cmf file 40 (2009) - the doctor's worldview

By John Wyatt

Worldviews are the understandings each one of us has about the way the universe is. All our thoughts, beliefs and actions are based on these fundamental presuppositions abou treality, and they are therefore critical in medical ethics. Different worldviews will sometimes lead to radically different decisions.But worldviews are not just to do with philosophical questions about belief. They are inextricably tied to the way we behave, the choices we make, and the way we interact with others. The philosophical idea of the worldview links up with the biblical concept of the heart.

The story is told of an Indian sage who taught that the world rested on the back of a giant elephant that stood in turn on the back of an even larger turtle.A cynical Westerner asked the sage:
'And what does that turtle stand on?'
'Another turtle.'
'And what does that one stand on?'
'Another turtle' and so on....
'But what about the bottom turtle,
what does that one stand on?'
'Young man, it's turtles all the way down...'

Modern societies are often described as 'pluralistic'. They encompass people from many different cultures and backgrounds, from different ethnic and racial groups, with different attitudes and beliefs. Whether we like it or not, this is a feature of the modern world, and of modern healthcare systems. Behind the more obvious cultural differences between people, there lie much more profound differences in presuppositions and beliefs; there lie different understandings of right and wrong and of the nature of reality. These hidden presuppositions are much harder to identify and understand, but they play a crucial role in the way we think and behave, and they are at the root of many current ethical controversies in medicine and healthcare.

You may think that this subject is too abstract and philosophical to be interesting, but it is directly relevant to modern debates in medicine and ethics!

Worldview

The concept of the worldview(Weltanschauung in German) has been around in philosophy and the social sciences for more than 200 years, but it is difficult to provide a clear and coherent definition. In essence, someone's worldview is their understanding of the way the universe is. It encompasses the fundamental presuppositions about reality on which all their thoughts, beliefs and actions are based (whether those presuppositions are logically consistent or not). It's not possible to be neutral, uncommitted or 'agnostic' when it comes to a worldview. There is no neutral ground on which it is possible to stand. 'Everyone is coming from somewhere',whether they are prepared to recognise their presuppositions or not.

Some philosophers, such as Nietzsche(1844-1900) and Foucault (1926-1984),have used the idea to argue that every person's understanding of truth and of reality was relative to their particular time , history and social circumstances. In other words, there is no such thing as absolute truth. But we can use the concept of the worldview without accepting this relativistic understanding.

What is ultimate reality?
What is a human being?
How is it possible to know anything at all?
How can I know the difference between right and wrong?
What is the point of existence?
What happens to people when they die?
What is the meaning of human history?

It is obvious that an orthodox Christian believer, an atheist scientist, and a traditional Hindu would give radically different answers to these questions.

But worldviews are not just to do with philosophical questions about belief, and systems of thought. They are inextricably tied to the way we experience the world and the way we behave. If you want to know what someone's worldview is, look at the way they behave, look at the choices they make, look at the way they interact with others. This is where the philosophical idea of the worldview links up with the biblical concept of the heart.

Biblical perspectives

In biblical thinking a person's 'heart' is the core of their innermost being. The Hebrew word (Leb) occurs more than 800 times in the Old Testament, and the Greek equivalent (cardia) occurs more than 150times in the New Testament. To the New Testament authors, the heart is the centre of human affections, the seat of the intellect and the will, and the source of the spiritual life.

It was a central concept in the teaching of Jesus: 'The good man brings good things out of the good stored up in his heart, and the evil man brings evil things out of the evil stored up in his heart. For out of the overflow of his heart his mouth speaks.' (1)'…the things that come out of the mouth come from the heart...For out of the heart come evil thoughts...These are what make a man "unclean".' (2) 'I know that you do not have the love of God in your hearts.' (3)

For Jesus, the heart is the place where a treasure resides. Alternatively it is seen as a tree which produces fruit of various kinds, and from which words and deeds emerge. The heart is the unseen core, the nucleus of the person, from which all their thoughts, actions and words overflow. In the biblical language, all the experiences of life flow into the heart. As a child grows, learns and experiences the world, their heart is formed and moulded by the flow of information, sensations and relationships. In fact our hearts are continuing to be moulded and formed throughout our lives. In Christian thinking, conversion involves a radical change of heart, and sanctification is the ongoing process in which the heart is being moulded and formed by the Holy Spirit.

But just as our hearts are moulded by the experiences of life, our hearts are also the source of our thoughts, actions and words. These are what flow out of our hearts and they reveal the nature of the treasure within. This is why the writer of Proverbs instructs: 'Above all else, guard your heart, for it is the wellspring of life'. (4)

In passing, it is interesting to compare this Hebraic understanding of the human person, with the heart at the centre, with the ancient Greek philosophers such as Plato, who tended to emphasise thought,consciousness and mind (nous) as the most important aspects of human existence.

