Medical Ethics and the Amish Bus Driver Rule

Rachel Maddow, in a discussion related to the provision of abortion services, once proposed that we (society) should invoke the Amish Bus Driver Rule whenever medical professionals invoke their personal convictions in refusing to provide legal medical services.

The Amish Bus Driver Rule goes like this: If you're Amish, and therefore have religious convictions against internal combustion engines, then you have disqualified yourself for employment as a bus driver. (Presumably Ms. Maddow would not apply the Amish Bus Driver Rule to everyone, since it would disqualify, for instance, Al Gore from utilizing horseless carriages and other fossil-fueled contrivances.)

The Amish Bus Driver Rule would do far more than merely render it OK for doctors to perform abortions and other ethically controversial (but legal) medical services. The ABDR would obligate physicians to provide such services, whatever their personal moral or religious convictions.

The reason DrRich brings this up is not because he considers Rachel Maddow to be the giver of rules for the left, or for the government, or even for MSNBC. Rather, he brings it up because the Amish Bus Driver Rule is entirely compatible with Progressive medical ethics http://covertrationingblog.com/medical-ethics/progressive-medical-ethics, and therefore it has a pretty good chance, sooner or later, of becoming the official policy of our new healthcare system.

To spell it out: Once you agree to accept from the government a license to practice medicine, and thus accept a privileged and restricted position within our society, then you are naturally obligated to provide any medical services, approved by the government, that you are called upon to provide. In particular, you are obligated to check your personal — and most especially, your religious – convictions at the door. If you are unwilling to carry out this obligation, then, like the Amish bus driver, you have disqualified yourself from that privileged position. Go do some other job that does not violate your prissy sensibilities.

This logic is eminently simple. In fact, it can be reduced to an elementary syllogism:

Premise 1: Society awards physicians an exclusive license to provide legitimate medical services.

Premise 2: Society deems certain medical services such as abortion, assisted suicide, or euthanasia to be legitimate medical services.

Conclusion: Therefore, all licensed physicians are obligated to provide these services.

Many conservatives will be nearly apoplectic over the idea that doctors who are morally opposed to life-ending medical activities must either agree to perform those activities (once society decides they are legitimate medical services) or leave the profession. But conservatives, proud of their self-described tradition of acting on the basis of hard data and cold logic (unlike those silly liberals who let simple emotions rule them), find themselves in this instance stymied by the very foundation of logic — the syllogism. They are hoisted on their own petard.

Indeed, doctors who object to having to provide life-ending medical services find themselves in quite a fix, and what's more, it is a fix that has resulted from the actions of their own profession.

When we are faced with a syllogism whose internal logic is unassailable, but whose conclusion we strongly believe to be wrong, then Aristotle (him again!) teaches us to check our premises. But when we do so, in this case we quickly see that while both premises may "feel" wrong to many physicians, in 2010 they are indeed correct. And therefore, so is the conclusion.

Premise 1 asserts that the physicians' primary obligations are defined by a contract between themselves and society — or (let's be frank) the state.

Until just a few years ago doctors could have legitimately objected to this assertion, since from the time of the ancient Greeks the physician's prime obligation was defined by a direct covenant between themselves and the individual patient. And the precepts of medical ethics that governed the behavior of physicians were focused entirely on sanctifying that doctor-patient relationship. Those ethical precepts took precedence over everything else, like ethical precepts are meant to do, and at least in principle superseded all other authority down through the ages.

But alas, modern doctors don't hold to such things anymore. And in recent years they have made their departure from their ancient ethical principles, and from the traditional doctor-patient relationship, fully explicit and quite formal http://covertrationingblog.com/medical-ethics/drrich-the-acp-and-medical-ethics. They have done this to such an extent that they can no longer even aspire to the relatively minor sin of hypocrisy. (Say what you will about hypocrites. At least they espouse firm principles which they can then violate.)

