Episteme and Phronesis

The Welby case in Italy recently has stirred a veritable chorus of different opinions on the issue. This signifies a healthy interest in issues of bioethics, but also highlights how important the subject is becoming and how lacking we sometimes are in legal and ethical tools to deal with this subject.

I shall not be taking sides or giving explanations for what happened, or for what should have happened, or who was right or whatnot! This is beyond this article. I shall simply raise a few points that should lead people to think and be able to reach their own conclusions on the issue.

End of life issues are as touchy as beginning of life issues and, as expected, many people come to different conclusions according to the dictates of their well-formed consciences, which, as we all know, are binding on the individual, even if not being so well formed!

The evaluation of ethical problems is not a simple weighing up of theoretical points, principles and "laws", which can lead one to rock solid conclusions about different issues. Although this theoretical background of knowledge of taxonomy is important, it is by no means the only consideration that should be weighed up.

In Aristotle's Nichomachean Ethics, in section VI, he clearly draws the necessity for resolving ethical issues to stand on two bodies of knowledge. One he calls Episteme, or theoretical knowledge, with a well established "scientific" taxonomy of well-known and not so well known principles, while the other he calls Phronesis, or practical wisdom, the prudence to deal with issues in a perceptive and timely way as they arise.

Phronesis is very similar in analogy to the clinical practice of medicine. As doctors, we all know our scientific facts, or Episteme, about important diseases presented as theoretical text book signs and symptoms. However, we also all know from experience that when we apply these scientific facts to clinical practice, we all have to constantly weigh up and down these facts according to different patients and different presentations of the same illness. This important Phronesis has to be done on the spot according to prudent judgment borne of experience.

It is the same in ethical and moral evaluation. Legally, this has a corollary in the difference in the concepts of law and equity. The Roman Pontiffs (not Popes) of early ancient Rome specialised in dishing out equity measures similar to those in a small claims tribunal, as opposed to the full weight of legal measures or laws in a law court proceeding which could provide justice as we legally understand it but fail to provide equitable solutions. There is a discretion and discernment of the former that is not present in the latter. As Rome grew from a city state into an empire it became impossible to maintain hearings by these Pontiffs, the control of equity being assumed by the Emperor as Pontifex Maximus now assumed by the Popes.

Episteme obliges us to keep in mind a certain number of principles before deciding on a particular issue. I shall list a few.

First, the autonomy of different patients. The hospital is not a prison. Patients have the right to refuse treatment on their own bodies even if such treatment is beneficial to themselves. Lucid patients constantly sign themselves out of our hospitals against medical advice. Even persons not of a consenting age or not compos mentes should be accorded this important consideration.

Should a doctor proceed with treatment (except in an emergency) without the patient's consent? Definitely not! A patient's lucidly expressed wish has to be respected and adequately weighed against other factors of import. Nowadays people are resorting to "living wills" to express their desires should they fall unconscious and complicate the problem.

Second, is the patient or the doctor obliged to provide treatment that is extraordinary or disproportional to the case and its prognosis? Pope Pius XII clearly laid down that there is no moral obligation to accept or provide treatment that is disproportional to the illness. Is respiration by artificial respiration extraordinary?

Yes it is. Can treatment considered to be disproportional be stopped after being started? Yes it can and it often is.

Third, is the right to life an absolute right or not? It is, in fact, a fundamental but not an absolute right. Christ gave up his life willingly and I am absolutely sure that his action was morally correct when taken in context. He even stated that a fire was consuming Him, making Him eager to do His father's will which, as He well knew, included death by crucifixion.

What is absolute is the respect to be shown to the dignity of the human person (sive being).

Fourth, is killing someone actively (euthanasia), the same as letting a human being die naturally? No it is not; sometimes it is wiser and better to let nature take its own course rather than treat patients extraordinarily, submitting them to unnecessary hardships.

Fifth, when these principles and fundamental rights contradict each other as they often do, one must exert Phronesis to be able to decide and judge which right has to be accorded prima facie preference. This brings us to the point of prima facie rights, not an easy area to navigate.

The obvious result of this short exercise is to show how difficult these cases are, and one ought not to point fingers too sharply at anyone. They require profound thinking, discussion and consultation, thus the existence of heath ethics and bioethics committees.

Tea anyone!

Dr Asciak a Nationalist member of Parliament, is chairman of the Bioethics Consultative Committee.