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ETHICS MADE REAL

GORDON SELF

Earlier this month Covenant Health held its biannual ethics conference, entitled, Great Expectations? The allusion to Charles Dickens' masterpiece comes to mind, for the world of health care ethics today represents how both the "sun shines hot and the wind blows cold."

Ongoing advances in technology have created new possibilities, tempered, like a cold wind, by new ethical conundrums.

For example, medicine keeps pushing the limits of viability in how early we can intervene to treat a premature baby at 23 or 24 weeks gestation. At the outside chance survival is possible, and for an indeterminate period of time, the baby usually faces severe physical and cognitive problems that later people of good conscience, family and clinicians alike, wonder whether we have done the right thing for this child.

With this in mind, our conference title intentionally posed a rhetorical question. What great expectations in fact are we naming?

Speakers explored shifts in public expectations regarding treatment goals, perpetuated by fictitious (and often unbelievable) television medical dramas. As I always say, you have a better chance of surviving an unwitnessed cardiac arrest - and walking out of hospital with no co-morbidities - if you are resuscitated on TV.

Even reputable news hour reports turning the spotlight ("the sun shines hot") on the latest technological cure inadvertently feed into public expectations about receiving the best care possible, on demand, regardless of your disease trajectory.

Death is still an inescapable reality of life, but we act, and expect, that it is not. Thus, health care providers have increasing expectations placed on them to "do everything possible," even if it collides with the clinician's professional judgment.

CONSCIENTIOUS OBJECTION

A few years ago, exercise of conscientious objection was a hotly debated subject in the medical and pro-life communities, especially regarding matters of conscience in prescribing birth control or referral for pregnancy termination.

While understandably a lot of attention was devoted to these moral issues and the conflict it posed for clinicians in respecting their conscientious beliefs without putting the patient at risk of harm or abandonment, less attention has been devoted to the conflict of conscience when the health care provider is expected to aggressively treat a patient against their wishes.

On the contrary, I have actually heard more clinicians lament having to intervene when good medical judgment - and good conscience - tells them otherwise. How then do you support a nurse, therapist or doctor when they believe the treatment they are providing is a form of battery?

It is no wonder why some good people leave the health care profession given the untenable expectations placed upon them. The literature has long documented this exodus from the profession when people capitulate to other's expectations at the expense of one's own moral centre.

Clinicians and the health care public alike have to wrestle with the limits of these expectations and how best to respond when treatment cannot, or should not, be pursued. So perhaps then the most significant moral question we have to ask as a Catholic community is what expectations we have to move this conversation forward.

Sensational cases reported in the media unfortunately tend to polarize debate, with little attention paid to exploring what can be done to prevent moral residue. In keeping with Covenant Health's preventive ethics strategy, we chose to have a conference to discuss these extremely important societal issues with the great expectation that our dialogue can point us to proactive solutions, aligned with the Catholic moral tradition in weighing proportionate benefit and burden to determine appropriate goals of care.

REALITY OF DEATH

I believe we have only begun to fathom the emerging ethical dilemmas that technology will usher in. Nor have we, as an aging society, seemingly accepted the reality of death that necessarily limits what we can do when the margins of viability are near at hand.

The Paschal Mystery includes both Jesus' suffering and death. But we act as though it is only about resurrection, or, more likely, resuscitation. As a people of faith, we have a moral responsibility to orient our lives to the ultimate goal of life - friendship with God - not earthly existence achieved at all costs.

Despite the emerging ethical dilemmas that technology brings, the Catholic ethical tradition has much to teach about how to navigate these issues without losing sight of the ultimate goal of life, and setting realistic goals of treatment consistent with what good medicine and good conscience calls us. That is indeed a great expectation of faith worthy of our prayers, and support.

(Gordon Self is vice president, mission, ethics and spirituality for Covenant Health and can be reached at mes@covenanthealth.ca.)