Medical Ethics & Reverence for Life

- D.S.Sheriff, M.D.
Jubilee Mission Medical College and Research Institute,Thrissur,
INDIA
http://www.ddsl.net

Email: drdsheriff@eth.net

Eubios Journal of Asian and International Bioethics 13 (2003), 224-226.
There appears to be a lack of consensus regarding a governing ethical principle dealing with issues in medical ethics. Examination of several current ethical issues in the light of Dr. Albert Schweitzer's reverence for life suggests its wide applicability as an ethic to which questions may be referred, and against which proposed solutions may be tested.

Extraordinary growth in scientific information and technology, scarcity of resources, economic diversity, and ethnologic and philosophic heterogeneity all challenge ethical thought. The same factors also make it difficult to achieve a consensus on a governing principle that can be the basis for ethical problem solving. Therefore, the likelihood of arriving at a satisfactory answer to any ethical question arising in medical practice is considerably reduced when discussants differ widely as to which "principles" are operative in the given situation. Thus it is appropriate to attempt to define a fundamental principle, devoid of cultural and religious bias, which could be widely accepted as the rational basis for ethical problem-solving. To that end, Dr. Albert Schweitzer's philosophy of reverence for life is re-examined in the light of some of today's general medical ethical problems.

Reverence for Life

  "Reverence for life" was coined by Dr. Albert Schweitzer (1875-1965) in Civilization and Ethics, volume two of his Philosophy of Civilization (1923). Schweitzer saw all life as impelled by a "will-to-live." Whether conscious or not, all life shares an inner imperative, a metabolic, healing, homeostatic struggle to reproduce, to survive, to prevail. "Will-to-live" in this context is distinguishable from a conscious will (desire) to live: successful suicide requires that the traumatic insult be sufficient to overcome life's innate will-to-live. Despite the claim, "I think, therefore I am", thought does not define existence. To Schweitzer, elemental consciousness of existence, of this will-to-live, is the prerequisite of thought.

  Ethical thought derives from a consciousness of one's own existence in relation to the existence of others. True philosophy must start from the most immediate and comprehensive fact of consciousness, which says: 'I am life which wills to live, in the midst of life which wills to live.' ... Ethics consist, therefore, in experiencing the compulsion to show to all will-to-live the same reverence as one does to his/her own. There we see the basic principle of the moral which is a necessity of thought. It is good to maintain and to encourage life; it is bad to destroy life or to obstruct it [1]. It is not possible to derive ethics from thought alone. The world of knowledge and experience is so vast that one becomes overwhelmed before being able to comprehend a meaning for the whole. Ethics must begin from an intuitive awareness of the interdependence of all life. We are obliged to live at the cost of other life, and thus experience other life in our own. Yet ethics may not be realized without thought. From the tension between awareness of existence and thought comes the concept that it is good, not simply to preserve and to promote life, but also "to elevate to its highest value life which is capable of development" [2]. From awareness of will-to-live arises the widest possible ground of understanding of ethics.

Physician-patient Relationship

As an individual affirmation engendering respect for all other individuals, reverence for life influences all relationships. It respects patient autonomy, which is the basis of insistence on fully informed consent, and enriches the concept of the "patient as a person". It evokes the ideal of service: "A man is truly ethical only when he obeys the compulsion to help all life which he is able to assist, and shrinks from injuring anything that lives." [3]. Thus the ethics of reverence for life provide a basis for the claims of professional duty enshrined in various medical oaths. In reverence for life, "primum non nocere" finds not only its ethical basis, but also its positive corollary.

The Dying Patient

    In its affirmation of individual responsibility for ethical decisions, and in its respect for the autonomy of others, reverence for life acknowledges the perogative of patients to withdraw from treatment at any time, or to "withdraw" prospectively through a clearly stated "Living Will". Reverence for life treats all persons with dignity. It finds dignity, not in the coming death, but in the remaining life. This was vividly illustrated by the medical care he received during his terminal stages of life. Because of the evident irreversibility of his condition - deepening cerebral coma, increasing uremia and developing pneumonitis - no further diagnostic measures or specific therapeutic measures were carried out. He continued to receive constant and excellent nursing care, but he did not require any analgesic medications, for at no time was there any evidence of suffering [4].

The Unborn

  His general affirmation that "Ethics are responsibility without limit towards all that lives" [5] would extend ethical concerns to the fetal patient, in the present age of fetal surgery. Such concerns are not limited by considerations of fetal age. Nor does Dr. Schweitzer write specifically of abortion. In his general writings we find clear acknowledgment that in the chain of survival of all life, life takes life, and that of necessity some choices must be made. Yet: The ethics of reverence for life know nothing of a relative ethic. ... [they] compel [man] to decide for himself in each case how far he can remain ethical and how far he must submit himself to the necessity for destruction of and injury to life, and therewith incur guilt. [6] Choices must always be individualized. The ethical tension must be resolved in each case and the ethical responsibility may not be displaced to others.

