For nearly two months this winter, America was caught up in a debate over John Tower's ethics. We scrutinized his personal life and we endlessly deliberated over whether he was morally fit. It's the kind of ethical debate Americans love.
But as a nation we're much slower to tackle the harder ethical questions - particularly, says Dr. Anne J. Davis, questions about health care.Davis, a professor of nursing at the University of California San Francisco, is in Salt Lake City this week as part of the Distinguished Residents Program at Westminster College.
America has no national policy regarding health-care delivery, charges Davis. Cases of medical ethics "are decided on an individual basis, by different folks, at the moment."
There is no consistency from state to state, for example, on how we feel about when and how people should be allowed to die.
California has recently adopted the practice of "durable power of attorney," which empowers a designated person to decide the medical fate of another. But this is such a very new development, says Davis, that it has not yet been tested in court.
In the Netherlands, reports Davis, "active euthanasia" is now allowed, under strict guidelines and at the patient's request. Active euthanasia, unlike passive euthanasia, not only allows doctors to unplug life-support machines but would permit doctors, presumably, to cause death. So far, though, American medical ethicists have not been able to learn much about how the policy is working, since the only studies done have been in Dutch.
"In the real world," adds Davis, "passive euthanasia and active euthanasia are not so mutually exclusive." When a dying patient is given increased doses of morphine, for example, it relieves pain but it also suppresses respiration, perhaps hastening death. Is a doctor or nurse in this instance practicing active euthanasia or just making the patient's suffering a little more tolerable?
As thorny as these ethical questions are, however, Americans are more prone to think about them than they are to think about another big ethical problem: the allocation of resources for long-term care. Who should pay for the care of AIDS patients, for example, or the "old old," that fastest growing segment of the population? Without a coherent national policy, says Davis, "an awful lot of people are going to go without."
The United States and South Africa are the only industrialized nations in the world without any form of universal health coverage, she notes. The result is that in America we ration our health care based on factors like wealth and luck.
When it comes to health care for children, studies show that poor children are sicker than children from families of means. In the case of kidney transplants, we are more likely to help white males, says Davis. And in the case of AIDS, a patient in San Francisco will probably get better care than a patient somewhere else.
"The medical profession does not want to be regulated and the public doesn't want to pay for it (universal coverage). . . . We haven't come to grips with this."