One of the first things to understand about ethics is that we all ascribe to some sort of 'worldview'. This is a set of presuppositions by which we sort out what is meaningful in our lives. We all have one, whether we like to admit it or not. It may be based on religious teaching, rebellion against religious teaching, whatever our best mate believes, or can even be a result of our own indecisiveness. Our worldview is shaped by a complex interplay of our cultural background, our education, our personal experience and the social group to which we belong.

Whatever your worldview is, it will influence your decisions in life, and this becomes most evident in the life of a doctor. We will routinely be making decisions which have much wider implications than 'what shall I eat for breakfast?'

Any worldview should answer these questions: How do we know what we know? What is truth? What is right? How should we meet our goals? How is the world made up? Where are we heading?

A common worldview within medicine and science is reductionism; a view glorified by Richard Dawkins and other members of 'the Brights'. This worldview suggests that 'properties, concepts, explanations, or methods from one scientific domain (typically at higher levels of organisation) can be deduced from or explained by the properties, concepts, explanations, or methods from another domain of science (typically one about lower levels of organisation)'. (1)

Practically, this has been reflected over the last few decades in a progressive reduction of a whole person with an illness (the fundamental unit of clinical medicine) to cellular and molecular biology as the ideal level for scientific medical research. Perhaps this is useful in providing an objective basis for practising evidence-based medicine as opposed to relying on mere intuition or superstitious beliefs. However, reductionism neglects other important aspects of being human which are essential in understanding and practising medicine, such as communication or human interaction and its impact on health.

Not all of the questions posed above can be answered by reductionism. Reductionism is only concerned with cause, not purpose. Take the question 'Why did you cross the road?' One (teleological) response would be 'to get to the other side'. Reductionism however would answer 'because I was pushed'. Reductionism is only concerned with looking back on the causality of an action and never forward to the 'intent' of an action. So while reductionism seems very 'enlightened', it merely hides behind a barrier of science to congratulate itself on its own cleverness, pushing aside the other 'big questions' and passing them off as unimportant.

Another widely-held worldview in our society is 'post-modernism' - when someone's view is that 'anything goes' and 'there is no such thing as absolute truth'. In my opinion this is sheer laziness - the path of least resistance. Someone assenting to this is likely to encourage anybody to do anything they choose without questioning, even if they know it would be to their detriment. In itself it's based on a self-refuting statement: if there is 'no such thing as absolute truth' how can that statement itself be true for everyone?

How might it work practically? Miss A, 19 year old student, comes in requesting an abortion. As the doctor I could answer this request without any questions thinking 'who am I to say that it is right or wrong? Whatever my views on abortion, I cannot impose them on someone else, therefore I should not question her decision.' I can respond to my patient's demand as if they are a consumer or customer I have to please.

If I did this, following a post-modern worldview, I would be avoiding an opportunity to have a difficult, but necessary, conversation to ensure that Miss A is not being coerced into this decision and is, in fact, making an informed choice. The end result may well be the same but surely the second option is the better way to really care for our patients?

Reductionism and post-modernism are just two of the worldviews we encounter every day without realising it. They may project a certain degree of reality but they also have serious problems, failing to address many of the important questions demanded by an ideal framework to explain the reality and world. We should take the time to think about our worldview and how it impacts on our opinions and decision making in medicine. By doing this, we will not only clarify a lot of issues in our own minds, but it will also help us to understand those people who may be opposed to our views – always remembering that this is just as likely to be a patient as a colleague, both now and in the future.

If this has all been a little bit close to the bone then I'm glad. Please write in with different views, have discussions with your firm about what is right and wrong; question your lecturers next time there is something that doesn't sit right with you. Don't ignore an uneasy feeling until you adapt to cope with it. Whether our conscience comes from evolution, societal norms or a creator doesn't mean it should be ignored. Our differing worldviews need to be voiced, discussed and debated so that each of us can have a firm understanding of our own opinions, and a greater understanding of those around us.