The Myth of Moral Neutrality Medicine is a Moral Activity: But whose Morals rule?

Author: 
John Patrick, MB, BS, MRCP, MD (Lond, UK)
Article Type: 
Feature Article
Issue: 
Summer 1996
Volume Number: 
1
Issue Number: 
2

Introduction

You must not impose your values on anyone else, particularly a patient. This principle is so ingrained in medical school that virtually no one questions it, yet it is more of a piece with the bizarre world that Alice entered through the looking glass than with ours. It is a world where “words mean what I choose them to mean neither more nor less.” Only a very brief consideration is necessary to uncover the fatal logical faults contained in this modern dogma. If everyone is as entitled to his values as everyone else, only when consensus is reached can anything be done. Sadists and masochists can go ahead with their pleasures, abusive relationships must be as honoured as loving ones, attempting to prevent suicide is intrusive, only individual choice matters. Nothing can be declared inadmissible if the participants are content. This is absurd; in fact, it is an inexhaustible mine of absurdity.

The Devastating Question

Only one question is necessary to expose the shallowness of the intellectual position of those who demand moral neutrality in the practice of medicine. The question is why? Why should I practice medicine in this way? The answer must take one of two forms, either they will say that it is good or sensitive to do so, or they will say that someone might otherwise be upset. In the first case, all that has been accomplished is to change the type of moral imposition required from that derived from the rich tapestry of more than 2000 years of philosophical reflection incorporated in medical traditions to a debased untested creed, primarily concerned with the desires of the autonomous self. I am to take the morals of the ruling elite instead of my own into the consulting room. In the second case, it is being proposed that my primary professional function is to make my patients feel good about their lives even if that is not justified. This latter position has nevertheless to be suspended whenever the implications of a serious diagnosis must be explained to a patient. In both cases, an attempt has been made surreptitiously to bypass the ancient question of what is good? It is my intent to show that moral neutrality is neither acceptable nor sensible.

Defining the Good

As yet, most of us think that we know that some things are always right and others wrong but these certitudes are now under attack. Killing one another, for example, might seem a suitable candidate for universal disapprobation. However, if the one to be killed is a widow in some cultures, or an unwanted unborn infant in ours, or an ailing parent in the future, perhaps then, this ancient landmark moved. This leads the exultant modern to the conclusion that all truth is relative (except that statement!), that we must accept all these behaviours as ethical within their cultural context. But all truth is not relative; some things can be and are truly known. The categories of truth and lies define the limits of our moral universe in one plane of experience, justice and injustice in another, honour and dishonour in another, love and hatred in yet another. We know these great categories in part, through a glass darkly, but we have all experienced them truly. What is relative is the way we translate these categories into the details of living. It may be honourable to respond to a business failure by committing suicide in Japan, but in the West, it used to be honourable to wind up efficiently and pay as many debts as possible, nowadays, it appears to be honourable to hire a clever lawyer to avoid paying as many debts as possible; nevertheless, I believe that a debased idea of honour persists. If it is to be preserved within medicine, we shall need to be much more insistent on thorough discussion of changing modes of expression. Words are dangerous, they change the cultural ethos. Evacuating the products of pregnancy seems a much smaller event than abortion.

How Did We Come to be so Committed to Moral Relativism?

Claims to know are often arrogant and overbearing, especially in the area of ideas about good and evil, and in disputes between religious groups. The wars of religion bear eloquent and sad witness to the dangers associated with moral and religious dogmatism. The exclusion of religious debate from practical politics was one way to contain these tensions.

Furthermore, in the glow of post-enlightenment discoveries, it seemed that science offered certain knowledge that was based on systematic doubt, and the use of provisional hypotheses, to be cast aside when defeated by “facts.” Facts changed their meaning to be applied only to what can be appreciated by the senses, (with a few notable examples, like evolution, which are not discussed). Moral knowledge was personal, private, and subjective by comparison. Scientists could settle their disputes whilst theologians could not. What emerged was a good and defensible desire for religious tolerance and a particular respect for anything with the title scientific. The way this would lead to moral relativism was not appreciated and still is not in some quarters, but once moral truth was replaced by subjective moral opinions, relativism was inevitable. The reversal of this error demands a critique of the anthropological arguments for moral relativity.

