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Clinical ethics: Somewhere between absolutism and relativism

Standing at one end of the moral spectrum are absolutists who believe in universal standards, golden rules, and a sacred list of "Thou Shalt Not’s” which are used to judge actions as good or bad. Absolutists make no concessions for unique context or extenuating circumstances; there are no excuses that might suspend or alter ethical standards. The presumption of absolutism is that ethical principles are based on the conviction that absolute laws are perfect and immutable: i.e., "God given.” For example, when debating life and death issues such as abortion and euthanasia, absolutists may support their arguments against the taking of a life by quoting religious doctrine.

Absolute ethical standards are explored through rational discourse. Inflexible presuppositions about life and death may be challenged with questions such as, "How far off must a patient be from death to be considered dying?” and, "What if an abortion might save the life of a mother with an ectopic pregnancy?” There are always one or two students in every ethics class who remain unbending in their absolute notions of right and wrong. Absolute beliefs die hard, and as Abraham Lincoln warned, "Men [and women] are not flattered by being shown that there may be a difference of opinion between the Almighty and them.” True to form, by the end of the semester these same moral absolutists reconcile questions that challenge their values and beliefs by repeating the same ecclesiastical mantra, "If I doubt my own faith, I have nothing.” If absolutism is true, I am right and you are wrong (if you are willing to agree I have a direct line with the truth, and am not shackled in a cave somewhere staring at the same shadows as you).

Unfortunately, there are few absolutes in clinical ethics; so, when different students arrive at different decisions based on varied professional and personal values, they are sometimes lured to the other end of the moral spectrum: relativism. The relativist believes all perspectives are valid, and judgment of good and evil boils down to one’s personal preference. Relativists acknowledge that personal perspectives are based on cultural, ethnic or religious traditions. Culture and tradition "tint the color of our eyeglasses” so that everything we see is influenced by entrenched beliefs and values. Beholding a mixed bag of opinions, some students complete their study of ethics under the misconception that right and wrong decisions are relative. In part, this misconception is the result of political correctness gone overboard, and students are led to believe that a rejection of moral relativism is a sign of intolerance or prejudice. If relativism is true, no one person’s opinion is better than another’s; moral values are instilled at an early age and all ethical judgments are subjective.

Clinical ethics is applied ethics - the application of ethical principles that guide a morally correct course of action in patient care. Clinical ethics teachers can promote rational discourse by challenging both absolutism and relativism. If absolutist arguments are not questioned, discussions become a smackdown, and the classroom an arena of gladiators battling for supremacy. If relativist arguments are left unobjected, the class becomes a circus carousel, students go round and round, and discussions go nowhere. Absolutism should be saved for philosophy and religious classes, where students can impress each other with rote memorization and recitation of Augustine, Aquinas, Descartes, and Pope Benedict. The encouragement of relativism should be saved for courses on anthropology to promote an awareness of the dimensions and complexities of cultural diversity. Both absolutism and relativism have the unacceptable implication that the views of the group to which we belong are acceptable just as they are.

Clinical ethics demands attention to learning practical approaches that can be used to promote trust and enhance the professional relationship between health provider and patient. Professional relationships are not enhanced by the application of absolutism and a blatant disrespect for different cultures and religions. Neither are they enhanced by the application of relativism and a wanton disregard for best practices.

In the real world, medical professionals need a practical approach based upon socially acceptable actions and rationally determined consequences. Applied ethical issues require more than the application of principles, because these principles are not direct edicts from the Almighty; these principles are the product of relevant mortal customs, laws and traditions. Likewise, just because cultures or religions disagree doesn’t mean there is no ethical resolution. Clinical ethics is applied ethics and, as such, is somewhere between absolutism and relativism. Where exactly that is on the spectrum between absolutism and relativism will depend more upon the practitioner’s ability to determine practical consequences than theoretical principles.


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