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The search for " 'a moral calculus' is the most crucial problem we have in medical ethics and medical care…. No longer can we turn to the teachings of Jesus or Moses for direct moral guidance. Things are not that simple any more. Medical ethics therefore has to become truly a social ethics, not a simple interpersonal morality. The world is so tied together now that even the words' neighbor' and' 'stranger' have become archaic. We even need a new ethical language."

Medicine, Morals, and Religion
By Joseph Fletcher

HOSPITAL, hostel, hospice, hotel-all carry the meaning of shelter and care as well as treatment. The religious inspiration behind it all is an old story, going back to the first refuges for the sick, which were the temples of Babylonia, India, Egypt, and Greece. The earliest people who came anywhere near to being a guild or profession of nurses in Christian Europe were nuns. The Sisters of St. Augustine were the first to be specially dedicated-a kind of vocation within their vocation. But they were anticipated, in fact, by the men of the Knights Hospitallers, the Knights of St. John of Jerusalem. We have a growing number of men in nurses' training these days (a kind of unisex counterpart to the young women going into doctors' training), but like so many other so-called new departures, they really are only a return to ancient examples.

What is different, of course, is that in the old days the hospital was the hostel for the hopeless. Only the incurable and moribund went there. Physicians and surgeons did their work in their own or their patients' homes, and hospitals were caring programs rather than treating programs. The marriage of the two functions-care and treatment-is hardly more than a hundred years old.

I

But my focus is on the modern setting, on medicine as it functions within the hospital system. It might be of interest to explore the curious

Joseph Fletcher is Professor of Medical Ethics at the University of Virginia Hospital, Charlottesville, Va., and the author of Situation Ethics (1966) and Moral Responsibility (1967). This article has been adapted from his remarks during the dedication celebration of the new facility of St. Mark's Hospital in Salt Lake City, Utah, on May 6,1973. The St. Mark's Hospital is the earliest hospital in the city and is affiliated with the Episcopal Church. The speech was part of a continuing program connected with the dedication and was sponsored by the hospital's medical staff, headed by Dr. Roy E. McDonald.

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fact that doctors are among our most conservative people, and therefore the very idea of collectivism is alien to their social values, therefore the very idea of collectivism is alien to their social values, but the hospital is obviously a radical collective. The success of modern medicine and medical care is a result of the interdependence of medical specialties; its secret ties in the "division of labor" and complex referral system between the primary care physician and his many medical colleagues. Medicine can no longer be practiced out of a little black bag. Medicine is at last a collective enterprise, no longer a private one. It has turned into far more than a place; it is a system.

The motive or inspiration behind medical care is still religion, as much as it always was in the past. To say so, however, is to use the word religion in Tillich's sense of one's "ultimate concern." Religion is what we hold to be our first-order value or highest good, the "imperative" that pushes us on to do what we do. This is not, of course, the meaning given to religion in general or popular use; most people mean by it a faith tradition of some kind (Christianity, Buddhism, or some other belief-system) or an outlook on health and human obligation which has its final sanction in the will of God. The French word for hospital, hotel Dieu, reflects this theistic religion, and service under God is its explicit obligation.

Theism is not the only worldview at work in hospitals; there is humanism too, which acts with some as a motivational faith. I feel, as many others do, that it makes no practical difference whether physicians and nurses put God or man at the center of their faith. Whether we believe with Protagoras that man is the measure of things, or with the Bible that God is, the virtues of compassion and fortitude can and do follow from both standpoints. In a good hospital there is no such thing as a theological or canonical test for orthodoxy.

What counts is what is called "love" in Christian ethics, loving concern for human beings. Professing Christians certainly have no monopoly of love or any kind of patent on it. For example, when Erich Fromm says that "love is the only sane and satisfactory answet to the problem of human existence," he speaks and describes love exactly as a Christian would-except that he does not bring God into it. He thinks Christianly but talks humanistically. ¹

Humanists and theists are similarly humane. They may give different answers to the Why question (why we should bother to help the sick), but they have much the same answers for What we ought to do and How we can do it best. In short, our guiding principle is what is humane and rational, not what is revealed or authoritarian.

¹ The Art of Loving (New York, 197 1).