As the philosopher David Naugle has pointed out, the ancient Hebraic and biblical concept of the heart links in closely with recent philosophical thinking about worldviews, as a life-determining vision of reality.

Worldviews in medical ethics

Since our worldviews affect every aspect of the way we view reality, and especially our understanding of right and wrong, it is not surprising that they are critically important in determining our attitudes to fundamental ethical questions. But it is interesting that writers, speakers, and teachers of bioethics rarely refer explicitly to their fundamental presuppositions and beliefs. When academic philosophers discuss bioethics they tend to imply that reason and rational argument are their only starting points. The fundamental presuppositions and assumptions tend to be concealed within their arguments, and hence it is easy to miss their central importance.

As an example, let's look briefly at the writings of the influential bioethicist Peter Singer, and particularly his book Practical Ethics. (5) Singer starts by claiming that ethics has nothing to do with religion: 'I shall treat ethics as entirely independent of religion' (p3). However, he also opposes relativism and argues that ethics require us to go beyond the individual to the universal law, the standpoint of the impartial spectator (p12). He supports utilitarianism: the rightness or wrongness of an action is justified solely by its consequences - whether it increases or decreases the total happiness in the world (p3,14).

Singer draws a distinction between membership of the species Homo sapiens and being a person, a self-conscious being aware of having a past and a future(p85-90). He famously argues that to give preference to the life of a being simply because it is a member of one's own species, as against another species, is ethically identical to racism where one's own race is preferred against another(p55-82). He then goes on to argue on logical grounds that killing an embryo, a fetus, a newborn infant, and a demented adult may all be morally good acts if they accord with the preferences of conscious adults and lead to an increase in the total amount of happiness in the universe.

Although Singer does not explicitly state most of his presuppositions, it is possible to deduce most of his fundamental beliefs from his writings.

1. What is ultimate reality?

Singer states that ethics has nothing to do with religion. Presumably by 'religion' he means orthodox theistic religious beliefs about the existence of a Supreme Being who created us and to whom we are accountable. Since he believes that the morality of human actions as important as homicide can be decided without reference to religion, he must assume that there is no Supreme Being to whom he or anybody else is accountable. Hence it seems that Singer is a naturalist. He believes that ultimate reality consists of matter, and energy, and the scientific laws which govern their interaction.There is nothing else.

2. What is a human being?

As a naturalist, Singer believes that human beings are self-replicating organisms which have arisen on the planet by random and meaningless processes over 3 billion years. Homo sapiens has now evolved to the point at which self-awareness has emerged from our neural functioning. So human beings cannot have any ultimate purposes or goals beyond passing on our genes to the next generation, or other goals which we choose to invent for ourselves. This is also evident in his refusal to treat members of the species Homo sapiens as morally different from other self-aware organisms or more valuable than them.

3. How is it possible to know anything at all?

As a naturalist, Singer must believe that human knowledge is only possible because of a particular quirk of brain functioning which had a survival advantage in our evolutionary past,allowing us to reproduce successfully.

4. How can I know the difference between right and wrong?

As a utilitarian, Singer believes that the only way to know the difference between right and wrong is by calculating and summing from the objective of an impartial spectator the total preference satisfaction, happiness, and pain caused by any action, sometimes called 'the perspective of the universe'.

5. What is the point of existence?

Singer clearly believes passionately that human beings should commit themselves to reducing the total amount of suffering in the world, with regard to the suffering both of humans and of animals. He famously attempts to live and behave in a manner consistent with these beliefs, at considerable personal sacrifice. So Singe rbelieves that at least part of, if not the whole point, of existence is reducing human and animal suffering and maximising the personal preferences of conscious self-aware organisms.

6. What happens to people when they die?

Singer believes that death involves the extinction of consciousness, and the permanent dissolution of any self identity.

7. What is the meaning of human history?

As a naturalist, Singer must believe that ultimately human history can have no meaning, as ultimately the universe has no meaning. The only meaning of human history, like the only meaning of our lives, is the meaning which we choose to give. As we have seen, Singer appears to have chosen to put the reduction of human and animal suffering as a goal of ultimate significance for his own life, and he argues it should be the same for everybody else.

It is clear that Singer's presuppositions have a decisive effect on his bioethical argumentation and on his conclusions. Itis also clear that if we start with different presuppositions about the way the universe is, we are likely to come to very different conclusions. So for the orthodox Christian, ultimate reality resides not in matter and energy, but in the being of the creator God who made each one of us, and to whom we are ultimately accountable. If it is true that this creator God is a speaking God, a God who has revealed himself in nature, in Scripture and ultimately in the person of Jesus, then we have to take what he has said about matters of life and death with profound seriousness. Clearly, starting from the presuppositions of a Christian believer, it would be illogical, irrational and indefensible not to do so.

So it is not the case that Peter Singer is being logical and rational while the Christian believer is being irrational,bigoted and prejudiced. What is the case is that we have different worldviews, and that these lead us logically to different conclusions.

