarianism, or deontology or virtue theory, etc. As a result, our moral debates have a characteristically shrill tone as Alasdair Maclntyre points out (Maclntyre 1985). This shrill tone can characterise even our internal moral debates within our own selves. For example, a Roman Catholic GP faced with a woman facing abortion might hear two opposed internal voices, one saying "You should at all costs prevent this woman murdering her baby" while another says "You must respect her autonomy and her right to decide for herself".
I would like to look at two serious contemporary attempts to see if moral dialogue is possible. One is the Four Principles approach (Beauchamp & Childress 1983) and the other is the book of Alasdair Maclntyre "After Virtue" (Maclntyre 1985).
The Four Principles approach:
These were first elaborated by Beauchamp and Childress at Geogetown University (Beauchamp & Childress 1983) and subsequently championed by Gillon (Gillon 1994). They consist of four unexceptional principles that most western doctors today would agree to:
The principle of respect for autonomy
They have been widely taught, especially in the USA, and so are familiar to many doctors. They certainly enable doctors to describe the grounds for their moral decisions in a way other doctors can understand.
There are however some limitations. The choice of principles appears arbitrary, and there is no reason to suppose that they include all the moral principles that a doctor might wish to consider. Beauchamp and Childress feel that the principles are strengthened because some of them can be derived from different moral theories (which is what they call coherentism). While this will help people familiar with different moral systems communicate, it does not to my mind increase their truth value. Finally, while the four principles may help people to communicate, because there is no way of weighing one up against another, they can only offer a framework for making or evaluating moral decisions (Finnis & Fisher 1994).
Maclntyre s "After Virtue"
Maclntyre certainly takes the problem of moral dialogue seriously (Maclntyre 1985) (chaps. 1&2). He claims that the moral concepts that we use today are like the ship-wrecked fragments of older and more consistent moral theories (in particular Aristotelian theories) and that, wrenched from their contexts, they are not only mutually incompatible but often left with little meaning.
To simplify, the history of ethics as he sees it goes a little like this. Aristotle (and his descendants, in particular the Thomists) had a metaphysical biology and ethics. All creatures strained towards an appointed end which was intrinsic in their nature. With the Enlightenment the metaphysical biology was abandoned. We no longer look for the end, purpose or, in Greek, 'telos' of biological phenomena but rather their cause. Maclntyre has no quarrel with that but holds that the enlightenment project of replacing an ethic linked to the proper end of man, a teleological ethic, with one based on reason alone, was misplaced. He holds that it was not only bound to fail but actually did fail. It can be seen to have actually failed because it has spawned a host of reason-based moral systems: utilitarianism, the philosophy of Kant, etc., which are not only incompatible but also successful and forceful critics of each other. It was bound to fail because ethics or virtues, as he sees them, are what lead man from the state he actually finds himself in to that state which is his proper end. Now for Aristotle that proper end was to be a free citizen of a Greek city state, and for Thomists it was to be a citizen of the heavenly city. While we clearly may not share those views of man�s ideal state, we can agree with the argument that to think clearly about ethics we need to start by thinking about man s ends and purposes and not causes and reasons alone.
Maclntyre's positive suggestions are that virtues are the particular human qualities required to excel at and enjoy certain ways of life, such as being a doctor or a chess-player or a gardener. These must then be related to the narrative account of a whole life. Finally the life itself must be lived within a social tradition.
How does this account help us understand the consultation with the patient? Firstly the difficulty in talking about moral questions with people from a different background is well caught by his account. Secondly we are very likely to recognise some of the concepts they do use, and, in so far as we share them from personal experience, or recognise them from our reading, we are better able to understand what our patient is saying. A patient, for example, might say "I could not get rid of my baby because he is alive". Even if she is a not a practising Catholic the origin of this concept can clearly be recognised. Thirdly, a woman whose concept of herself is within the narrative of a whole life, rather than broken fragments she feels beyond her control, will, at the least, approach the question of termination differently. Indeed it could be argued that the role of motherhood only makes sense within the narrative concept of a whole life, and that a drastic shortage of "tales of motherhood" in modern culture has something to do with the large number of terminations. For how is a woman in a culture whose dominant stories are of woman as a "career girl" or as a "sex-object" to cope with being pregnant? Finally his account has some resonance with Gilligan s classic feminist analysis (Gilligan 1993), based partly on interviews with women facing an abortion, that women�s moral development (as op posed to men s) is characteristically based around relationships rather than rules.
As with the Four Principles, virtue theory gives us a way of thinking about moral actions but little content. It will not help us much in judging between right and wrong in a particular case. However one area where it is helpful is in the distinction between the Nazi genocide and the current large number of terminations.
A digression: the distinction between the Nazi genocide and the current large number of terminations.
Aristotle thought that for an act to be virtuous it was necessary both for the action to be in itself virtuous and for it to be carried out for virtuous reasons. If a shopkeeper is kind to his customers in order to increase profit, that is not virtue. The converse argument, to be found in Thomism, is that for an act to be sinful it is necessary both for it to be intrinsically wrong and for the person carrying out the act to know it is wrong. This explains why women who have terminations, and gynaecologists who carry them out, are not corrupted by the acts they carry out, although, in my view, the acts are objectively wrong. For whereas the Nazi executioners were obviously and grossly corrupted by what they were doing, paradoxically that was because the moral upbringing they had received made them know that what they were doing was wrong, and it was this same knowledge that made them hide what they were doing. A modern gynaecologist doing terminations does not believe what he is doing is wrong, and for that reason his character is unaffected. Paradoxically again, it will be the Roman Catholic who feels he has been inveigled or pressured into terminations who will be corrupted, as I discussed in the section about private judgement above.