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II

It is impossible to look closely into modern medicine without seeing some very thrilling and often troubling questions. Technically they are posed by medicine, but they immediately take a moral and religious shape. Let me list some, only by title. What are we to do or not do, morally regarded, about such matters as truthtelling in medical diagnosis and disclosures of medical records; voluntary sterilization; transplants and implants; intensive care and resuscitation; defective newborns and high-risk pregnancies; in vitro fertilization in embryology and in therapy; triage decisions about conditions like complicated hepatic coma; selective abortion in intrauterine diagnosis; abortion on request a la the Supreme Court's recent decision; genetic engineering?

Again without discussing them, what should we do or not do about behavior control by psychosurgery or chemotherapy; positive and negative euthanasia; cyborgs and prosthetic amplifiers; transsexual operations in cosmetic surgery; selection procedures for hemodialysis and other allocations of scarce life-saving resources; artificial insemination and enovulation; bypassing refusals of consent to medically indicated treatment; ghost surgery in teaching hospitals; the non-medicinal use of drugs; clinical experiments; fetologic interventions? The list is long and growing longer.

These are all agonizing questions, and they face us every day in hospitals across the land. The decision making in most other walks of life is picayune compared to what confronts the practitioners of good medicine these days.

These are success problems, not failure problems. They come about because of biomedical advances. The entrance of science into medicine at the Renaissance changed it from stop-gap fatalism to a real and effective control over illness and health. For example, when I listed the various historic meanings of the word hospital, I left one out- "spital." At one time, hospitals were places where the victims of pulmonary tuberculosis came to spit their lives out. That common killer is now a thing of the past.

But success has its price. One of our troubling problems is how to balance what we gain and what we lose when a new drug or therapeutic agent carries undesired side effects. We are only barely beginning to realize the extent of iatrogenic illness-diseases due to cures. The illnesses are the built-in consequences of the cures. Look at what the viruses have done since the polio vaccine went to work. Since all drugs have toxicity points, 15 to 20 percent of patients suffer adverse reactions; more than half of them are minor, but one to two percent are fatal. Steroids are more specific, but they increase susceptibility to some infections. It is an ominous fact that by saving the lives of babies with genetic diseases and anomalies, they reach reproductive age and further pollute our common gene pool.

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By what moral calculus can we face and deal with such issues? No cost-benefit analysis can work without ethics, for ethics deals with values, and such trade-off decisions have to calculate the weight or worth of one value against another. The same problem arises in a more intense form at the clinical level. For example, which patients in renal failure will share in the available slots of time on artificial kidneys or in the short supply of cadaver tissue? How are we to choose sides in the argument about whether to put hard drug addicts on methadone? It too is addictive. Do its lower cost and its freedom from the narcotics pusher tip the balance? We lack what might be called a mathematics of mercy, but until we find one we are flying blind.

III

Another issue crystallizing lately is latent in the phrase "quality of life." It is said that quality of life is more important than quantity of life and that therefore in terminal illnesses patients should not be kept going beyond a reasonable point. At the other end of the human life spectrum, in prenatal or reproductive medicine, it is contended that a defective fetus should be ended by pre-emptive abortion. I am personally confident that this is indeed good medicine, i.e., humane, but to see it this way is to have chosen a quality-of-life ethics instead of the traditional sanctity-of-life ethics. ² The issue has its bearing on many other problems of medical management, such as the current National Institute of Health policy of bowing to the Right-to-Lifers.³ This agitational group denounces the research use of live fetuses even though such organisms cannot survive and the chances to study them might prevent many of the tragedies of genetic and congenital disorders. It is a typical success problem; in earlier times we had no knowledge or control over the quality of birth and death.

There are some who listen to us wrestling with the resulting problems of medical success and cry out, "Stop! You are playing God, and it is wrong to do it." As one of several explorers of biomedical ethics, I am at least persuaded that we should accept the charge. We should say, "Yes, we are playing God"-meaning that we are responsible, that we assume the burden and risks of decision making about many things which once were outside our powers to control, ameliorate, avoid, or cure.

The real question, however, is which God or whose God we are playing? It used to be thought that God has a monopoly control over life and health and death. This was the primitive God of the Gaps-the God whose role was to fill in the gaps in man's knowl-

² J. Fletcher, "Ethics and Euthanasia," American Journal of Nursing, 73 (April, 1973),670-675.
³ Boston Evening Globe, April 13, 1973.