Ethical Relativity and Anthropology

One of the most common supposed facts, upon which arguments for ethical relativity and hence for the denial of objective moral truth is based, is the existence of dramatically different ethical codes found around the world. These are undeniable phenomena extremely well documented by anthropologists. But the essential question is what are these different codes attempting to achieve? I wish to argue that in every case the behaviours deemed ethical are attempts at Honour, Truth or Justice, or some other major category. The appropriate response then is not to declare all ethical opinions relative, but to decide which most closely achieves conformity with the fundamental principles. Over some issues we respond intuitively, reflecting our own cultural history and with quite remarkable forcefulness for so-called multiculturalists. For example, in parts of the Sahel, girls are subjected, by older women, to extensive and painful circumcision to signal their passage into womanhood and to preserve their’s and their family’s honour. When they migrate to Canada, they wish to continue this practice, but we call this practice child abuse and it is forbidden. In other words, over this issue, we are prepared to say that our understanding of how the concept of honour should be translated into the ethics of everyday life is better than that of the Sahelians. What we have done is to say that the power of our cultural story to give meaning and honour to female puberty is greater than the Sahelian one. Multicultural sensitivity accepts that the intent of the Sahelians was good, but denies the appropriateness of the practice. For this practice virtually everyone agrees, but we need criteria for making such judgments in less intuitively obvious cases.

How Can We Judge?

Historically, all cultures are forced to judge, and the success or failure of cultures is probably more dependent upon these judgments than on economics or politics. Perhaps, the most noble description of what an ethical society would be like is contained in the law of Moses. Sadly, no society has ever come remotely close to such standards. The authority of the Mosaic law is rooted in its claim to be spoken by God, a claim derisively dismissed by modernity. Were the claim accepted, then the logical response of the Jews, namely the attempt at obedience, would be rationally mandatory for all.

An alternative approach is to attempt to reason one’s way to what is good. The Greeks attempted this, and subsequently their efforts were synthesized with the gospel by the great thinkers of the middle ages to provide a basis for Christendom. It is fashionable to decry those efforts, but as we sink into a sea of relativism, the medieval belief in an objective natural law which held sway over all things begins to look like a highly desirable one.

The modern approach, based on individualism where feelings are given as much weight as careful thought, is exceedingly shallow by comparison. It lacks any consistency or means to achieve consensus and must ultimately depend upon power, even though at present that power is exercised only through intimidation. Lewis expressed our dilemma with characteristic elegance:

For the wise men of old, the cardinal problem of human life was how to conform the soul to objective reality (God) and the solution was wisdom, self-discipline and virtue. For the modern mind the cardinal problem is how to subdue reality to the wishes of men and the solution is a technique. The pursuit of happiness in the modern sense is therefore self indulgent. Man’s conquest of nature must always become man’s conquest of other men using nature as the means. But these powerful people no longer think of God and God’s laws as objective reality so they are controlled not by God’s supernatural ideals but by the natural forces of their own heredity and environment. Thus man’s conquest of nature turns out to be nature’s conquest of man.(1)

This scenario is being played out in medicine at present as competence is displaced from first place by various forms of affirmative action. Whenever a cultural elite uses connotation words like male, or white, or Caucasian to justify their attempt to enforce quotas or speech codes, they invariably talk about victimization. We should resist derisively pointing out that it is particular people who are victimized, not groups, and therefore, it is always human rights that need consideration, not sex, race, or class in a group sense. They talk of paternalistic demeaning of groups, and then inconsistently demean a whole group by proposing to “empower” them. Ask those who have triumphed over great odds what they feel about affirmative action and quotas. Why should any person’s subjectivity dominate another’s without objective justification?

