There’s an essay by Diego Gracia called “Palliative Care and the Historical Background” that I frequently use in classes about Care ethics, and there’s a passage in it that always gets a fascinating reaction from students.  In this passage, Gracia claims that

the true goal of medicine has always been curing, rather than taking care of the patient. Caring has never been the goal of medicine.

In fact, in the context of palliative care, he takes this one step further:

Thus, if the type of care specific to medicine is curing, then palliative care has nothing to do with medicine…

I came across this essay a few years ago while preparing a session for students on Keele’s MA in the Ethics of Cancer and Palliative Care, when the cohort was split between doctors and non-doctors.  More recently, it gets trotted out to my intercalating MSc ethics students here at Manchester: they’re all taking a year out from their medical studies.  But the reaction tends to be similar: Gracia’s claim will be dismissed… and then one person will say, “Hang on, though…”, and a genuine and probing debate will emerge.  The claim is not so easy to dismiss as would seem.

I mention this here because, in the replies thread to a post below, I mentioned the possibility that medicine displays a pro-life bias.  By this, what I mean is that it is possibly built into medicine that death is seen as always being the outcome we’d most want to avoid – it’s not only a defeat, but an indication of the failure (or, at best, incompleteness) of the medical project.  (Indeed, we might be able to go further, and say that even non-life is seen as something of an insult, which is why we try so hard to “cure” infertility.)  On this account, a discipline like palliative care, just because it’s not concerned with cure, would seem to have an ambiguous relationship with medicine – which seems perfectly compatible with Gracia’s point.  Moreover, the imperative that drives medicine does not seem to be the same imperative that drives palliative care – or, if it’s the same imperative, it’s very differently manifested.

If it’s true that medicine is somehow essentially about cure and about saving lives by curing, it’d go some way to explaining the opposition to euthanasia in parts of the medical profession.  It’d also go some way to explaining the hostility that does appear from time to time to respecting refusals of treatment – one of the most extreme examples of which I’ve seen in the comments to this BBC article:

I am a doctor specialising in accident and emergency medicine and I have no intention of following any such instructions. I will continue to strive to save the lives of all my patients so long as I feel that there is a reasonable chance of recovery. That decision will be made on clinical grounds and I will not be influenced by any “right to die” card. It is my right to treat my patients as I see fit in accordance with Hippocratic principles, and the GMC would have to strike me off the Medical Register to stop me following my conscience in these matters.

OK: maybe that’s not exactly representative, but it’s the kind of response that I – and I suspect others – do see in essays, and it’s not exactly rare either.

Moreover, a couple of the standard objections to euthanasia are that a cure might yet be possible, or that the desire for death is actually a desire for better end-of-life care.  I don’t think either of these is convincing, but they’re frequently trotted out.  And it is, of course, fairly intuitive that death is, in most cases at least, the worst possible outcome.  We’d also be able to explain why health outcomes are frequently measured in terms of survival rates.

Is this the only way of thinking about medicine, though?  Lest I get accused of presenting a pro-death or anti-life bias, I’m proposing no such thing, and that would be a false dichotomy.  Moreover, I don’t think that “bias” has to be seen as a pejorative term (yep, I’ve read my Gadamer, and am willing to bastardise what I found).  What I am wondering, though, is whether there might be alternative ways of thinking about biomedical ethics that aren’t predicated on the notion of saving life as being the primary goal, and whether they might be cogently applied to conventional medical practice.

I think that it probably is possible to avoid a pro-life default.  Palliative care shows a possible way: death here is not seen as a defeat, but as just something that happens to a person.  The aim is not to preserve life, but to preserve its quality to the greatest extent possible.  Strip away all the nonsense about “spiritual” needs, and I think that that’s quite an attractive way of thinking.  But even if you take away that tacit pro-attitude there, you can still accept that it’s coherent and makes a lot of sense.  What we see in palliative care is not the privileging of life in its own terms, so much as the desire to promote a particular kind of life.  And I don’t think that anyone in the palliative care field would claim to be in competition with medicine “proper” – they’d claim to be doing something that compliments it.

Does the same attitude about complementarity work the other way?  Increasingly, I suspect it does.  Palliative care has become increasingly respected, and rightly so.  Nevertheless, I suspect that there’s still a lingering sense that we should be trying to save lives.  At risk of transferring the debate in the replies below to this post, some of the comments regarding Kerrie Wooltorton could, perhaps, indicate that much.

Other areas of medical practice might be interesting to examine through a “non-vitalic” lens, and the task may have been begun.  I’m thinking here of Hursthouse’s account of virtue ethics and abortion, the important bit of which I take to be the idea that the moral status of the foetus, and its putative entitlement to life, is actually less important than understanding how the pregnancy fits into the mother’s life and her more generalised account of the good.  The idea here might well be that it’s bad that a life ends, but that it’s also far from the whole story: the end of a life is a characteristic, but it’s not the central one.

But even away from an Aritotelian field, there might be things to say.  For example, there’s a lot of utilitarian thought that has death as the greatest harm that can befall a person, and, implicitly, continued life as a way to avoid that.  There’s a significant number of people, not all of whom are cranks, who’re seriously interested in immortality or something like it as a goal.  But why should this be?  Presumably, it has to do either with the idea that life is valuable in its own right – which I find implausible (and the Cumaean Sibyl agrees with me) – or with life as being the criterion for achieving any goal whatsoever – which I think is more likely to be right.  But if it is right, then life as a default good doesn’t look tenable: it would make sense to ask a person what they want to be alive for, and life’s importance would be a function of this.  Put another way, it would be the reason for being alive that did the important moral lifting.  Our focus would be on projects, not on life.  And if a person decided not to be alive any more, then the loss of that life would be considered to be correspondingly less of a loss.  Finally, the focus of medical care when seen through these glasses would not be on saving a life, but on underwriting projects.  We could still assume that most people would not want to die, and so it’s not as if I’m advocating no more life-saving medicine, but it wouldn’t be merely being alive that really counted.  It probably isn’t anyway.

Granted, this is probably at best a rough-and-ready account.  Any suggestions?