Part Two:


To The




6.1. Applying ethics

In the preceding part, we discussed the specifically ethical dimension of our choices: what we basically have to do (never choose to act inconsistently with what we are), why we should bother doing this (because not doing so leads to eternal frustration), and how emotions and our knowledge of the facts are involved in our choices, and so how this knowledge affects our willingness to do wrong.

REMEMBER, a morally wrong act is one which contradicts either the humanity you were "given" genetically, or the modifications you have made of it by promises and so on.

From this point on, what we are going to be doing is exploring what the facts are about the humanity of a health-care provider, so far as we can know them, and drawing out the implications of what acts are inconsistent with these facts, and when and to what extent. The assumption here is that when people join the health-care profession, they alter their humanity into (also) being that of health-care providers. So it is immoral to be willing to contradict yourself either as a (generic) human being or as a health-care provider.

We are going to move from the general to the more specific in this investigation: first getting an idea of what health is (and so what the provider is supposed to be providing), mentioning briefly a couple of health-care-related issues of the provider's duties to himself as an individual, then discussing the relation of the provider to others in general (the realm of rights and society), and then to the patient.

Since the provider is performing a service, we will then explore the implications of this, and since it is a necessary service, we will get into the question of compensation vs. the right of the patient to receive the service.

We will then devote our attention to the physician, in his relation to the patient's life and the patient's physical integrity, then pass on to the nurse, giving particular attention to her as an assistant to a physician. Then we will discuss what mental health and unhealth are, and relate this to the provider of psychological care.

NOTE that the discussion will show that many so-called "difficult" ethical questions are not morally difficult at all, but practically "difficult" in the sense of inconvenient--or even tragic as far as this life is concerned. In this connection, it is well to keep in mind the following:

It does not matter how much you or anyone else suffers because of your being moral in this life; you (and they) are always going to be worse off if you choose what is morally wrong to avoid it.

This is a harsh saying, but it is either true, or the whole enterprise of discovering what is right and wrong is a waste of time.

For instance, the issue of abortion is said to be one of the most "controversial" and "complex" moral issues of our time. Actually, there is nothing complex about the morality of it at all, really. The only complexity is over the factual question of whether fetuses are human beings or not--and even that does not make the issue morally complex. If fetuses are human beings, you can't kill them, except under the circumstances you can kill any other human being (i.e. self-defense). If there is any doubt whether they are human beings are not, then, if you choose to kill them anyway, you are willing to kill a human being, and are morally guilty of the same thing as murder. What could be simpler? Only if you can prove beyond a reasonable doubt that fetuses are not human would it be morally right to have an abortion.

Thus the whole value question of whether the fetus would be "better off dead" than having a mother who didn't want him, and what this will do to the mother's life and health and so on is completely irrelevant, morally speaking, because the end doesn't justify the means. You can't choose wrong for any purpose, however good--as can be seen from changing the question to whether you can kill your six-year-old because you now can't stand to have him around and the whole rest of his life is going to be miserable (which might even be true).

We will discuss the abortion issue in some detail later; but this will be to find out the factual issue of whether fetuses are in fact human being (and persons), and so in fact possessed of human rights, including the right to life (they are, by the way). Once that is established, then "compassion" and so on are simply smokescreens for choosing what is known to be wrong

And once you do that, anything goes, as we are now seeing. As I write this, President Clinton has vetoed the "partial-birth abortion" ban, and thus allowed the following procedure to continue:

The abortionist prepares to deliver a live baby, reaching into the uterus to turn him around so that he comes out feet-first. He pulls out the feet, the torso, the arms, and everything but the head. He could also pull out the head, and the baby would be born, and then have legal protection against being killed.

But he leaves the head inside, so that "it" can still be called a fetus, and be legally killed. Then, holding the face, he takes a pair of scissors with his other hand and snips a hole at the base of the back of the skull, inserts a suction tube, and proceeds to suck out the brain of this squirming infant, and then, now that he's good and dead, crushes his skull and pulls out the corpse.

This "procedure" has actually been defended on the false grounds that it is "necessary to save the life of the mother." There is in fact no case in which the mother would die if the baby's head were simply removed without this grisly act of killing. The real reason for justifying it is that if it is forbidden, this creates the legal precedent of forbidding the killing of some fetuses, and there are no logically defensible grounds for not applying this to all of them.

