1.5 The decline of moral authority

The cynical view of society is that power rests solely with those bold enough or rich enough to seize it, but in the 21st century moral authority is still important. The schoolteacher is still regarded as more of an authority within society than, for example, the bookmaker, even though the income of the latter may be five, ten or twenty times that of the former. This authority derives in part from the moral position of the schoolteacher in society, with the generally held view that teachers are engaged in a task which is seen as having a morally justifiable dimension, namely the guidance of the young.

The moral authority acquired by clinicians in the 20th century has declined in recent years.

Patients now also have much clearer legal rights. The European Convention on Human Rights was adopted by the United Kingdom when the Human Rights Act became law in 1998. The Act came fully into force on 2 October 2000. The European Convention gives the patient the legal right to refuse treatment and, perhaps more significant, consultation with parents and, if necessary, other family members is now legally required, although parents do not necessarily have the last word. A court rules against the parents if it believes that the parents are not acting in the best interests of the child, because the child has also been given greater legal rights by the European Convention.

1.5.1 Doctors are seen to be ordinary mortals - good and bad

The rules governing the medical profession list among the gravest of misdemeanours a sexual relationship with a patient because of the power that a doctor holds, and the possibility of misusing this, to take sexual advantage of a patient. In more recent years, other moral misdemeanours of doctors have received publicity and perhaps the financial shenanigans of doctors who defraud healthcare systems do as much to reduce the moral authority of the medical profession as does sexual indiscretion in these more sexually liberated days. Furthermore, revelations about doctors whose actions have harmed or killed patients, whether for gain, as in the case of Harold Shipman, or because of incompetence, as in the Bristol heart surgery cases, have damaged the moral authority of the profession by shaking public confidence in self-regulation, a cornerstone of the claim that a profession makes to be morally detached from other trades.

The medical profession has suffered a decline in its moral authority, however, not only as a result of changes in public attitudes towards the profession, but as a result of general changes in society's attitudes to science.

1.5.2 The end of the honeymoon with science

For most of the 20th century, science was viewed as an unalloyed good because the Second World War created the power base of science.

For the first time, war was won not by the bravest soldiers or the cleverest generals but by the best scientists, and in the years following the Second World War, science grew in power because of the authority granted to it by society, which accepted the view that science had a moral purpose of creating a better society.

The Manhattan Project, which led to the development of the atom bomb, had shown clearly how science could focus on a major problem and solve it, although even at that time there were doubts about the moral wisdom of using science for this purpose. Nevertheless, for the next twenty years, science was in the ascendant, turning its attention to problems such as cancer and starvation, and producing solutions which were generally regarded as good by society. In the 1960s, however, all this began to change, as a number of people began to describe the down side of science. Some of the key events and trends were:

• thalidomide - the negative side of medical breakthroughs
• the Vietnam War - the misuse of science to solve a moral and political problem
• 'Silent Spring' - the ecological harm of science

For readers who want to get a feeling of the heady excitement of the days when science, including the social sciences, were thought to be the solution to every problem from cancer to urban poverty, the best read is David Halberstam's wonderful book The Best and the Brightest, which describes the hubris of science and the belief that human beings could solve any problem with its help, epitomised by the excitement of the election of John F Kennedy to the American Presidency. Kennedy was assassinated before the Vietnam policy demonstrated the impotence of science, when the world's most powerful army failed to overcome a committed people and an army of poorly equipped men using bicycles. The Kennedy years were the honeymoon period in the relationship between science and society.

1.5.3 Fear of a scientific conspiracy

Many people now think that scientists are in league with industry. If science has simply got it wrong, the public could forgive it, but in the 1960s concern started to be expressed about the possibility that science was misusing the trust invested in it by society by conspiring with government and big business to advance its cause, not solely for the good of society, but also for the good of the scientists. The first description of the inter-dependence of science, government and big business came not from an analysis of medical science but from a study of the relationship between science and the defence industry provided by John Kenneth Galbraith, who was both one of Kennedy's closest advisers, and also one of the most perceptive and trenchant critics of the Kennedy hubris of the early 1960s. Galbraith was not only a leading economist, he was also that very rare type of academic - wonderfully readable. His book The New Industrial Estate, published in 1967, described an alliance between what he called the military industrial complex, as follows:

• Scientists working on defence R&D contracts advise
• generals and admirals who make decisions for
• politicians to take which increase investment in defence and give contracts to
• defence industries which give
• scientists research contracts and
• political parties donations and
• generals jobs when they retire.

