DALLAS (BP)–When Robert Orr was in medical school in the 1960s, the training he received in medical ethics amounted to an hour-long lecture on etiquette. Only three students showed up that Saturday morning.
“It had nothing to do with what we think of now as medical ethics,” Orr said during the “Cutting-Edge Bioethics: Human Life on the Line” conference at Criswell College in Dallas.
After a lifetime of practicing medicine for which he was named Vermont’s family doctor of the year in 1995, Orr also has become an ethics consultant. In the more than 1,400 cases for which he’s offered advice, questions often center less on what can be done than what should be done.
“The first people who started asking questions about what should be done [in medical care] were the theologians,” Orr said, alluding to moral issues such as abortion that moved medical ethics to the forefront.
“Sadly, over time, the voice of the theologian has gotten weaker and weaker and less listened to as the baton was handed over — first to philosophers. Then clinicians —- the physicians, nurses and social workers who deal with patients daily — became involved and engaged.” Next came the attorneys and judges and, more recently, people with a business background analyzing the cost of care, said Orr, a faculty member at the University of Vermont’s College of Medicine and clinical director of the Center for Bioethics and Human Dignity, a Chicago-area bioethics think tank.
Ethics committees were formed in the 1980s in response to cases such as that of brain-damaged Karen Ann Quinlan whose family fought for the right to remove the respirator when she was in a comatose state. Now, such situations often involve a dozen or more consultants in assisting patients and next of kin regarding “do not resuscitate” instructions and various other decisions.
“When I was in medical school in the 1960s the question was, ‘Should we tell the patient he or she is dying?’ Ninety percent of the time patients were not told,” Orr said of his early experience. “Now there’s been a sea change to 98 percent of the time we do [tell them].”
Orr said breakthroughs in medical care have led to:
— involvement of medical personnel in executing prisoners through lethal injections.
— protecting patient confidentiality as records are stored electronically.
— access to healthcare among patients who are uninsured or underinsured and the rising cost of care.
— xenotransplantation utilizing organs from animals to replace diseased human organs.
— reproductive technology that provides “babies without sex.”
— so-called “gene enhancement” to remove unwanted traits that threaten a patient’s health.
— artificial intelligence and artificial life, which raise the question of what it means to be human.
“What is normal?” Orr asked. “Should we eliminate those who are not normal? Once we start being able to change genes, we’ll be asking the same question of who should live and with what characteristics.”
Orr noted that technology “raises questions of can-do versus should-do. When you have a man dying of lung cancer with difficulty breathing, can we put him on a ventilator to postpone dying a few days or weeks? We can, but should we?”
Raising the issue of “marginal benefit,” Orr said decisions must be made between differing plans such as one treatment that works 87 percent of the time and costs $100 versus another treatment that works 92 percent of the time but costs $20,000. “Is it worth it? These are tough calls,” he acknowledged.
“The impulse [of doctors] is to do everything you’re trained to do regardless of the cost. If respiration fails, put him on a ventilator. If a kidney fails, put him on dialysis. It’s a knee-jerk reaction that says, ‘I know how to do that.’”
Orr referenced a statement he heard more than 30 years ago that “the ability to act does not justify the action.” Even among Christians, cases are not easily settled, he said.
“Under the shadow of forgiveness, difficult decisions are possible.”
Orr said he is distressed “when I see two Christians going at each other” instead of engaging in a discussion that leads to responsible action.
In an earlier era, Orr said, doctors were always thought to know what was best for the patient, calling it the “Marcus Welby” era of paternalistic medicine, referring to the 1970s television show. With the social upheaval of the 1960s and 1970s, Orr said the emphasis was on patients’ rights and involvement which declared, “This is my body, my health.”
“The pendulum swung from paternalistic physician to autonomous patient,” Orr said. “I think it went too far and the pendulum is coming back with shared decision-making.” He contrasted the concept of a consumer provider in which the practice of medicine is a routine, legal, business transaction to a covenant relationship focused on the patient’s best interests.
Often doctors aren’t involved in the decision-making process; it is common for treatment to come from “absolute strangers” in the emergency room or hospitalists who only work within a hospital, Orr said. The pressure to maintain costs also adversely affects a patient-doctor relationship. “More scientific and economic input makes it a more complicated business than it used to be,” he said.
The threat of lawsuits further limits physicians, Orr said, suggesting that the best defense is to “practice good ethics and document it” when a doctor meets with a family to make decisions based on his understanding of their values.
“When I was younger and smarter, things were black and white,” Orr said. “Life was so easy when I was so clear on what was good and what was bad.
“The older I get the more gray I see,” he said, noting that some decisions are morally neutral. The knowledge and wisdom of God is not always easily discerned, he added. “Part of my job is to help people cope with the gray.”
The “Cutting-Edge Bioethics: Human Life on the Line” conference on “end-of-life issues, reproductive technologies, stem cell research and beyond” at Criswell College, April 29-30, was cosponsored by Trinity International University, the Center for Bioethics and Human Dignity, Christian Medical & Dental Associations, The American Academy of Medical Ethics and Baylor Health Care System of Dallas.
Tammi Reed Ledbetter is a contributing writer to the Southern Baptist Texan, newsjournal of the Southern Baptists of Texas Convention, online at www.sbtexas.com.