Of the five women President Clinton had with him during the signing, alleging that their lives were saved by the "procedure" not one had an abortion that was anything but "elective." Their lives were not at risk at all.

The point of mentioning this is that there are all kinds of complications you can bring forward to obfuscate moral issues with tragic overtones. But all of this is obfuscation, not complication. Life can be tragic; but avoiding tragedy does not justify choosing wrong--because if it does, then since one person's difficulty is another's tragedy, anything is justifiable. And once that principle is taken, then the really horrendous rapidly turn out to be commonplace.

6.1.1. Informing the ignorant

There's a very important point that applies in many areas in ethics, dealing with what you are to learn (and I hope be convinced of) in the pages that follow. It would be well to keep it in mind in all considerations of ethical matters.

You have a positive obligation to provide information to a person who is contemplating doing wrong only if (a) someone else's right is involved; (b) he seeks your advice, or (c) your not providing it is the equivalent of preventing him from finding out the information. Otherwise, your providing the information can be immoral.

As to the case of rights: If you have a chance to protect someone's right and you do nothing, you have been willing that the right be violated. And (as we will see later) we cannot will any violation of any right of any person.

So even though cases involving a violation of rights are "moral issues" and in pure moral issues (i.e. not involving rights), what I am going to say in a moment applies; still, violations of rights are not just moral issues, and to remain silent is to connive in the violation.

That said, what of purely moral issues? Another person is doing wrong, and doesn't know he's doing wrong; no one's right is being violated by it. Do you tell him? There is a very narrow tightrope to walk here. Even if you are a clergyman or an ethical expert (whose business is moral rightness and wrongness), your gratuitous offering of information to a person is an interference in his control over his life; it is clear that you want him not to do something that he wants to do. So there is a question of how much this "providing of the facts" is an attempt to get him to live according to your will, not his--of how much you want control over his life (which is immoral). After all, if he's acting in ignorance, his eternal life is in fine shape; so what's your problem?

When you can intervene is when you have reason to believe he would honestly want to know the facts. The point I'm trying to make here is that you had better be very sure of your own motivation in this. Of course, if he asks you, then clearly he wants to know. But if he doesn't, and you have no reason to think he'd want to be informed, then it's not only the case that there's nothing morally wrong with "not getting involved," you shouldn't try to inform him--especially if you're not an ethical expert.

The reason this is tricky if you are a clergyman or ethical expert is that if he knows you're aware of what he's contemplating (even if he doesn't ask your advice), he may take your saying nothing as meaning that you think what he is doing is all right. He has, as it were, tacitly asked your advice by expecting you to say something if you thought he was wrong; in which case, by not informing him in any way, you are withholding information.

This does not apply if you are not an expert, however, because he has no reason to expect that you're any more knowledgeable about the facts of the moral situation than he is. So he rightly will resent your interference, unless he makes a positive gesture of seeking your advice.

Now the reason it's morally dangerous to inform an ignorant person when he's not looking to be informed is that if you do interfere, it might be that you convince him or even place a doubt in his conscience. But then if he decides to do the act anyway, he is now making an immoral choice, which would not have been immoral if you hadn't informed him. Thus,

Informing an ignorant person of a morally wrong act he is going to do can lead to his deliberately doing it anyway; in which case you are also responsible (along with him) for the immorality of what otherwise would have been a moral, but ignorant, choice.

The fact that you didn't intend him to choose the act knowing that it is wrong is irrelevant. This is a possible side-effect of what you have done; and so you can't escape responsibility for it. You might be the cause, for all your good-hearted desire, of another person's damnation; and this is a severe burden to take upon yourself.

If the person asks your advice and you give him the facts, whether you are an expert or not, then you have simply supplied him with the condition under which he makes his own choice; and so you are not responsible for it. It would be wrong for you to withhold information from a person who wants it in this situation.