Of course there are many different worldviews which impinge on the ethical conclusions which people come to. Some worldviews emphasise the right of personal autonomy - my right to do with my life as I please. Some lay stress on respect for 'nature' - leading to acceptance of disease and death as part of the natural order. Others assume that death is the ultimate evil and that there is a moral duty to use technology to extend human lifespan indefinitely. What is clear is that a person's worldview plays a critical role in their decisions about good and evil, and about right and wrong.

Is Western medicine based on a particular worldview?

This is a large and complex topic and it is not possible to deal with it in any depth in this File. However, it is very clear that the history of Western medicine is based primarily on an alliance between the ancient pagan craft cult of Hippocrates(which was probably in turn based on Pythagorean philosophy) and the ethical tradition of Judaeo-Christianity. (6)

The earliest version of the Hippocratic oath starts with an invocation to the gods: 'I swear by Apollo Physician, by Asclepius,by Hygeia, by Panaceia and by all the Gods and Goddesses, that I will carry out,according to my ability and judgement,this oath...' In the first centuries after Christ the oath was Christianised, and the introduction was changed to the words: 'I swear by Almighty God...' but the basic structure is unchanged.

It is clear that at the heart of the Hippocratic oath is a recognition that the individual doctor is practising before a higher power - a power to whom he or she is accountable. But it is striking that Hippocratic doctors did not swear by the Emperor, by the State, or by local lords and authorities. Their oath was taken before the highest possible authority. In philosophical terms it is a recognition of transcendence, an appeal to ultimate authority. So, historically, the moral framework of medicine fitted within a theistic worldview, where moral accountability lay not with the State, but in the realm of the transcendent,the divine.

The Hippocratic oath also reflected moral presuppositions about the significance of human lives. It reflected a reverence for the sanctity of all human life; for the intrinsic value of human existence,however affected by disease, suffering or disability; and for an absolute requirement on doctors to respect and protect the integrity of their patients, even at the cost of their own wellbeing.

Glossary

Naturalism - the philosophical position that everything can be explained in terms of natural causes and laws.

Utilitarianism - the belief that good actions are determined by maximising the total happiness and satisfaction and minimising the total pain and suffering in the world.

Theism - Belief in the existence of a personal God who created and sustains the physical universe.

Transcendent - a form of reality which is beyond and independent of the physical universe.

The UK General Medical Council

The GMC guidelines Good Medical Practice (7) uphold the Hippocratic values of self-sacrificial caring and respect for patients,whatever their life choices and beliefs; together with the duty to protect patients from all kinds of harm or threat; and to act in their best interests. The GMC also recognises that doctors have a legal right to conscientious objection to perform certain procedures (such as abortion). (8)

The GMC has recently published more detailed guidance called Personal Beliefs and Medical Practice. (9) It recognises that 'personal beliefs and values, and cultural and religious practices are central to the lives of doctors and patients' and that 'all doctors have personal beliefs which affect their day-to-day practice'. However, the GMC states that doctors who practise in the UK must be prepared to set aside their personal beliefs where this is necessary in order to provide care in line with the principles in the official guidelines Good Medical Practice.

The GMC also recognises that 'for some patients acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to care', but warns: 'You should not normally discuss your personal beliefs with patients unless those beliefs are directly relevant to the patient's care. You must not impose your beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or values.'

In essence, the GMC recognises that doctors have different worldviews and that this will inevitably lead to differences in attitudes and practices. However, GMC registration as a doctor requires that all doctors agree to follow the broad ethical principles and practices within Good Medical Practice guidance. Implicit within this is the assumption that despite differences of worldview, a large measure of agreement and convergence in medical practice is possible.

Implications and conclusions

Although worldviews are rarely discussed or mentioned, they are crucially important in medical ethics and practice. It is therefore helpful to become more consciously aware of, and to reflect about, our own fundamental beliefs,commitments and presuppositions, and to encourage others to be more honest and transparent about their own presuppositions and assumptions. When discussing ethical issues with colleagues or fellow-students, we should be encouraging one another to identify our presuppositions and how they influence our ethical beliefs.

Despite holding different worldviews, it is usually possible to collaborate with other healthcare professionals and seek agreement in practical action, provided we maintain a respectful and tolerant attitude. However, we must recognise that, while rational and respectful debate between opposing ethical views is helpful, there will be times when agreement is not possible because of a fundamental divergence of worldviews. In these situations we must respect the integrity of the other and agree to disagree, whilst requesting that others respect our integrity by granting us the right of conscientious objection to actions which fundamentally conflict with our moral values.

From a Christian biblical perspective, our goal is to guard our heart, to ensure that it is continually moulded and transformed by the truth and power of Christ. 'The good man brings good things out of the good stored up in his heart, and the evil man brings evil things out of the evil stored up in his heart. For out of the overflow of his heart his mouth speaks.' (1)