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edge and ability to control things or make sense of them. God was an hypothecation of human ignorance and helplessness.

Medicine made the first attempt to "play God" by investigating and controlling health, either with the help of or in spite of nature, God's creation. Now, like health, birth and death-the start and stop of life-are becoming areas of human responsibility. Among believers we are turning from the God of the Gaps to a God who is the creative principle behind all things, who is behind the test tube and amniocentesis as much as the earthquake and the volcano. The old God is dead. A good definition of medicine is "interference with nature" or "playing God."

There are other such issues. On the social and political side we can see that at least three reforms in the delivery of health care are coming. They are insurance for everybody for both hospital and office visits, special protection against the catastrophic costs of serious illness, and an increase of Federal commitments both to more treatment funds and more governmental supervision. These things, plus the emergence of health maintainance organizations and prepaid medical care, are going to stretch the moral muscles as well as the "system" of conventional medicine. Another example, at the working level, lies in the American Hospital Association's recent "Patients' Bill of Rights," which is bound to upset physicians who like the medical mystique and the doctrine that "doctor knows best." The customer, the patient, is going to have more to say in the future.

IV

We not only have to think again about man's notion of God's role in human affairs, if we believe there is a God; now we also have to think again about who or what man himself is. And we all believe that man exists. Tied to this question is the determination of when a new person comes into being and when a person is dead and gone. The ethical importance of the Supreme Court's abortion decision is its judgment that an embryo or fetus is not a person. Obviously it belongs to the human species, although even this in the first weeks of pregnancy is only determinable microscopically, and it is definitely alive in the sense that cell division is going on.

But the indicators of humanhood, the criteria for humanness or personal quality, are certainly something besides biological functions, important as they are. The word "vegetable" for ex-cerebral or pre-cerebral individuals is as old as Aristotle and Thomas Aquinas and moral theology, and as new as the lexicon of house officers in modern hospitals. The vitalistic idea that life itself is the summum bonum, regardless of its quality, has never passed muster with pagans, Christians, or humanists, and in our time this naive vitalism is the Achilles heel of the whole anti-abortion, anti-euthanasia movement. Commitment to life at any price comes into

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collision with an ethics of loving concern. It is a question of the vitalistic versus the humanistic morality.

Granted that a person or a truly human being is more than merely biological functions, no matter how spontaneous the functions might be, what more and how much more is it? There is, as far as I can see, no neat or confident answer available. The fact is that all of our classical definitions of man have to be re-examined in the light of modern medical knowledge, just as we have to review our concepts of life and death. As these things stand, we take a spooky and cruel posture too much of the time.

Suppose we ponder an actual case. A little boy with a severe neuroblastoma of the lung is admitted late at night, with perhaps four to five hours of life left. The physicians order the nurses to keep the child sitting up, to hold death off by preventing the lungs from filling. The child cries, over and over, "Please! Let me lie down. I hurt." But the nurses, unhappily but obediently, obey their orders. (Nurses are the people that doctors leave their problems with.) The chaplain next morning, in the cafeteria, asks the young doctors on that service why another hour or two of semi-life was worth the little boy's suffering. They have no answer; they "stand mute," as lawyers might say, with a glazed look in their eyes. Uncomfortable. Stubborn. Now, what does this little scenario teach us?

Let me go back again to the non-clinical side. It may well be, and I believe it to be true, that the search for what I've called a "moral calculus" is the most crucial problem we have in medical ethics and medical care. Sophisticated discussion of public policy, health, medical care, and research-all social-ethical concerns-keeps popping with terms like systems analysis, value judgment, priorities, triage, allocation of scarce resources, cost-benefit balance, choice options, and distributive justice.

The scope and arena of decision making has widened enormously since the days when being one's brother's keeper and loving one's neighbor was a direct matter between you and a handful of people you know personally, often by name. The pastoral, rural-agrarian and village society in the Bible, for example, no longer exists in this country. No longer can we turn to the teachings of Jesus or Moses for direct moral guidance. Things are not that simple any more. Medical ethics therefore has to become truly a social ethics, not a simple interpersonal morality. The world is so tied together now that even the words "neighbor" and "stranger" have become archaic. We even need a new ethical language.

