FROM A MEDICAL ETHIC TO A MORALITY OF HEALTH CARE By Gabriel Moran During recent years I have team-taught in two ethics

courses, one for business students, the other for nurses. I much prefer nursing students because they already have a sense that morality is intrinsic to their work. I think that in the business world ethics is usually seen as a set of rules brought in from the outside. The ethics course in NYU=s Graduate Business Administration was recently written up in the New York Times. On paper, it is an impressive sounding course but I find it frustrating in practice. The ethical questions asked in the business world are how to live reasonably, how to be successful without hurting too many people along the way, how to protect oneself against corporate power. This attitude of reasonableness is not to be disparaged; it represents progress away from ruthless conflict with one=s enemies. Nonetheless, this very progress reveals the inadequacy of modern ethics to cope with a world that refuses to fit the modern meaning of reasonable. In contrast, the world of health care is never far removed from the unreasonable realities of pain, suffering and death. The first question in this area is not how to act reasonably but how to care for human beings. The very category of Ahealth care@ is one of the forces that is changing the entire field of modern ethics. When not reduced to a meaningless cliche, health care - the care of health - is a way of thinking that differs from medical thinking. Modern ethics can be dated from about the 18th century. For several centuries before then, human reason had been making progress in the direction of autonomy, technical skill and institutional order. A conflict inevitably arose with Judaism and Christianity. Jewish religion, centered on the practice of law and ritual, suffered even more than did Christianity from a triumph of rationalism. Given a choice between Christianity and modern enlightenment, many Jews went with the latter at least until the Holocaust revealed the tragic flaw of trusting in reason alone. There have been two main systems in modern ethics, although the two are variations on a single theme. Pushed to the limit, one system will lead to the other. The first system, called Ateleological,@ begins from a
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conception of the good, and the argument is over which are the reasonable steps for accomplishing the good. The competing system, called Adeontological,@ begins from a conception of Aright@; the argument is over which are the reasonable ways to exclude passions from interfering with doing the right things and observing the rights of human beings. Not many people would wish to do away with the apparatus of rights. Anyone who has lived under the protection of the western ideal of civil and human rights would be wary of living in Iran, China or Iraq. However, the failure of a rhetoric of rights in much of the world indicates that this language assumes a context and a history. In the United States, the limits of this language are shown in the abortion issue. Both sides use the language of rights, one talking about the right of the woman to control her body, the other the right of the fetus to life. I doubt that any progress can come while the language of rights is the only one used. In much of the world, including the business world, the first system, the teleological, is dominant. There is more concern for the acquisition of goods than for the observance of rights. Ethical rules in the business context pertain to fairness in buying and selling. From the 18th century to the present, the image of Amarket@ has dominated this kind of thinking. This form of teleology is based on a remarkable premise, namely, that if each individual were selfish, everyone would be happy. AIf men were actuated by self-interest,@ wrote Bertrand Russell, Athe whole human race would cooperate.@ And today Edward Wilson still insists on the same premise in the recently invented field of sociobiology: AHuman beings appear to be sufficiently selfish and calculating to be capable of indefinitely greater harmony and social homeostasis.@ Although it is not easy to spot a logical flaw in the position that greed is good, most people know that something is awry. For a logical analysis of what is wrong with a system of ethics based on selfishness, I refer the reader to Fred Hirsch=s The Social Limits of Growth. Hirsch uses a distinction between material and positional wealth. Although material goods may be indefinitely expandable, other values which are dependent on human relations are of their nature limited.

The confusion in the twentieth-century version of teleology is indicated by Hirsch=s principle: AMore wealth of the kind attainable by all paradoxically means an increased scramble for the kind of wealth attainable only by some.@ Here is an example of the problem: One of the things that the rich could once buy was a quiet place in the suburbs. But as more people acquire the means (including an automobile) to get a quiet place in the suburbs, then the very existence of quiet places in the suburbs is threatened. An individualistic ethic makes both city and suburbs disintegrate. The same is true for most kinds of human services that are not available today at any price. What has become evident in the large economic sphere is well known by people in their personal lives; for example, you cannot buy good sex at any price. Human care, love and patient attention are not to be acquired by an ethic of market exchange. Health care thereby becomes one of the chief tests of modern ethics. Health care has been subjected to the market ethic. The free play of competition, it was assumed, would produce skilled technicians who would put their heads to curing disease. Everyone would profit, or at least everyone who had the money to buy the physician=s time and his expensive technology. Like civil/human rights, few of us who live under the aegis of the American Medical Association would wish to abandon the progress of medical technology. But the skills of the medical doctor and the impressive technology of the medical system cry out for a human context. The impossible situation of astronomical costs is forcing a redesign of the whole area. The necessary reform is not a reformed profession of medicine but a different profession of health care. A Aprofession of health care@ is in a fragile moment of birth. Inherent to this profession would be cooperation between men and women, in contrast to the male-dominated history of modern medicine. The central concern would be the relation of body to environment, person to community. A health care team has to include the patient and the patient=s family as well as the people who have technical training and specialized knowledge. The rights of the individual and the goods of medicine need a context in which every human being, indeed every living being, is a patient, that is, one who suffers and eventually dies. The human being as one who needs gentleness, care and love is a much better image for ethical thinking than is Francis Bacon=s image of Aman putting nature to the rack and demanding answers.@ Given its

presuppositions, modern ethics has concentrated on Adilemmas,@ conflicts of rights or conflicts of goods. A profession of health care would be concerned not merely with dilemmas or cures but with what kind of persons we are becoming and in what kinds of communal settings. Stanley Hauerwas writes: AWe need an account of morality worthy of requiring ourselves and others to suffer, and thus releasing us from the prison of our own interests.@ There is no guarantee that talk about health care is going to get us a profession worthy of that name. But the men and women who are working to fashion genuine health care are also laying the foundation of a better way to approach all ethics.