Background

If you follow a doctor around a hospital on a working day, it is very rare to ever hear him or her mentioning an ethical dilemma or a moral value. Instead, cases are understood, analysed and discussed in medical terms, such as a patient’s prognosis, the probability of a favourable outcome and possible complications. Some researchers have suggested that doctors cover their reasoning in medical terms to avoid ethical justifications (Sayers & Perera, 2002); others have proposed that doctors have poor moral perception (Casarett, 1999). In his doctoral thesis, Terje Mesel found a discrepancy between the normative ground of the medical profession

and the moral reflections of the interviewed doctors (2009). He suggests that professional codes of ethics are often considered alien to daily practical work. While the field of medical ethics is growing, it is more grounded in the tradition of moral philosophy than that of medicine. Most of the scientific articles on the topic are confined to specialist journals dedicated to issues of ethics and philosophy, and do not, therefore, come to the attention of the majority of clinical doctors. The introduction of medical school courses devoted to medical ethics may be taken as a sign of progress when it comes to appreciating ethics in medicine, but these classes are sometimes characterised as poorly integrated in the rest of the curriculum (Coulehan & Williams, 2003; Loewy, 2003).

Nevertheless, doctors are not insensitive to moral issues. On the contrary, they often set high moral standards for their work, and being “a good doctor” is a powerful ideal for most of those engaged in clinical practice (see for instance BMJ’s special issue

“What's a good doctor and how do you make one?”, 2002). Indeed, the medical profession has long-standing moral traditions, some of which stem from the Hippocratic Oath from 500 BC. The traditional aphorism “To cure sometimes, to relieve often, to comfort always – this is our work” is also the symbol of good clinical practice today (Strauss, 1968), and is incorporated in the first article of the Norwegian Medical Association’s Code of Ethics (Legeforeningen, 2011).

Moreover, the aims of a good clinician are normally perceived to include practical human knowledge and empathy, while relieving suffering and helping patients is seen as central to the role of the medical profession.

This leads us, however, to a paradox which reflects my puzzling experience referred to in the opening case: the field of medicine has evident moral dimensions, and yet they are barely visible in practice. It is difficult to see the relevance of the principle of justice or the value of autonomous choice when you are examining a middle-aged woman for sub-acute abdominal pain. Somehow then, it seems as if the norms and values of medical ethics do not fit properly with medical reality. One reason for this might be that the field of medical ethics has, above all, concentrated more on the big and controversial issues in medicine, like abortion, euthanasia and genetic technology, and less on the field of everyday medical practice, which occupies most doctors’ working life. As a result, the focus of medical ethics may well not be

relevant for most doctors. This lacuna could also be interpreted as a universal gap between theory and practical work, which exists in many different fields. There is a divergence between theoretical knowledge of how to do the work and a practical understanding of how to actually perform it, referring to an age-old distinction made by Aristotle (1980). Abstract ideas can be difficult to transfer to the nitty-gritty of everyday practice, and this could be the reason why practicing medics find ethical theory so difficult to apply. Yet doctors are certainly used to relating their practical work on individuals to theoretical models and abstract concepts, since medical practice is firmly built on scientific medical theory. While it is often difficult when dealing with a patient to determine how one’s general knowledge of medical theory applies to this particular case, problems with medical ethics seem to be of a different nature altogether.

Some empirical studies have indicated that the principles of medical ethics are not wholly internalised in the medical profession, and that doctors instead feel alienated by the language of bioethics (Davies & Hudson, 1999; Karnieli-Miller & Eisikovits, 2009). Doctors rarely articulate moral judgements in their daily practice. Yet, rather than interpreting this as a lack of moral understanding, it could be that medical language and clinical practice are “morally loaded”; in other words, the moral dimension is always implicit in the medical judgements that doctors make in a way that means that it is superfluous to refer to a moral principle. Some studies have mentioned the concept of responsibility as being an important notion with which to understand doctors’ perceptions of morality in medical practice, yet this is not a concept that is much used in the medical ethics’ literature. Søren Holm, a medical doctor and philosopher, and Reet Arnman, an experienced doctor, have both interviewed health care personnel, and describe the discrepancy between bioethical concepts and the practical reasoning of doctors (Holm, 1997; Arnman, 2004). Holm came up with the notion of “protective responsibility”, which he argues is a better description of what health care personnel perceive to be morally significant. Arnman also emphasises how doctors’ moral experiences deviate from medical ethics discourse. “The doctors did not talk like moral agents with dilemmas (…) they spoke like moral persons with bad consciousnesses” (Arnman, 2004, p. 85). This leads Arnman to conclude that doctors’ perceptions of ethics are closely related to their experiences of professional responsibility.

The discourse of medical ethics does not seem to reflect doctors’ own moral experiences, making it difficult for them to relate to its moral demands. Moreover, the ethical dimensions of doctors’ current medical practices remain tacit and, as such, hidden from moral enquiry.