Ethics and Subjectivity

The assumption that all ethics are subjective expresses itself in such phrases as “good for you” or “wrong for you.” Subjective ethics would make it impossible to demonstrate that anything was always right or always wrong, independent of what a given individual thinks. In practice we all live as though objective right and wrong exists. If you do not believe me, stamp on the toe of a subjectivist. The University myth of the student’s essay on relativism makes the point neatly. The student had worked hard, organized a lot of material, written well and clearly understood much of the material, but had failed to grasp the implications of subjectivism adequately. The professor, to instruct the student, gave an F. The student, incensed, returned to argue. After listening for a while the professor said, “Ah, but you don’t understand, I hate blue folders.” The student took the point and was given a more appropriate grade. For “Justice,” which the student demanded, to exist something beyond individual preferences is necessary. Professor Leff, from Yale law school, expressed the dilemma eloquently:

I want to believe — and so do you — in a complete, transcendent, and immanent set of propositions about right and wrong, findable rules that authoritatively and unambiguously direct us how to live righteously. I also want to believe — and so do you — in no such thing, but rather that we are wholly free, not only to choose for ourselves what we ought to do, but to decide for ourselves, individually and as a species, what we ought to be. What we want, Heaven help us, is simultaneously to be perfectly ruled and perfectly free, that is, at the same time to discover the right and the good and to create it.(2)

Leff recognized that moral freedom of that sort would lead to anarchy, but he could not solve the conundrum. He knew that if all opinions were equal justice was an illusion but couldn’t bring himself to accept the inevitable consequences of objective moral truth.

Are All Ethical Opinions Equal?

Only a moment of serious consideration is necessary to answer this question. To equate the ethical sophistication of the Greeks with the now extinct Ik is nonsense. The Ik were a nomadic tribe caught in a terrible predicament where their traditional way of life was threatened. Their responses were selfish and far from noble, and led to their extinction.(3) Similar foolish choices, such as the current adoption of crass egalitarianism, are destroying the University, because recognition of real scholarship and erudition is necessarily hierarchical. Grade inflation, also part of this process, is intrinsically unjust to the most talented.

The conclusion of Leff’s essay dramatically illustrates our dilemma:

All I can say is this: it looks as though we are all we have. Given what we know about ourselves and about each other that is an extraordinarily unappetizing prospect; looking around the world, it appears that if all men are brothers the ruling model is Cain and Abel. Neither reason, nor love nor even terror, seems able to make us good, and worse than that there is no reason why anything should. Only if ethics is something unspeakable by us could law be unnatural and therefore unchallengeable. As things stand now everything is up for grabs. Nevertheless napalming babies is bad, starving the poor is wicked, buying and selling each other is depraved. There is in this world such a thing as evil.

Sadly, having demonstrated that his premise did not lead to a morally consistent conclusion, Leff did not re-examine his premise, and, as Johnson wrote in his essay, Leff spent the rest of his life on the minutiae of the law and never returned to the weightier issues.

Tolerance

So far, we have seen that moral neutrality presupposes the absence of metaphysical truth, that it espouses a moral subjectivity which is easily shown to be unacceptable and unworkable, that it necessarily accepts the equal validity of everyone’s moral choices, but nevertheless, passes legislation outlawing some cultural choices. The primary driving force of the morally neutral is a fear of intolerance and a love of individual liberty, which verges on libertarianism. The question is: can a society be built on the basis of tolerance and untrammeled individual liberty?

