Recently Published Book Spotlight: Rethinking Health Care Ethics

In a diverse career, Stephen Scher has taught clinical medical ethics in Harvard Medical School–affiliated hospitals and professional ethics and organizational behavior at Yale School of Management. He joined the editorial staff of the American Journal of International Law in 1999 and stepped down as Senior Editor in 2016. He is now in his seventeenth year as Senior Editor of the Harvard Review of Psychiatry.

Why did you feel the need to write this work?

The story behind this book reaches back decades, to when I taught clinical medical ethics—at the bedside, to young doctors—in Harvard Medical School hospitals. What struck me then, and what continued to impress me as the years passed and as I moved into other sorts of work, was the discontinuity between what I saw in the hospital and what “bioethicists” were saying about it. A fundamental idea in the early years of bioethics, the 1970s and 1980s, was that doctors couldn’t be trusted to be ethical on their own. It was only an influx of bioethicists—philosophers, lawyers, theologians, sociologists, and such with claimed expertise in applied ethics—that could ensure that doctors stuck to the straight and narrow.

On the intellectual side, bioethicists’ perceptions of doctors had its source in the social and political environment of the time. Paul Starr’s Pulitzer Prize–winning book, The Social Transformation of American Medicine, effectively captured these perceptions and what surely was, to invoke Starr’s subtitle, the rise of a powerful profession.

But my experience teaching young doctors also belied these perceptions. I was impressed by their thoughtfulness, desire to learn, determination to learn and master medicine, and dedication to help the sick. Whatever Starr and the bioethical community were talking about, it wasn’t this group.

It was more than this obvious discontinuity, however, that motivated my book. What happened, over time, is that bioethicists themselves became further and further established, first in American medicine and then in the rest of the world. And they brought with them, in an exercise of their own power and authority, a way of thinking about ethics that made sense to professional academics of various sorts but that left health professionals scratching their heads as to how to make practical use of this newly imposed, theory-driven approach to health care ethics.

The book is, in effect, an effort to explain the above and to provide a model of learning, teaching, and thinking about health care ethics that is actually useful for health professionals.

A book intended for health care professionals written by people who know about the practical problems they face sounds useful. Since philosophers aren’t part of that group, what attitude should they take towards it?

This book isn’t just watered-down philosophy, and it does raise important, typically unaddressed questions for philosophers who “do” ethics or who teach it. An easy way of understanding the setting for the book is by relating an anecdote by the former co-editors of a major medical journal who had just finished reading the book. They were working as visitors at a particular hospital, and they described (to the resident ethicist) “an everyday clinical decision (one of very many).” The ethicist replied, “That would take days—even weeks—for me to analyze properly.” Moreover, “If the end results of [their] decision were harmful,” the two doctors, he said, “would have been unethical.” The problem, of course, is that health professionals need to make these decisions quickly, often immediately. And they often even make these decisions more or less automatically, without thinking. How can that be?

The way of understanding what might be called this “real world” of ethics is obviously not through ethical theory, at least if that’s understood in terms of principles or other abstract constructs that need somehow to be applied to concrete practical situations. In the book we address these matters by making some important, and crucial, philosophical distinctions not usually made in the bioethics literature—most notably, between formal and informal ethical discourse. But we also develop the view that ethics, considered as involving an intersection of thought, emotion, and action, is actually embedded in the people we are. In elaborating this view, we make central use of some concepts from the social sciences, including Daniel Kahneman’s distinction between fast and slow thinking (as presented in Thinking, Fast and Slow) and from literary theory—in particular, Stanley Fish’s notion of “interpretive community” from Is There a Text in This Class? and Doing What Comes Naturally. These materials generate a way of understanding how thinking (about ethics, or anything) can be embedded in our selves and generate ethical outcomes of one kind of another that are immediately available without conscious thought but nevertheless rich and complex.

How does one actually teach ethics, according to this view?

There are two parts of this question. What are one’s goals in teaching ethics, or—to address the question to those who teach moral philosophy in colleges and universities, including professional schools—what does one hope to achieve by teaching a course or seminar in ethics, especially to those who are not training to be philosophers. If the goal is to challenge students to develop high-level skills in analysis and criticism, then a course in ethics is just as apt as any course in philosophy to achieve that end. But if the goal is to somehow make people more ethical or more ethically aware, and in a way that stays with them over the long term, then I’m skeptical about the value of standard ethics courses that start with any sort of theoretical or abstract analyses of ethics and then try to bring such analyses to bear on the real world. That approach works for philosophers and when the audience is the philosophical community and graduate students in philosophy, but other students (no matter how bright) are not apt to carry much that is ethically “new” with them after the course is over. Whether that is perceived as a problem in teaching courses in moral philosophy is a serious question for each professor. But it is a problem in professional education in health care (and in professional education generally) because an explicit goal is to help students to provide more ethical or humanly responsive care (or services) to their patients (or clients).

As for how one would actually teach ethics, that particular matter takes up three full chapters of the book, and those chapters are themselves based on the central substantive position developed in earlier chapters. What I can say here is that it’s not just about the mind. For more, I can only suggest that you take a look at the book.

What kind of reception have you had for these ideas, which run very much against the current of contemporary bioethics?

The audience for most academic work in bioethics has been other bioethicists. My own view is that the field is ingrown, which is especially troubling when that field has had such a profound impact on another field—namely, health care—as well as on patients. The reason for making the book open access (free download) was specifically to make it available to health professionals themselves—who would never lay out 60 or 80 dollars for a book on bioethics. So far, the response from health care professionals been uniformly enthusiastic; someone is finally speaking their language. It’s unclear what the response of the bioethics community, with all its entrenched interests, will be.

Any final thoughts?

My final thought is mainly about something that isn’t directly about the book. Stanley Fish’s notion of interpretive community is surprisingly powerful and illuminating. I think that anyone doing moral, political, social, or legal philosophy should become familiar with that notion. And if they want to see how it works in practice, Rethinking Health Care Ethics is a good place to start.

A free download or low-cost hardback (free shipping) copy of the book is available here.

You can ask Stephen questions about his work in the comments section below. Comments must conform to our community guidelines and comment policy.

*

The purpose of the Recently Published Book Spotlight is to disseminate information about new scholarship to the field, explore the motivations for authors’ projects, and discuss the potential implications of the books. Our goal is to cover research from a broad array of philosophical areas and perspectives, reflecting the variety of work being done by APA members. If you have a suggestion for the series, please contact us here.