Practical problems in medical ethics: I. An unexpected finding of non-paternity

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As you probably know, this site is dedicated to practical philosophy, which includes discussions of philosophies of life (Stoicism, Epicureanism, Buddhism, and the like), issues in metaphysics and philosophy of mind that have practical import (free will, anyone?), and of course ethics. Lots of ethics. After all, for the ancient Greco-Romans, “ethics” literally was the study of how to live one’s life. It hardly gets any more practical than that.

This week we are going to take a look, in three installments, to a number of problems in practical medical ethics recently posed at a departmental colloquium at the City College of New York by my colleague Jeff Blustein. Jeff provided us with a set of criteria by which to evaluate the three ethical dilemmas he posed, then presented each dilemma, and asks us the sort of questions that a medical doctor, as well as his patients, would have to face under the circumstances. I’m proposing this as an exercise in collective ethical evaluation. I was surprised to find that my own reactions were very clear in two of the three cases, as I almost immediately zoomed into one of the possible answers. I will provide my reasoning in each case, but I would love to hear what readers have to say in each instance.

First, though, a quick run down of the six criteria Jeff suggested for a good philosophical evaluation of the case studies:

1. Formulate the problem. This is not always as easy as it sounds, as there may be more than one way to formulate the problem itself, before we even begin to consider possible answers.

2. Consider the relevant information. If there are critical pieces of information that are missing, articulate why they are relevant to the ethical analysis, and what follows from the fact that they are currently missing.

3. Refer to the ethical principles involved. An ethical dilemma arises when some values dictate incompatible courses of action, and it is not immediately obvious which should take priority.

4. Review alternative courses of action. Consider the possible alternatives, compare the range of outcomes against relevant principles and values. Keep in mind that it may be necessary to accept trade-offs.

5. Suggest an ethical solution. Consider the solution that appears to be best, all things considered, that is, taking into account all the various ethical principles at stake in the case.

6. Suggest how to best implement the proposed solution. Who, how, where, and when?

Okay, let’s start with the first case (we’ll get to cases 2 and 3 later in the week): an unexpected finding of non-paternity. Joe and Ellie are married and have a young son, Tom, 13 years of age. Joe spends several months a year in the Merchant Marine, during which time he is always away from home. Ellie is a stay-at-home mom. Tom has inherited a kidney disease called Alport syndrome from his mother, which requires frequent dialysis treatments. He is nearing the point in his care when he will need a kidney transplant to survive. His mother received a transplant years before and is doing well. The doctors caring for the boy search for a compatible kidney donor. His mother obviously is not a suitable donor. Joe, the father, offers to be tested, in the course of which it is discovered that he is not Tom’s biological father. It is unclear to the doctors whether Ellie or Joe have any inkling of this. Though Joe is not the biological father, he is a good match for Tom and would be a suitable donor. No other better candidate has come forward so far. The doctors are, understandably, unsure as to how to proceed ethically.

The questions raised by this case, following my colleague’s recommendations, are along the lines of:

Should the doctors discuss their finding of non-paternity with Ellie before proceeding?

Should they disclose to Joe their finding before they proceed with any transplant?

Or should they accept Joe as a donor without informing him of their finding?

My initial intuition was that of course the doctors ought to tell Joe about the mismatch in the paternity analysis. After all, he is about to give a kidney under the false assumption that the recipient is his biological son. Yes, there is a chance that Joe will decide not to proceed with the operation, which would imperil Tom’s health. Then again, Joe might go forward with it anyway, on the grounds that, biological or not, Tom is still his son. Or perhaps by reckoning that the boy has no fault in the situation, and that he had already decided to donate the kidney.

To my surprise, two of my colleagues had the exact opposite, and equally strong, intuition: the doctors should say nothing and proceed as if they had no knowledge of the mismatched paternity. When I challenged them, they invoked utilitarian reasoning: the greatest good for the most people, in this case, consists of lying by omission to the father, because then the family will likely stay together, and Tom will get the kidney.

But this sort of defense is open to a number of well known objections to utilitarianism. To begin with, how, exactly, is such calculus carried out? The doctors actually don’t know what the long-term consequences of their decision are going to be. A number of not unlikely scenarios is possible. Joe may find out later on, break up his family, and sue the hospital. Or Tom may run into a different health problem, being asked by doctors if there were medical precedents for that disease in the family, and unwittingly provide incorrect information to his health care providers.

Another objection is that if the doctors are going to proceed regardless, what would stop them, next time, from tricking another person in a similar way, obtaining a kidney under false pretense? And if that kind of modus operandi makes the rounds, wouldn’t the population at large be significantly less happy, knowing that they can’t trust their doctors to tell them the truth?

On the positive side of my argument, it seems to me that an adult in full possessions of his cognitive capacities has a right not to be deceived, even by omission, and to make his ethical decisions according to his own moral compass. As I said earlier, he may still decide to donate the kidney. And even if he doesn’t, the doctors may yet be able to find an alternative donor. (Indeed, I can disclose that, in this case, they actually did.)

Both Kantian deontologists and virtue ethicists would object to the doctors treating Joe as a means to an end. In the first case because the doctors would violate one of the two famous formulations of the categorical imperative, from Kant’s Grounding for the Metaphysics of Morals:

Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end.

By not disclosing what they know to Joe, and taking the kidney anyway, the doctors are treating him merely as a means to an end, not as an end in himself.

In the vase of virtue ethics, the doctors would be violating the virtue of justice, which — similarly — advises us to treat other people as worthy of intrinsic respect qua human beings. Of course, a doctor informed by a virtue ethical framework may then immediately attempt to persuade Joe to go through with the operation regardless, appealing to his sense of justice and fairness.

Clearly, there is room for disagreement here, even among professional philosophers. So, what do you think? Please do not provide just an answer to the conundrum, explain your reasoning to back it up.

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