Heads I Win; Tails You Lose
In a true ethical dilemma different rational approaches can lead to different, even contradictory, resolutions. In fact, when it comes to resolving an ethical dilemma, my students fall into three main camps: those that argue "pro,” or in favor of a specific resolution; those that argue "con,” or against a specific resolution, and those who "abstain,” or argue that the issue is "unresolvable.”
"Unresolvable” does not to say that medical ethics is relative, merely that at the moment there does not appear to be a single best answer. The following actual case (Haner & Higham, 1992) serves as an example of a dilemma that can elicit all three kinds of responses:
Baby Theresa was born anencephalic, without a brain. Her parents decided that before she died, they wanted to donate her organs to children who might benefit from transplantation. Physicians were in support of the parents’ decision, but Florida law was against it. Is it ethical to remove Baby Theresa’s organs, resulting in her immediate death in order to save the lives of other children?
Students on the "con” side of the argument, i.e., against transplanting Baby Theresa’s organs, support their position with deontological rationale, and argue against the idea of sacrificing a life, even if that life has minimal quality compared to those who may be saved. Deontologists recognize problems with treating patients, especially vulnerable ones, as a "means” rather than an "end” unto themselves. Some might even equate the act with "murder” or "playing God.”
Students on the "pro” side of the argument often rely upon utilitarian approaches, and defend the parents’ decision to donate their dying child’s organs by arguing for "the greater good” and weighing features relevant to "quality of life.” Students argue that it isn’t murder to hasten the pain free demise of a futile case and that "playing God” occurs whenever providers intervene to save a life.
So, it is plain to see that "pro” and "con” perspectives give different and mutually exclusive recommendations for what should be done in this case. But, a third and often even larger group of students refuse to choose sides, stating that the case has no right or wrong answer. These students invariably conclude their analyses of both sides of the dilemma expressing "great relief that they don’t have to make these kinds of decisions.” There was a time, not too long ago, when I’d chastise these very same students for remaining on the fence. It could be viewed as a demonstration of utter laziness, which might have been the true for a couple students who aren’t motivated to explore the full breadth and depth of complex issues. Now, I’ve come to realize that my judgment was unfair, especially considering the emphasis I placed on selecting case studies that represented bona fide ethical dilemmas.
In all likelihood, if the students in my ethics class constituted an actual hospital ethics committee, the end results for Baby Theresa’s organs would have been the same. Whether the delay was a consequence of the stalemate between "pro” and "con” sides, or the result of an utter lack of commitment to either side of the debate, the irreconcilable differences between opposing camps and the inability to commit to one side or the other both have the same outcome - inaction. We could just sit back and justify our inability to arrive at a resolution to Baby Theresa’s case, along with all the other dilemmas we face in medicine such as stem cell research, abortion, and health care as a right versus a privilege by surrendering all hope for a consensus.
The moral imperative to act is often lost in debate, sometimes on purpose (by stonewalling), and sometimes inadvertently (by waffling). The debate over Baby Theresa’s case need only last nine days – that is when she died and the organs became nonviable for transplantation. On the tenth day, all parties, "pro,” "con,” and "indifferent” went their separate ways, complacent at the thought that at least they had done no harm (not directly, anyway, even if there were other ‘unknown’ lives that might have been saved).
I don’t know of any specific ethical theory, deontological, utilitarian or otherwise, that says the consequences of inaction are as bad, or even worse, than the consequences of the wrong action. But, it seems to me that most of us recognize a moral imperative that says it is not acceptable to do nothing. If so, would tossing a coin be an ethical approach for deciding the best answer to a true dilemma? Perhaps, but I doubt doctors deciding against a court order to harvest Baby Theresa’s organ would be able to justify her death using this approach in a court of law. "Heads I win, tails you lose.” Legal and ethical justification might have to wait until the recipients of those organs are old enough to testify in a court of law.
- Haner, J. & Higham, S. (1992). A short life ends for baby Theresa. Knight-Ridder Newspapers. Retrieved from: http://community.seattletimes.nwsource.com/archive/?date=19920331&slug=1483940
Holub P. Heads I Win; Tails You Lose. The Internet Journal of Allied Health Sciences and Practice. 2011 Jul 01;9(3), Article 2.