A Bull Market for Biomedical Ethics

Medicine has changed greatly in the 20 years since I graduated from medical school. In the 1970s and early 1980s medical training focused on scientific knowledge and motor skills. There was so much to learn, and always new things to learn. There were newly discovered diseases, new medications, and evolving technology. Ethics was evolving right along with the scientific developments, but most ofthe teachings were ancient—we took the Oath of Maimonides on the first day of school and said the Hippocratic Oath at graduation. The principle of nonmalefi- cence—do no harm—covered all situations; there was little need for other principles. There was no specific coursework in ethics, just a reminder to do no harm, get informed consent, and let your conscience be your guide when difficult problems arose.

After completion of internal medicine and rheumatology training, I began a solo geriatric rheumatology practice. I immediately discovered that scientific knowledge was only part of the equation and that my conscience did not know how to handle the increasingly difficult and frequent ethical issues that were part of everyday practice. Unlike in medical training, where there are lots of colleagues around (except perhaps on call), in solo practice I had to make decisions alone. When I spoke with colleagues in the hospital doctors' lounge, I discovered that we were all grappling with the same issues, feeling unprepared and overwhelmed by the problems facing us. So, between glances at the stock market tickers, which were always on display on the lounge's televisions during the long stock bull market (and subsequent downturn), we discussed the bull market in ethical issues, for which there is no downturn in sight.

These issues include end-of-life concerns, including patient autonomy, futility, withholding and withdrawing care, euthanasia, and physician-assisted suicide; how to maintain professional integrity and continue advocacy for our patients in the face of the growing domination of managed care; the ever increasing costs of medical care and insurance—and possible solutions, including national health insurance; and the growing shortage of physicians in many specialties and the rise in "physician extenders." While there is no shortage of older concerns, every day brings new issues to ponder: the proper use of palliative care; should prisoners on death row be transplant donors or recipients (and what should we do about rumors of countries that force their prisoners to donate all of their organs); proselytizing patients and evangelical physicians (should physicians pray with their patients); assisted reproductive technology (should senior citizens have babies); confldentiality of records (how can this be maintained in the age of the Internet); cloning and stem cells; evidence-based versus alternative medicine; the need for placebos ... new concerns every day. While the discussions are always stimulating, they frequently get bogged down, as we do not have the tools to evaluate the issues.

In 1999 Midwestern University announced a new program in bioethics. I eagerly signed up; finally I would learn the skills to confidently answer all the questions. My colleagues expressed concern that after expenditure of much time and money, I would be better at arguing questions with no right or wrong answers but have nothing else to show for the effort. I started with one class, Ethical Issues in Death and Dying, which met weekly for ten weeks. Every day at lunch my colleagues demanded to know what reading was assigned (and wrote the titles down so that they, too, could read the books) and what the discussion was; then they gave me cases to present in class. Discussion of the stock market nearly ceased, as everyone wanted to sit at my table and discuss ethics. Our noontime debates were at least as boisterous as previous discussions of the economy, politics, and sports. The whole lounge got involved.

My colleagues have been interested in every course that I have taken—not interested enough to join me in class, but eager to absorb what I've learned. Interest...