V

The problem of moral calculus-the daily headache of hospital administration-is what makes directors and managers in the modern world our unsung heroes or martyrs, as the case might be. It is seen in its simplest shape as triage; deciding what to do or not to do

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when supplies, funds, and personnel are in short supply. Triage aims at the greatest good (i.e., the best treatment) for the greatest number (i.e., the most patients). On a city hospital's emergency service, swamped by referred and unreferred patients, if the triage officer (the physician in charge) cuts out pregnancy tests because they are not instantly urgent, he or she is doing two things which are supposedly non-medical-practicing utilitarian ethics and economics. Utilitarianism aims at spreading expectable benefits, and economics is a studied judgment about preference among competing choices.

All of this means that physicians, nurses, paramedical professionals, and hospital officials will no longer be able to live by the traditional but too-simple one-to-one medical ethics. The philosopher Hans Jonas said recently, "In the course of treatment the physician is obligated to the patient and no one else."⁴ Obviously Jonas sees the road through his rear-vision mirror. He is contradicted by quarantine, compulsory vaccination, and mandatory autopsies in mysterious epidemics. And these things are only minor complications of traditional medical piety, compared to what is coming. What medicine needs is a moral telescope, not a moral microscope.

Allow me to describe an actual clinical situation. A patient is 47, married, has a wife and two children. He is an industrial engineer. His son is 18, his daughter 16. His condition is polycystic kidney disease, a genetic disorder. His father died of the same illness at 44, before dialysis or transplants were available. He and his wife know that the disease is transmissible to and through their children, but they insist on keeping the facts from their children because it might frighten them and inhibit their social life and courtship hopes. In this case to preserve the professional confidence, which the parents insist on, could be to victimize the children, their spouses, and their offspring. If the patient remains unchanged in his attitude, a medical ethics of compassion would require the renal service staff to violate the medical convention against disclosures. This is an example of the telescope replacing the microscope.

But triage is a small-scale and easy version of our moral calculus. Here is a down-to-earth case of the real thing. The hyperbaric chamber at a famous uptown New York hospital cost $750,000 to install, $600,000 per year to operate. In five years the total dollar cost was $3,750,000; 900 patients were treated at a cost of $4,166.65 each. For the same amount 20,000 outpatients could have been treated per year, or 100,000 altogether. Or, a screening program could have been set up in East Harlem to detect lead poisoning and anemia in a million children-to keep their brains from being ruined.

How are we to use a moral calculus in the forum of conscience when we look at duty and obligation through the telescope? That seems to me to be the over-arching ethical problem in medical

⁴ Daedalus, Vol. 98 (Spring, 1969), p. 238.

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ethics or any ethics that is sincere enough to be realistic and to take all of the factors into account as honestly as we can. I do not pretend for a second that I can provide the solution. Actually, I am convinced that the only good answers will have to come from the hospitals and the clinics, not from libraries and kibitzers like me. But still I like to think that even kibitzers can sometimes ask good questions.

VII

Let me try to summarize four points about medicine, morals, and religion.

(1) Some people believe in God's existence; all of us believe that men exist. Our medical philosophy should therefore be humanistically, humanely motivated. If human compassion is reinforced by a theistic faith, all the better. But it is only better if the faith happens to reinforce the compassion. Alas, not all religions do.

(2) Patients are persons, not just bodies. A truly human being is mental and moral as well as physical. The physical side, physiology, spontaneous or artificially supported biological functions, by themselves do not make a human being. The practice of medicine can become the ministry of medicine only if we realize that the quality of life is more important than mere quantity. Our devotion is not to life but to human life.

(3) In order to be morally responsible we should not wear blinders, seeing only one patient at a time. We need a telescope to see our true obligations. In our society and culture there are so many of us and we are so interdependent that we need mathematical morality, ethical arithmetic, a statistical sense of obligation-not the first-come-first-served simple doctor-patient ethics of the horse-and buggy era.

(4)We shall have to learn to live without absolutes, such as "Our sole obligation is to the patient under care" and "Life must be prolonged as long as possible" and "We must not disclose what we have learned in professional confidence" and "No cost is too much to cure a human ill." Instead of moral norms or principles of such undiscriminating and universal application we must make medical decisions by a situation ethics; what is right depends on loving concern for persons and the variables in each case. Situation ethics is clinical ethics. No good clinician finds the answer to any patient's problem in a prefabricated form out of a book. He sees the patient.