Tolerance and Freedom Are Not Supreme Virtues

No one likes to be called intolerant, but it can be demonstrated that intolerance in certain things is critical to the stability of society. Consider the following scenario. There is a society in North America with the declared aim of legalizing sexual activity between adult males and pre-pubertal boys. “Eight is too late” is their slogan. Now imagine yourselves as parents of an eight year old boy who find themselves with one of these men as a house-guest for two weeks. He is charming, witty, intelligent and full of fun, but he does have this quirk. Will you allow him unopposed opportunity to use his charm and sophistication to persuade your eight-year old that he is being deprived of the rightful experiences of every eight year old? I have asked this question of several audiences. No one has said yes. There are activities which all of us will not tolerate, and we feel no shame in displaying our intolerance. 

What sorts of behaviours do we legitimately attempt to suppress? I would suggest a starting list of four — unloving, unjust, untruthful, dishonourable behaviour.

Love, truth, justice and honour cannot even share a sentence with the verb to tolerate. You do not tolerate love, you embrace it, you seek it; you do not tolerate truth or justice, you demand them and honour is admired not tolerated. Tolerance and compromise are not the stuff from which great societies, great stories, or even great professions are made.

But tolerance is important. It is the oil which lubricates so many human interactions; but often its strength is to overlook error or wrong-doing, to have compassion on the human frailties which beset us all. Unlike truth, love and justice which brook no rivals, the proper use of tolerance involves wise judgment. To lack the necessary skills of prudent judgment will lead the defective into either bigoted narrow-mindedness or libertarian excess.

The Necessity for Appropriate Tolerance

Neutral values do not exist, but we do need the tolerance they would seek to protect to adjudicate the conflicts which arise in our attempts to translate the unchanging but only imperfectly known truth into the working ethics of daily living. Human judgments on how this should be done are very culturally dependent, as even a brief list of practices considered ethical in different parts of the world in the last century clearly illustrates. Such a list would include: widow burning, ritual prostitution, infanticide, slavery, abortion, and euthanasia. Changes in what is considered ethical occur very slowly, but they are dependent on dogma for their foundation. Christians, for example, affirmed that all were one in Christ Jesus, that there was neither Jew nor Greek, neither male nor female, neither slave nor free from the time of Paul. But this doctrine did not translate into the practical condemnation of slavery for 18 centuries, and the war of the sexes is still continuing!

What is desired, and rightly so, is tolerance as a normal virtue in our human interactions, but it is clear that the espousal of neutral values is not the way to create the appropriately tolerant society. Neither is the refusal to accept every opinion as equally valid truly intolerant; rather those who would demand such things are intolerant of logic. It is becoming apparent that the atheistic secularist has no adequate basis for tolerance because if this life is all we get, and there are no individual moral consequences, it is logical to use power to achieve your own ends. The Christian, on the other hand, believes in both his own fallenness and the ultimate unknowableness of God in His entirety, and therefore, has good reason to be humble in the face of contrary opinions.

The Hidden Premise

Those who want a neutral value policy usually say something like; “you keep your opinions on morals private and I will do the same, and in that way we will both be happy.” This slick piece of sophistry is neither true nor honest. The hidden implication is that there is no objective truth at stake — but, as we have already seen, in order to have justice objective truth is necessary. We have to have means to judge. But, I believe the real motivation behind the “I have my values you have yours” argument is the objective of a libertarian society and this follows by default without the risk of rigorous debate, if we accept their argument. It is the old hatred of our creatureliness in modern dress. Pascal expressed it most eloquently:

It is the nature of self-esteem and of the human self to love only oneself and to consider oneself alone. But what can a man do? He wants to be great and finds that he is small; he wants to be happy and finds that he is unhappy; he wants to be perfect and finds that he is riddled with imperfections; he wants to be the object of men’s affection and esteem and sees that his faults deserve only their dislike and contempt. The embarrassing position in which he finds himself produces in him the most unjust and criminal passion that can possibly be imagined; he conceives a mortal hatred of the truth which brings him down to earth and convinces him of his faults. He would like to be able to annihilate it, and, not being able to destroy it in himself, he destroys it in the minds of other people. That is to say, he concentrates all his efforts on concealing his faults both from others and from himself, and cannot stand being made to see them or their being seen by other people.(4)

Throughout history there have always been those who wish, as they put it, to be free. But unless we are good, our freedom always deteriorates to license, and usually to the tyranny of the few over the many. The bane of human history is the desire to be an autonomous self, to be beholden to no-one. But such autonomy is not the truth, ethics is the condition of man (Wittgenstein). Conscience is real. For those who accept an over-arching reality, it is a gentle nudge towards truth, and for those who refuse, it is the guilt trip laid on them by society.

