Tuesday, January 14, 2014

Health and Tradition

It's no secret that I do not have a high opinion of bioethics as a field. Indeed, I think that it is, of all philosophical fields one is likely to come across, consistently the most embarrassing -- much of the work is low quality and, while I try to be charitable, it is difficult to avoid the conclusion that an absurd proportion of bioethicists would have difficulty reasoning their way out of a refrigerator box. Udo Schuklenk, who teaches philosophy at Queen's and is an editor for Bioethics is out to prove my opinion right.

It's an attack on the tradition of the Hippocratic Oath, and it's a sign of the awfulness of the argument that he can't even be bothered to get it right. He says, for instance, that the Oath involves a promise "not to participate in what we would describe today as surgery", which is misleading at best. The corresponding clause in the Oath is to leave surgery to surgeons ("I will leave this operation to be performed by practitioners, specialists in this art" -- and even then, the Greek can't be made to cover any and all operations that we would call surgery). Even just looking up the text of the Oath would have prevented him from making such an obviously stupid mistake, if he can't be bothered to know what it is in the first place. And anybody who thinks this is a "silly promise" shouldn't be allowed anywhere near medical ethics, because non-specialists engaging in surgical operations they have no qualifications for has been one of the endlessly recurring problems in the history of medical ethics. You can find it all over the place in history, sometimes in places you wouldn't expect. For instance, one of the background points in Flaubert's Madame Bovary is that Charles Bovary is a low-level medical practitioner -- he isn't qualified for more than the basics. But in order to make a name for himself he practices surgery -- and, of course, flubs it. Flaubert isn't just making this sort of thing up out of thin air; this sort of thing happened, disturbingly often. It's why we have medical licensing and surgical certifications. Yes, the Oath identifies the problem in the terms it would have been known to Greeks in the fifth century BC or thereabouts, but precisely in doing so it shows that it is a constant problem, one that medical professionals need always to be vigilant about.

It's not really surprising that Schuklenk wouldn't grasp this very basic point, I suppose, because it is clear from Schuklenk's op-ed that on his conception of medicine, medicine is amnesiac and does not learn from its ethical history. It has no memory. Of course, Schuklenk attacks this ethical memory in the profession by calling it 'tradition'; this allows him to call into play a lot of bad, amateurish, undergraduate informal logic:

The point I am making here is that arguments from tradition have zero substance as arguments. They are non-arguments. Each time someone tells you that you should do a certain thing because of tradition, it’s best to tell them to go away and get a life. They merely describe what we have always done or what we have done over extensive periods of our history. If that was sufficient, we could justify slavery. After all, if we bought and sold other people for such a long time, surely it’s a tradition of sorts. The fact that there was such a tradition doesn’t provide us with any moral guidance with regard to what we should do in the future.

And to say that this argument is bad, amateurish, and undergraduate is not really fair to many amateur undergraduate bad reasoners. It's false to say that traditions "have zero substance as arguments" for the same reason it is false to say that memory has zero substance as argument: 'tradition' is nothing other than the word of handing down what has been learned, or what people think they have learned. To say that an argument from tradition is a "non-argument" is to say that nobody has ever learned anything through actual practice -- like, for instance, that important tradition of pointing out that surgery is best left to surgeons. This is something that sums up a long experience, across many generations. Over and over again certain temptations arise for doctors; the ethical advice has come down from ancient times, and survived the journey, that surgery should be left to surgeons, and that is just what the tradition is. But even that aside, look at the nonsense of the rest of the argument, in which Schuklenk attempts to justify "arguments from tradition have zero substance as arguments" by arguing that they are not intrinsically sufficient for justification -- that is to say, he thinks that from mere appeal to tradition does not necessarily justify, which is what the slavery case would show, he can derive tradition doesn't provide us with any moral guidance with regard to what we should do in the future and arguments from tradition are non-arguments. But what serious ethicist thinks that no ethical arguments provide moral guidance unless the bare appeal to them is sufficient to determine right or wrong?

Apparently Schuklenk, who seems not to grasp the elementary idea that arguments can be provisional, defeasible, probable, presumptive, and the like. The room for parody-by-parity reaches hilarious heights here. The fact that you remember something is not in and of itself a guarantee that things will happen again. Yes, this is a commonplace. Therefore a Schuklenkaster will conclude, "arguments from memory have zero substance as arguments, they are non-arguments, they don't provide any guidance with regard to what we should do in the future". No, that does not follow. But the structure of the argument is the same: this kind of argument has sometimes led astray; therefore it is of no use at all. And it is an illicit jump in reasoning that would get a corrective comment in the margin if it were found in an Intro Phil essay; to have someone at a philosophy department actually bandying this about in public is an embarrassment to the profession.

Ah, but you might say, it's only an op-ed, with limited space! Then why does he elsewhere waste the reader's time with useless rhetorical blither-blather rather than doing justice to the question at hand? Schuklenk is clearly trying to make it easy for himself by picking on the Hippocratic Oath --which is, it should be pointed out, often delivered in forms the modify it for precisely some of the reasons Schuklenk has problems with it. Let's take something along the same lines, like the Declaration of Geneva:

At the time of being admitted as a member of the medical profession:

I solemnly pledge to consecrate my life to the service of humanity;
I will give to my teachers the respect and gratitude that is their due;
I will practice my profession with conscience and dignity;
The health [originally: health and life] of my patient will be my first consideration;
I will respect the secrets that are confided in me, even after the patient has died;
I will maintain by all the means in my power, the honour and the noble traditions of the medical profession;
My colleagues will be my sisters and brothers [originally: brothers];
I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
I will maintain the utmost respect for human life [originally: the utmost respect for human life from the time of conception];
I will not use my medical knowledge to violate human rights and civil liberties [originally: the laws of humanity], even under threat;
I make these promises solemnly, freely and upon my honour.

It's obviously indebted to the Hippocratic Oath, but was formulated in 1948 in light of World War II and Nazi medical experimentation. It has many of the occasions of griping that led Schuklenk to rant against the Oath, but since it's a twentieth-century summation of basic medical ethics, not considering it conveniently lets Schuklenk get away with a lot of irrelevant potshots about Pythagorean cults and the like that contribute nothing to the essential argument. (It's actually quite controversial how the Oath is related to Pythagorean brotherhoods, incidentally, with some arguing that it is fundamentally Pythagorean in origin, and others arguing that any Pythagorean influence is very limited; but there's no need to break Schuklenk's head with accuracies when he's clearly having fun with mere rhetoric, which, apparently, he regards as having more substance as argument than tradition arising from actual practice.) It was adopted by the World Medical Association; and it was formulated with the intent to express the practical ethical experience of medical professionals, distilling the basic default principles preventing egregious medical malpractice and malfeasance, which the world had all too clearly seen. It took two years of arguing and comparing to draft. And, more than this, it was put forward to summarize the tradition -- for that is what it is, a tradition -- that medicine should be humanitarian. It's this that Schuklenk is attacking, just as much as the Hippocratic Oath; this, and things like the Declaration of Helsinki and the Nuremberg Code, for research ethics, which also distill what professionals think they have learned in dealing with the ethical temptations of their profession, and which are also carried forward as traditions -- the 'common property of humanity', as the Declaration of Helsinki is often called.

And we see through it all the very problem with bioethics these days: people whose primary ethical work is mostly theoretical and speculative, and in the long run likely to be of very little practical relevance outside (perhaps!) a handful of cases, sniping at summations of ethical experience that are taken by many actual practitioners (e.g., here) to have ongoing practical relevance -- yes, even if the details have changed a bit -- with arguments so bad that they should make real philosophers blush. It's frankly a bit sickening.

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