It is clear, of course, that doctors do not work for their patients anymore. Instead, they now work for the government and the government-regulated insurance companies. Still, this new kind of working relationship does not necessarily have to wreck medical ethics or the doctor-patient relationship, were it managed thoughtfully. But rather than figure out how to preserve their professional obligations within a new economic paradigm, the medical profession instead has chosen to issue a revised set of ethical precepts "for a new millennium," aimed at adjusting what were supposed to have been (and had been, for the prior two millennia) timeless principles, in order to comport with the changing needs of society. And so, of its own accord, the medical profession has abandoned its foundational ethical precepts, and thereby has abandoned the classic doctor-patient relationship — the very thing which defined the practice of medicine to be a professional endeavor in the first place. The medical profession has redefined itself by a new obligation to the changeable needs of the collective, instead of its old obligation to the expectations of the individual patients who place their lives in their hands.

In short, the profession of medicine has formally and voluntarily converted itself into a primarily contractual enterprise (ie, as contractors for the government and government proxies), instead of a primarily ethical enterprise between themselves and their patients.

And so, whereas Premise 1 could have been easily cast aside just a few years ago (which is why it still "feels" wrong to a lot of doctors), today it is entirely legitimate.

Premise 2 recognizes certain life-ending activities to be legitimate medical services. Abortion, of course, has been legal in the US for several decades. Since many of his readers will quibble with the assertion that abortion is life-ending, DrRich has decided to make Premise 2 somewhat forward looking, and so he has included the other two life-ending actions which will very likely become legitimate, approved "medical services" in the foreseeable future.

The medical profession not too many decades ago was quite clear on the ethical status of life-ending actions taken by physicians. Such actions in all their forms were proscribed. The Hippocratic Oath forbids taking actions intended to end life, and specifically calls out abortion as one of those forbidden actions. But the Hippocratic Oath (like the Declaration of Independence and the Constitution) has become merely quaint in our modern, advanced society.

One of the reasons DrRich appreciated the Hippocratic Oath, when it was recited at his medical school graduation way back in a different era, was that it so clearly reflected non-religious standards. Yes, it blustered on about Asclepius and Hygieia and so on, but even the ancient Greeks didn't really take their gods seriously. The Oath invoked the gods in the same manner in which, some assert, our founders invoked the Creator in the Declaration of Independence. Whether or not they were actually asserting that our foundational principles come directly from a being named God, they were making a very powerful statement. At the very least, they were saying, "We hold these principles to be so fundamental to the essence of man that to violate them would violate our very reason to exist. They are our bedrock, and to challenge them would be fatal to our enterprise. Here we draw our line in the sand, and we will defend this line to our deaths."

The Hippocratic Oath was kind of like that.

The Hippocratic invocation against physicians ending innocent life was a clear line in the sand, and its purpose was a practical one rather than a religious one. For, in order to legally take an innocent life, we are required to say either that sometimes it is perfectly OK to kill an innocent human being, or that for some reason (because, for instance, at such-and-such a stage of fetal development the potential human is not yet viable) a particular innocent life is not really a human being after all. If it is sometimes perfectly OK to kill an innocent human being, our society is terminally corrupt. On the other hand, if society has the temerity to define "human being" in such a way as to meet its exigencies of the moment (beyond the most conservative possible definition suggested by nature, that is, the point where sperm and the egg combine to form a new life entity), it will necessarily be a fundamentally arbitrary definition. And once society undertakes to define human life arbitrarily, then there is nothing to stop society from changing that arbitrary definition as expediency requires.

Wise Hippocrates (DrRich suspects), foreseeing that mankind was likely to continue with its periodic spurts of genocidal indignation against this or that sub-human subset of our species, and seeing that it would be fatal to the medical profession to allow its special arts to be turned toward aiding such efforts, and realizing that it would be impossible, once physicians engaged in any small but legitimized taking of innocent life, to keep from escalating those activities if the needs of a society under duress demanded it, came to the conclusion that the profession required an absolute proscription here. This proscription was not a religious statement, but a practical and entirely secular one, based on a long and thoughtful observation of human nature, and aimed at keeping the medical profession focused on its real mission (caring for individual patients) rather than becoming an instrument of societal or political imperatives. And for over two thousand years the medical profession followed this line of reasoning.