In ethical conflicts humans can arrive only at subjective decisions. No one can decide for him at what point, on each occasion, lies the extreme limit of possibility for his persistence in the preservation and furtherance of life. He alone has to judge this issue, by letting himself be guided by a feeling of the highest possible responsibility towards other life." [6]

Scarce Resources

  Rapidly increased costs of health care, have forced planners and practitioners in the developed nations, as their Third World counterparts always have, to face ethical questions arising from limits in health care resources. Economist Lester Thurow pointed to the ethical burden now forced upon individual practitioners who must choose between a practice style which will use any treatment (even an experimental one) which does no harm, and practice which will use a treatment only when one is "sure that it will make a noticeable improvement." [7] Dr. Schweitzer's experience in Africa seems to advance much the same argument. Dr. Schweitzer was criticized for his seeming slowness to adopt new treatments and new technology at his hospital in Africa. Yet he seems to have been quick to adopt new treatments that were clearly beneficial and could be administered with minimal toxicity in the primitive environment of his practice. He was slow to electrify the Lambarene hospital, fearing inordinate dependence on the difficult and uncertain chain of fuel supply. [8] His concerns foreshadowed the later literature on "appropriate technology" in the developing world [9].

Corporate Decision-making

    In matters of corporate or social policy, such as allotting the use of scarce medical resources and administering systems of health care, ethical responsibility still evolves on decision-makers individually. Holding "supra-personal responsibility" (as in management) does not relieve personal responsibility to act ethically: I am not at liberty to think, that in the conflict between personal and supra-personal responsibility I can balance the ethical and the expedient to make a relative ethical, or even annul the ethical with the purposive; I must choose between the two [10]. Reverence for life argues that the corporate decision-maker (the manager of health care resources) must also act so as to "obey the compulsion to help all life which he is able to assist" [3].

Medical experimentation

Dr. Schweitzer wrote specifically about animal experimentation: Those who experiment with operations or the use of drugs upon animals, or inoculate them with diseases, so as to be able to bring help to humankind with the results gained, must never quiet any misgivings they feel with the general reflection that their cruel proceedings aim at a valuable result. They must first have considered in each individual case whether there is a real necessity to force upon any animal this sacrifice for the sake of mankind. And they must take the most anxious care to mitigate as much as possible the pain inflicted [11].

Discussion

Reverence for life is not a creed. Reverence (Ehrfurcht) implies awe, wonder, and respect rather than worship. It provides a basis for a mystical sense of oneness with all life, but it accepts life as it finds it, without intruding on the question of the meaning of life. It conflicts with no religion. Its insights enrich them all, and provide a basis for broader understanding among peoples of different religion. It is not a code. Schweitzer refused to define rules or values for individual lives, stressing instead individual responsibility and individual decision-making [12]. "To become ethical means to begin to think sincerely" [13]. Reverence for life is the basis for individual thinking rather than rule-making. It is not a cause, and does not give rise to any particular political agenda. Reverence for life is not argued in terms of personal "right", and does not appeal to enforcement. Nor is it argued in terms of mere sentiment. Its ethics appeal to a strong sense of personal responsibility, and require rigorous individual analysis of all factors bearing on a life-question. Illumination of ethical problems by the lamp of reverence for life does not automatically provide universal or even predictable answers to problems in patient care. It does, however, establish the ethical milieu in which appropriate questions are raised. It sets the tone of discussion, respecting the life that is the subject of discussion, and the lives and views of all lives affected. It provides the principle against which proposed solutions can be tested. Physician-patient interaction is a dynamic "quantum field" in which action is not governed by ethical insight alone. A clinical "uncertainty principle" dictates that one may not be able to satisfactorily isolate a particular ethical rule in the complex field of economic, legal, scientific, and technologic forces competing in the shaping of any action. Reverence for life does not yield a generalized protocol for care. Reverence for life must be viewed as the field itself, in which clinical decisions are always formed in an attitude of "sincere thought". It is now 62 years since the publication of the "Philosophy of Civilization", and 20 years after its author's death. There have been many changes in society and in medical technology and practice. Yet as this study suggests, the ethics of reverence for life are pertinent to a broad range of current medical ethics issues, and deserve continued study and application.

References

1. Schweitzer A: Philosophy of Civilization. New York (Macmillan) 1949. Reprint 1981, Tallahassee (University Presses of Florida). p 309. 2. Schweitzer A: Out of My Life and Thought. New York (Henry Holt) 1933. p 188.

3. Philosophy of Civilization. p. 310.

4. Dr. David Miller quoted in: Brabazon J: Albert Schweitzer - A Biography. New York (Putnam) 1975. p.465.

5. Philosophy of Civilization. p. 311.

6. ibid p. 317.

7. Thurow L: Medicine versus economics. N Eng J Med 1985 (Sept 5); 313:611-614.

8. Brabazon, op cit, p 341 f

9. Lomax CA: The design and use of appropriate health technologies for developing countries. J.Med.Engineering & Technology 1980 Jan. 4(1): 11-15 (18 ref.).

10. Philosophy of Civilization. p 324.

11. ibid p 318.

12. Out of My Life and Thought. p 271.

13. Philosophy of Civilization. p 308.


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