The extension of this argument to biological sciences was made by Ulrich Beck in his famous book The Risk Society, or, in the original German, Risikogesellschaft. In this book Beck, Professor of Sociology at the Ludwig Maximillian University in Munich, observes that science and scientists have thrown in their lot with capitalists and politicians, and as a consequence so-called safe levels of, say, pesticides, are in fact simply a means of licensed poisoning.

1.5.4 The remoralising of medicine

The decline of moral authority provides a strong foundation for the development of a moral basis for clinical practice, to replace the specious authority with which medicine was invested in times past. Instead of assuming moral authority, the 21st century clinician recognises that responsibility has a moral dimension. The clinician who strays from technical to moral decision-making must act with responsibility and not simply shoot from the moral hip.

20th century clinicians made moral decisions on the basis of their personal beliefs and values. Ethics was regarded as a subject which had a bearing on only a few types of clinical decision, notably abortion, euthanasia, and research. The need for research ethics committees was recognised more than thirty years ago but in the 21st century, the dramatic development is that of the clinical ethics committee. The need for such committees arose from the greater awareness among clinicians that they face many moral dilemmas.

Consider the case of Mrs N., a young woman with AIDS in the Intensive Care Unit of the San Francisco General Hospital, as described by John F. Murray in his Intensive Care: a Doctor's Journal. The problem was that:

To the doctors who talked to her at the beginning of this hospitalization, she made her views unmistakably clear: 'I've had AIDS for a long time, but my family don't know about it, and I don't want them to know about it now.' I am quite sure she is going to die, but if she instructed us to be aggressive, we might prolong her life a few weeks and get her back on treatment. At this point, though, we cannot find out what she wants because she is too sick and sedated to tell us.

Because of this commitment he had to seek advice and reports that:

I met with the chairman of our hospital's Ethics Committee, Dr. Richard Broderick to discuss my concerns about her. We desperately want guidance in determining what we should do if, as seems inevitable, her condition deteriorates. Should we insert more chest tubes if her other lung collapses? Should we use medications to support her blood pressure if it drops? Should we pound on her chest and shock her heart if it stops beating? These are all real prospects. I can't stop thinking about how she's only nineteen years old. Would even a few more weeks of life mean something to her?

'We have another tough one', I told him. 'A young woman with AIDS who is steadily losing ground and will probably die soon. We need to decide how aggressive to be. But she's in no shape to tell us, and she told everyone at the beginning of this hospitalization not to discuss matters with her family because she doesn't want them to know she has AIDS. There was and perhaps still is a Mr N., but he abandoned her and vanished a few months after their marriage. I'd like to talk to her father to try to find out if he had any indication about how she wants to be treated. But she has clearly said not to. What do we do now?'

Today, Dr. Broderick comes to the ICU to tell us that he has thought about our predicament and talked to others on his committee. Their conclusion is that, despite her explicit interdiction, we can disclose the fact that she has AIDS to her father. To serve as her surrogate and advise us medically on her behalf, he must be informed of the exact situation.

I see the logic, but I am uneasy with this decision because of its contradiction of Mrs N's stated wishes.

Influenced by the Ethics Committee, he proceeds to inform the family with great reservations:

Full of remorse, I break the news. No one expresses shock or surprise. Her father says, 'Yeah, we know that. She's had it a long time. But she didn't want us to know, so we didn't talk about it.'

These moral dilemmas have always been present in medicine: now they are recognised and managed more responsibly.

The decline of traditional moral authority has been complemented by the development of more thoughtful moral responsibility by clinicians and this provides a much more stable foundation for the resourceful patient who wishes to take decisions, and manage their care.

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