Moral and ethical considerations can greatly increase the complexity of medical decisions. The dilemmas described in Ellen Kolton's essay (“Ethics Consult: To Tell or Not to Tell;” The Intima, Spring 2015) and those that I experienced as a military doctor (“The Moral Matrix of Wartime Medicine;" The Intima, Fall 2015) share a similar frustration – the inability to find “correct” answers for difficult questions.
These essays also describe how the burden of having multiple but conflicting professional roles can contribute to a lack of success. Our conflicts were extreme, but they are not very different from those that occur in clinical practice: Physicians weigh a teenager's rights to privacy against a parent's need to know; public health officers can recommend quarantined isolation for a healthy patient based on suspicion of contagion; and a sports doctor’s advice might benefit the team but increase risk for his player-patient. Early in my pediatric career, I was called to examine a newborn that was missing most of her brain matter. Deciding whether to prevent her immediate demise allowed me one minute to prioritize at least six variables: I needed to advocate for the baby as her doctor, respect the wishes of her distraught parents, utilize hospital protocols as a condition of my privileges, protect my state medical license, recognize that failure to assist her breathing might violate civil law, and act within the boundaries of my conscience. Unfortunately, neither of the two most viable options were helpful: I could arbitrarily accept one obligation as taking precedence over the others or I could rely on intuition and deal with the consequences later.
Western ethicists are hindered by their reluctance to accept paradox as an explanation for the unexplainable. We prefer to use mental gymnastics to choose between opposite but equally persuasive arguments: To make our choice seem rational, we alter a crucial definition (e.g. modify the requirements for being a "good mother") or we use denial and rationalization to untruthfully ignore or denigrate a point of view. Even though paradox is central to many religious teachings, religious folks also try to explain it away by using logical-sounding language: An all powerful and loving God allows terrible things to happen because…. The Lord works in mysterious ways.
When paradoxical situations do arise, it takes courage to admit that, quite simply, they are what they are. These are the times when we cannot escape uncertainty by hiding behind moral code, logical thinking, or knowing what we would wish for ourselves. The most meaningful solution may really lie in the acceptance of its ambiguity.
A story is told about the rabbi who finalized a heated dispute by telling the husband, “You are right,” and then the wife, “You are also right.” They both glared at him. "With all due respect," they protested, "our opinions are complete opposites and there is no logical way we can both be right." The rabbi smiled. "That is also right," he said.
Jeffrey Brown teaches as a Clinical Professor at New York Medical College and at Weill Cornell. He has written three published book titles and many papers, articles, and book chapters. Before residency training, he served in Vietnam as a combat Army doctor where he was awarded a Bronze Star for Valor. Caring for sick and injured children in local villages resulted in his eventual career choice to become a pediatrician. Brown recently retired after forty years of full-time practice in Westchester County NY and has been active in improving the healthcare that veterans receive from community physicians. He also lectures on how moral injuries from wartime experiences affect soldiers following their return to civilian life.
© 2015 Intima: A Journal of Narrative Medicine