Conscience

The first thing to recognize is that the word itself shows its origins in the idea that conscience is not a feeling but a form of knowing. We all have the experience of being inwardly obligated to do “good” or to eschew “evil.” This is true even when it is to our own immediate hurt, as with passing up an opportunity to cheat. This is not a feeling, indeed it fights against our feelings. This is moral knowledge. In most cases, it offers no evolutionary benefit to our genes so that the reductionist is left with an explanatory problem. Whence cometh the moral law within? When one reads a law, it is normal to ask who is the lawgiver! The objection, of course, as Leff clearly understood, is that if we accept this view, we accept our creaturely status. A lawgiver, the legitimacy of whose laws we cannot deny, demands our obedience.

Conclusion

So, what needs to be done to remove the illusion of relativism from our teaching guidelines, and replace it with a more sophisticated understanding of moral truth, including appropriate tolerance of different ethical judgments? First, those who understand the process that has led to the logical nonsense of so-called neutral values must start saying so publicly, and doing what they can to redress the damage done. This damage is primarily to create an atmosphere where moral relativism is the norm. We must all examine our intolerances and decide whether they are bigoted or selfishly libertarian, and therefore to be decried and removed, or legitimate, and therefore to be defended. Judgment is hard, but it must be attempted if we are not to be left with a crude and debased culture. For tolerance to be properly exercised, it must be held in tension with all the other virtues. This is what character formation is all about. It requires the development of wisdom which is quite different from the acquisition of knowledge, and utterly different from the mere cataloguing of information which currently passes for education. It requires a recognition that metaphysical truth exists, even though our knowledge of it is limited. Sincerity is not enough. As Iris Murdoch put it, our failure as a society is that we have substituted for the hard idea of truth, the facile idea of sincerity.

Life requires us to answer the age-old key questions, or else to spend immense psychological energy in denying their cogency and paying the price for such denial in the neuroses characteristic of our society. Where did I come from? Why am I here? Where am I going? How can I make sense of suffering? How do I come to terms with mortality? How can I believe in justice? What can I know? What may I believe? What should I do?

These questions are compulsory. The Jews were told that the critical educational environment for answering them was the home; the conversations at meals, on journeys, the practice of giving thanks to God morning and evening, and of celebrating the feasts with joy before God. Moses taught the Jews that the reality of their faith in God must be lived out in the everyday environment. For work ridden professionals, framing life within these eternal realities is difficult and needs constant attention, but if our children have only an education that deals in facts perceived solely with the senses, with no space for the spiritual, then the future is grim.

Real education is rooted in the telling and retelling of culturally formative stories which give meaning to ideas of honour, courage, justice, truth, and love. An education without these foundations is an education that is not worthy of the name.

References

1. Lewis CS. The Abolition of Man. Macmillan, New York, 1972.

2. Arthur Leff, quoted by Johnson PE. Nihilism and the end of the Law. First Things 1993;31:20.

3. Turnbull CM. The Mountain People. Simon and Schuster, New York, 1972.

4. Pascal B. Pensees. Penguin Classics, 978.

Dr. Patrick is a Professor of Biochemistry at the University of Ottawa in Canada. His address is University of Ottawa, Departments of Biochemistry and Paediatrics, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada.

Originally published in the Medical Sentinel 1996;1(1):10-13,17. Copyright©1996 Association of American Physicians and Surgeons (AAPS)

 

 

 

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