COLUMN: Separation of Church and Fate

From Bertie Bregman's "On Call," Winter '94 From Bertie Bregman's "On Call," Winter '94Two weeks ago I attended a conference on Jewish medical ethics sponsored by Penn Medical School and Hillel. The highlight of the conference was a panel which included an Orthodox radiologist and a secular doctor who ran the intensive care unit (ICU) at HUP. One question, though, flitted around the edges of the discussion: doctors routinely encounter life and death situations, but are they any better qualified to make ethical judgements than the average Joe? The Orthodox doctor answered with a clear and resounding, no. First, medical students get no real training in ethics. Second, medicine, like science as a whole, is an amoral tool that can be used for both good and evil; doctors have no greater claim to ethical insight than do engineers or technicians. Third, doctors have shown time and again that the ostensibly moral goal of medicine -- to combat human disease and suffering -- is often just an excuse to wreak moral havoc. He cited as an example the Tuskegee experiment of the 1930s, where syphilitic Black men were tracked in an epidemiological study instead of being treated and cured. He could also have cited the recent revelations of radiation experiments done in the 1950s on mentally impaired children and other unsuspecting victims. All of which was done under the guise of legitimate medical research. The idea that an M.D. doesn't qualify anyone to resolve ethical dilemmas is not unique to Orthodox Jews; the veritable cottage industry of medical-ethics experts testifies to that. But it meshes well with the Orthodox world-view in which the precepts outlined in the Torah govern human behavior. In this view, the vast body of Jewish law encompasses all possible human dilemmas, and only its mastery qualifies one to render ethical judgements. The ICU doctor didn't directly challenge that view. If asked, I think he would agree that a mastery of ethics exceeds the scope of medical training and experience. He didn't champion the role of doctor as philosopher or rabbi. Instead, he showed by example how the steady picking and prodding of a good clinical mind could dismantle ethical dilemmas, leaving easy decisions in their place. Where others see quandaries, he seemed to suggest, a good doctor sees only a lack of information. The first case of the day best illustrates this difference in approach. A pregnant woman was involved in a car accident, and suffered severe head trauma and spinal cord injuries. She is now in a coma and being kept alive by a ventilator. The fetus has a normal heartbeat. The ethical dilemma boils down to choosing between the life of the mother and the life of the baby. Removing the extra strain of the pregnancy would increase the mother's chance of survival. Alternatively, the mother could be kept alive long enough to bring the fetus to term. The Orthodox doctor took the facts of the case at face value, and applied a rigorous and elegant talmudic analysis. Abortion is not seen as categorically wrong under Jewish law. If carrying a fetus puts the mother's life in jeopardy, then abortion is not only allowed but required. The fetus is seen as a "rodeph" or pursuer. Just as you are permitted to kill a man to stop him from murdering another, so you are required to abort the fetus to prevent it from killing the mother. The ICU doctor, by contrast, refused to accept the facts of the case. Rather than choose between the mother or the child, he insisted on returning to the data. What did it mean that she was in a coma? The case also stated that her pupils were fixed and dilated. If so, that was a bad sign, indicating a small chance of recovery. Were brain scans done? If so, was she brain dead? A wealth of neurological information remained to be collected before addressing the ethical dimensions of the case. Ultimately, he believed that armed with the right information, the patient's doctor could solve the problem by rephrasing it. For example, if you determine that the mother is really brain-dead and the fetus is really viable, then the dilemma disappears. You follow standard medical procedure and deliver the baby. This difference in approach may stem from a difference in training. Ethicists and talmudic scholars are trained to take a case and analyze its assumptions and implications, not to question the facts. They like to tackle moral dilemmas straight on. To change the facts is cheating when the name of the game is to reason your way out of a hole. Scientists and doctors, meanwhile, are taught that the facts of a case are never sacred. New data drives scientific evolution by undermining old theories. To reason your way out of a hole often is often a sign of desperation when the name of the game is to add to the facts. At a time when existing conceptions like doctor-as-technician, or doctor-as-ethicist are sorely inadequate, the ICU doctor's approach offers an intriguing alternative. Are doctors better qualified to make tough ethical decisions than the average Joe? The question may contain the answer: if he's a good enough doctor, the average Joe is often qualified enough. Bertie Bregman is a second-year medical student from New York City. On Call appears alternate Wednesdays.