The Hippocratic Oath has not been read aloud during medical school graduation ceremonies for decades now. The reason it was dropped has nothing to do with the usual claptrap you hear about not wanting to swear to Greek gods anymore. It has to do with the fact that doctors no longer subscribe to the content. It is no coincidence that the oath disappeared from the program in very short order during the 1970s, right after the Rowe v. Wade decision. In any case, over the past few decades many physicians — possibly a majority – have quite gotten over their queasiness about taking actions that either a) end innocent life, or b) admit that society has the right to define arbitrarily what it means by "human life." And the ones who still object to such actions are in dire risk of becoming the Amish bus drivers of healthcare.

So Premise 2 clearly expresses the actual default position of the medical profession today. While, for many physicians, it (like Premise 1) "feels" wrong, Premise 2 stands on its own merits.

Thus, like it or not, almost entirely due to the "evolution" of the profession of medicine itself rather than to any externally imposed changes, our syllogism appears entirely correct.

The implications are quite disturbing, and go far beyond the mere prospect of forcing pro-life doctors to either get with the program or get out. For what this syllogism really says is that the state will determine which medical actions are legitimate (or to be more specific, ethical), and that physicians being (through their own voluntary capitulation) mere contractors working at the pleasure of the state, are thus obligated to just shut up and sing. To say it more plainly, what is medically ethical is to be determined by the state, and individual doctors (except for the ones acting as collaborators and spokespersons for the state, whose job will be to make the ethical pronouncements seem medically legitimate), will have nothing to say about it.

When we view the history of mankind, we see that when the sovereign state is the entity which determines what is ethical, there is always hell to pay.

History teaches us that the state is sovereign not because it is inherently the most ethical entity within a social construct, or an ethical entity in any sense at all. Sovereignty is determined by power, not ethics. Indeed, the most useful definition of "sovereign power" is: that power which has the ultimate ability to impose its will by the application of violence. The state is inherently a political and power-based entity, whose survival depends on manipulating the political landscape and the ability to threaten (or exert) adequate violence whenever required. Such a beast is inherently poor at ethics.

DrRich happens to believe that American society is essentially good, and constitutes the most ethical large and sustained social system that has yet been devised by mankind. Yet when pressed by economics, war, political strife, manifest destiny or a myriad of other stresses, even our government has behaved dismally and frankly unethically, and has done so on numerous occasions throughout its history. One merely needs to consider slavery, the Dred Scott decision, the Mexican-American war, the treatment of native Americans, World War II internment camps, and the Tuskegee study (DrRich ignores more recent history here to avoid stirring up still-fresh controversies) to get a taste of what kinds of government behavior we in our culture are capable of justifying to ourselves when under duress. (To put this in perspective, of course, other highly-developed Western cultures during the past century, where powerful sovereign authorities assumed the right to define ethical actions, performed atrocities that cause ours to pale in comparison. But this mitigation merely reinforces DrRich's main point.)

As DrRich has been fond of pointing out on his blog, the need to find ways to ration American healthcare covertly has created extreme duress within our healthcare system, and within the government and the insurance companies responsible for administering it. And as a result covert rationing has already produced deeply and widely distributed behaviors that are harmful, inefficient, unfair and yes, frankly unethical, which affect every aspect of American healthcare. Ceding to the state — desperate to ration healthcare in any manner it can get away with – the right to define what is medically ethical, and assigning to doctors the obligation of simply obeying, sounds to DrRich like a prescription for catastrophe.

And in this way, Progressive medical ethics has brought us to a very dangerous juncture.