The same goes for me as I write this book, and ethicians who are teaching classes. The students choose to take the class, and are not forced to (even if it's a required course; they don't have to attend the college where it's required, or pursue the career it's required for); and so if you give them the facts and they get convinced by them and make immoral choices anyway, they are responsible and not you; because obviously in writing a book on ethics or teaching ethics, you would be acting inconsistently with yourself if you (a) taught what you thought was false, or (b) didn't give out information (because, for instance, it was "controversial").

Of course, one to teaches ethics is an expert, and so has the obligation to know the facts. Those ethicians who are "compassionate" and "tickle people's ears," as St. Paul says, have a great deal to answer for when they appear before the only Judge who matters.

6.2. Health

[This topic is also briefly treated in Modes of the Finite, Part 5, Section 2, Chapter3]

Now then, what is this "health" that the health-care provider deals with? It can't in a simplistic way be said to be "what is not diseased," because mentally unhealthy people are not healthy, but it is only by a kind of metaphor that you can call them "diseased" (because there is no agent attacking the organism, no clear symptomology, no definite cure, and so on). Similarly, a person who is crippled is not healthy, but it doesn't necessarily mean he's got some kind of a disease (he may have had a football injury).

So what we will have to do is come up with what is called an "operational definition" of health and unhealth that will cover all the bases.

DEFINITION: Health is the ability to act in accordance with one's genetic potential. Unhealth is the inability to do so, because of something within the person.

DEFINITION: The genetic potential of a person is what that person could be expected to be able to do because of the particular genetic structure he has.

Thus, if you are genetically capable of seeing and you get glaucoma, you are unhealthy. You are not unhealthy, however, if you can't see because someone has put a blindfold on you. The cause of your inability has to be something within yourself to call it "unhealth."

Also, if you are born with a genetic defect that involves blindness, then strictly speaking you are not unhealthy, but handicapped. You can do all that your genes allow you to do, but not what the normal human being's genes would allow him to do.

DEFINITION: a handicap prevents a person from doing what "practically all" other human beings can do. That is, what the vast majority of humans can do, resulting in our thinking that it is "natural" or "normal" for a human being to be able to do the act in question.

This definition allows us to talk about people being mentally (or even socially or spiritually) unhealthy without implying that psychological difficulties are some kind of "disease," however often we may hear people preaching that "alcoholism isn't a choice, it's a disease." It is not a disease, but it is a case of mental unhealth.

DEFINITION: A person is mentally unhealthy if he cannot control his actions by his choices, or if he cannot access the information stored within his brain.

Basically, mental unhealth is a "bug" in the organic computer which is the brain; and since the brain is what consciousness depends on, then the malfunctioning of the brain affects consciousness in one way or another. But just as in a computer, similar results can occur from either hardware problems or defects in the program (even in different parts of it), so apparently similar "symptoms" can have vastly different causes, some organic and some due to habits. And just as debugging a computer is not a simple task, so "curing" mental unhealth is not a question of finding what kind of "disease" this is and "treating" it.

Very often, in fact, a person with a psychological difficulty is going to have to treat it as a handicap and "learn to live with it," because in point of fact, there is no practical way to get to be able to do what normal people in his situation can do.

But all this is not to say that he's not unhealthy. It's just that this kind of unhealth is not directly analogous to physical unhealth.

DEFINITION: A person is spiritually unhealthy if his idea of God and what God wants of him induces him to do inhuman things.

We can call this "unhealth," though it is a kind of intellectual mistake, and we can know that it is unhealth and a mistake because we can presume that God does not contradict himself; and if he creates people as human, he cannot want them to be inhuman.

Thus David Koresh, who led the Branch Davidians to their fiery deaths in Waco, Texas recently, was undoubtedly mentally as well as spiritually unhealthy. But his followers were spiritually unhealthy, for believing that God actually wanted them to kill themselves in the way in which they did. Similarly, when James Jones of Jonestown induced his followers to commit suicide by drinking poisoned Kool-Aid, they were spiritually unhealthy to think that God actually wanted this of them. In their case, they were in control, and so not mentally unhealthy; but they were certainly deluded. So of many "cult" followers.

This is not, of course, to say that any of these people were damned because of what they did. Insofar as this was unhealth and they thought that they were doing the right thing, then their choices were moral and they gained eternal happiness by them.