B: Ought we to engage in dialogue?
In Aristotle the word "ought" has only one meaning: to conform to the norms of the Greek city state (Maclntyre 1998). But in our own language "ought" has taken on two meanings;
a) A moral ought. Is it right or wrong, according to some moral perspective?
b) A socially normative ought. Is it the done thing in this society?
a) Looked at, for the moment, from the Roman Catholic perspective, there are some clear limitations to this dialogue. We have a clear duty to express the belief that the fetus does have rights and to express it not just in words but in action (Finnis & Fisher 1994). Not only should the abortion form not be signed, but the referral itself should not be made. This is because actions speak louder than words and, if the patient perceives you as referring her (even though you do not sign the abortion form), she may form the erroneous impression that you approve of termination. This stance involves inconvenience to our partners and means that, as soon as one judges that a woman definitely wants a termination, she must be asked to wait and see another partner for the actual referral.
b) Is it socially acceptable to engage in this sort of dialogue? Surprisingly it is commended by a leading pro-abortion group (Lloyd 1996) who states that those who are against abortion and engage in counselling should be open about their beliefs. In practice I have carried out such consultations for ten years without any complaint, and so it appears to be socially acceptable behaviour. However some might still object that my counselling is not impartial. To this I would plead that impartiality is neither possible nor desirable. If I model openness, attentive listening and respect for the patient s autonomy and my own it may well influence them to follow these norms.
C: How should you engage in such a dialogue and is it effective?
This is something of an empirical as well as a moral question. From discussion with my colleagues it is clear that many GPs engage in this sort of dialogue. The only exception is the minority who believe that abortion is the mother's right on demand. For them there is no need to dialogue since they can just sign the abortion form. (Like all moral positions this one has its weak points; few such doctors would actually be happy with a termination on the ground of gender alone.)
Most doctors however do have a dialogue with the patient and naturally adapt the form of consultation they normally use when patients are facing a decision. For the RC doctor I have already pointed out two features designed to preserve his integrity:
Declare your own position;
Once it becomes clear that referral is decided upon, get another doctor to see the patient.
Clearly, while sharing one�s own position may be desirable, it does not follow that it should be done at the outset, or insensitively. On the contrary, in my experience, with few exceptions, after the patient has talked for quite a long time, it feels quite appropriate to share one�s own point of view with hers. Indeed in the small market town where I practise people may already know my point of view and have chosen me for it. On the other hand the position "if you need a referral you will need to see another GP" clearly has to be put early in the consultation to save the patient from the trauma of sharing her feelings twice.
In the early part of the consultation an opportunity must be given for the patient to share her thoughts and feelings. Paradoxically in some cases, in order to do this it may be necessary to tell the patient that a termination is easily available locally on the NHS, if she finally decides she wants one. Otherwise she may be so anxious about the possibility of a termination that her mind does not get beyond worry about this point.
Conventional advice might be to give the patient facts but not moral judgements. Unfortunately facts are not so easily separated from judgements (Maclntyre 1985) (pages 83-84). In our context the fact that the fetus has a heart beat might be seen by the pro-choice lobby as moral blackmail, while the fact that abortion is readily available and post-abortion trauma rarely seen might equally be interpreted by pro-life groups as reflecting a moral stance. A more useful model is that in "Breaking bad news" by Robert Buckman (Buckman 1992) which deals with terminal care.
The analogy with terminal care.
In my experience, most of the time, what the patient is asking for is not a termination, but not to have been pregnant at all. This can account for the great urgency felt by some patients and their reluctance to think too clearly. In other words the patient request ing a termination may be in a state of denial not unlike that of some terminal patients who do not believe they will die. In both cases breaking the denial can be traumatic. But in the case of termination the time frame is often only a couple of weeks and denial may well not be broken till after the termination. However Buckman�s model, some what simplified, is as follows:
find out what the patient knows,
find out what she wishes to know,
and close the gap.
Often the knowledge gap will include details of the local NHS availability for terminations. But it can be a comment like "I can�t go through with a termination because I know my baby is alive", a comment that could be taken as a request for information about the biology and the ethical status of the fetus. Where possible an attempt should be made to get past the stage of denial since an ethical decision (on almost any basis) cannot be taken correctly if based on a false premise (I am not pregnant).
I have now had fifteen years experience of consultations with women asking for terminations. In many cases the woman knows exactly what she wants, and no doctor is likely to alter her decision. Indeed I suspect doctors grossly overestimate their capacity for altering patients decisions. Nevertheless that does not diminish their duty to use what ever influence they have responsibly. For the doctor who believes he has moral obligations to the fetus such consultations will continue to be a source of anguish. Nevertheless on some occasions a moral dialogue is possible, perhaps because the mother shares a fragment of a moral system with her doctor. When dialogue can be undertaken I believe it is permissible to do so, though I have no quarrel with those who would not wish to do so. However I believe it can model an attitude of unhurried listening, of respect for the patient's autonomy and of respect for the doctor's own integrity. In spite, or perhaps because, of the fact that I make my own views clear, I have found that many women who choose to opt for termination do continue their doctor-patient relationship with me. Only a handful, however, have changed their decisions after consulting me, and in all those cases strong ambivalence was present before the consultation.
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Buckman, R. 1992, How to break bad news Pan books, London.
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Dr. Vernon is in general practice in Dunmow, Essex.