joseph fletcher and situation ethics and medical ethics and physician duty to tell the truth

It was an established principle well before the 1950s, then, that a doctor who performed an unauthorized surgery on an individual had committed a battery. Sometimes a claim for battery was supplemented with a cause of action for negligence, but the case ultimately rested on the theory explained in the previous essay: that of the bodily integrity of the patient. Consent was required before intrusive probing of the body was permitted.

But in order for consent to have any value, to be of any use for a patient, the doctor has to be willing to tell the truth to the patient. You can have all the consent that you want, but unless you know the truth of your condition, you will be unable to exercise intelligent judgment and choice as a patient. So, how did the medical profession look at the idea of truth-telling as the 20th century progressed?

Discovering a "Jewel"

In answering this question, I came across Joseph Fletcher's charming book Morals and Medicine. It was originally published by Princeton UP in 1954, but had morphed into a (unchanged, except for a foreward by Dr. Karl Menninger) Beacon paperback in the late 1950s and 1960s because Princeton at the time wasn't doing paperbacks.* The edition I used for this

[*Couldn't you just imagine the debates in the stuffy old Princeton UP in the late 1950s, as the paperback revolution began? I have no reason to believe it would have gone this way, but imagination is a wonderful thing to have. I am sure that the oldest of the old boys would have objected to paperbacks on the grounds that they were ephemeral and cheap and that, therefore, anything so ephemeral and cheap probably contained ideas that were as evanescent as the bindings of the books. Someone, no doubt, would have held out for "reality"--i.e., this is the way the world is going--but that person would probably have been scorned and possibly fired, because WE at PRINCETON just don't do such things. Our weighty ideas must be captured in weighty tomes. Well, the Unitarians (Beacon is the press of the Unitarian-Universalist Church) had no such hang-ups. Anyone willing to experiement with the divinity of Christ in early 19th century America would certainly be willing to try their hand at paperback books in the 1950s. Those who have been denominated infidels for 1 1/2 centuries can more easily take the heat than those who have stuffily held to a dying orthodoxy in the intervening years.]

essay is the 1969 Beacon printing. When I opened his book, my mind was flooded with memories, for it dawned on me that this was the Fletcher I was taught to hate when I was an Evangelical in the 1960s and early 1970s. Why? Well, he, who was an Episcopal priest at the time, came out with a 1966 book entitled Situation Ethics, which was roundly criticized by Evangelicals. Billy Graham, for example, whom everyone including the New Yorker is fawning over now that he is in his declining years (he was born in 1918), considered this book a sign of the moral decline of our society. When Richard Nixon resigned from the Presidency in 1974, it was discovered that Fletcher's book on situation ethics had been given as a gift to Nixon, along with 50 other books, upon his inauguration by a booksellers association. Of course, those who wanted to make a case connecting moral decline and situation ethics could now have a field day. There was no evidence, however, that Nixon ever read Fletcher's work or even knew his name. Evangelicals thought they won the round, however, when Fletcher eventually left the Episcopal priesthood and proclaimed himself an atheist. 'See what happens,' the Evangelicals said, 'when you abandon an abolutist position on ethical issues?' Well, if any Evangelical preacher wanted to bring this debate up in the present day sermon, his congregation would fall asleep even faster than it does already.

So it was this Fletcher whom I discovered really for the first time when I was doing this essay. Before achieving national notoreity through "situation ethics," he had established himself as the first academically-trained ethicist dealing with medical issues in our culture. As mentioned above, his 1954 book Morals and Medicine was the first real effort to deal with weighty ethical issues as they related to the practice of medicine. The subtitle of his work lays out the scope of his concerns: "The Patient's Right to Know the Truth; Contraception; Artificial Insemination; Sterlization; Euthanasia." Though consideration of many of these issues might be fascinating, my concern here relates only to his treatment of the patient's right to know.

What Does the Patient Have the "Right to Know"?

Fletcher's main point in his lucidly written ch. 2 is that patients, in a word, have the right to know the truth about themselves from their doctors. Why should that be such a controversial statement? Why shouldn't this simply be a self-evident observation? Because the history of the medical profession in this country (and in England before independence) did not hold truth-telling as a particularly high virtue for medical professionals. Doctors, as Fletcher points out, were "gentlemen," and in 18th-19th century Britain a gentleman, in Disraeli's words "is one who knows when to tell the truth, and when not to." Doctors were seen to be masters of equivocation at best or outright liars at worst. Dumas' hero in Camille was quoted as saying, "When God said that lying was a sin, he made an exception for doctors, and he gave them permission to lie as many times a day as they saw patients" (quoted in Fletcher, p. 34). Indeed, a late 18th century book by Englishman Gregory Glyster (A Dose for the Doctor, London, 1789), portrayed doctors as skilled masters of equivocation. One might say in their defense that doctors were forced into this position because of the rather rudimentary state of medical knowledge in those times, but it doesn't change the fact that until well into the 20th century doctors were not encouraged to be truth-tellers, especially when their patient was dying, and especially when it had to do with communicating this information directly to the patient. As late as February 1923 a headline from the NY Times screamed, when the great fighter J.J. Corbett died of cancer: "Ex-Champion Succumbs Here to Cancer. He Believed He Had Heart Disease." Medical truth-telling, and not telling the truth, lay behind this headline.

We need another essay to continue this topic.

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