DEFINITION: A person is socially unhealthy if the cultural mores he has absorbed are maladaptive to the society he is actually in.

There are many things that a given culture regards as "natural" simply because "everyone has always done it like this," when in fact it is only within this culture that "everyone" acts in this way. If such a person moves to a different culture, he can (without being mentally or spiritually unhealthy) be very uncomfortable, and make those around him uncomfortable, by doing what it "natural" and getting frowns of disapproval. This is currently called "culture shock," and of course very often it wears off as a person learns the ways of the new culture. But when a person sticks to the old ways, he is culturally unhealthy.

For instance, a young Vietnamese refuge I know was brought up never to say "No" to an elder; and when her American sponsor brought her to the store to help her buy a wedding gown, the sponsor would ask her, "Do you like this one?" and she would answer, "Yes, yes." But after all the trousseau was bought, she secretly went back to the store and exchanged everything. She did not realize that when Americans ask a question in a context such as this, they are not saying, "I want you to buy this," but want to know how she really feels.

It does not follow, by the way, that all social behavior patterns are merely cultural, and therefore subject to change. Some of the attempts of the feminists to alter "gender-based" behavior are in fact attempts to reinvent human nature, and are backfiring. If many cultures independently of each other have developed similar behavior patterns, this is an indication (though not necessarily an infallible one) that the basis of the behavior is genetic, not social.

6.2.1. The health-care provider

If this is what health is, then what exactly is a health-care provider?

DEFINITION: A health-care provider is a person who serves others by attempting to restore them to health.

So a health-care provider is not really someone like Mom who is taking care of Johnny when he has the sniffles; in our sense of the term, a health-care provider makes a profession or business of restoring people to health. So he is serving the public in this capacity. We will have to see the moral implications in this aspect of health-care delivery as well as those entailed in "restoring someone to health."

Observe that it is sometimes the case that the one you are serving and the patient (the one to be restored to heath) are different. For instance, a nurse or assistant to a physician is directly acting on the patient, but is serving the physician (who is, of course, serving the patient).

I should note here what I will spell out in its proper place, that it is inconsistent with an assistant to do something harmful to the patient because the physician orders it. On the other hand, as assistants, nurses would be acting inconsistently if they substitute their notion of what is "better treatment" for the one they are told to administer.

Secondly, a pediatrician who treats a young child is treating the child, but serving the parents, and therefore is to defer to the parents' wishes rather than the child's (always supposing, of course, no harm to the patient). Thus, if the parents think it better for the child to have braces on his teeth and the child doesn't want them, Junior gets the braces. Similarly, if the parents refuse a non-necessary treatment, then the child does not get it, even if the child happens to want it (and might be somewhat better off for it).

Obviously also, a veterinarian is always serving the owner of the animal, though he is treating the animal. Since animals do not have rights, if the owners want the animal "put to sleep," then the veterinarian is being perfectly consistent with himself in doing what is objectively harmful to the patient by killing it.

This is not to say that a veterinarian could be justified in inflicting needless torture on an animal just because the owners want him to do so. Even though the animal does not have any right, strictly speaking, not to be tortured, such an act dehumanizes the one who does it, and so would be inconsistent with the veterinarian himself as an "empathizer."

There are peripheral aspects of the health-care profession that do not, strictly speaking, deal with restoring people (or animals) to health. Technically (at least based on our definition above), treating genetic defects is not restoring the handicapped person to health, since he can do what his genes allow him to do; it is just that his genes don't allow him to do what normal people can do (i.e. he is abnormally limited in his humanity).

But this is a technicality, since correcting genetic defects involves the same sort of knowledge as that involved in restoring a person to health, and the practical effect of an abnormal genetic limitation is the same as that of being unhealthy.

Nevertheless, since "unhealthy" tends to imply "sick," those with genetic handicaps sometimes rightly resent being treated as if they were "sick people" who need to be "cured."

So the distinction here is not just terminological. It is better to call the difficulty what it is: a genetic defect or handicap that might be corrected or overcome, rather than "unhealth" or "sickness" that should be "treated" or "cured." But it is the health-care profession that takes care of this sort of thing.

It is also the case that cosmetic plastic surgery is not really "restoring a person to health," because (except in the case of correcting disfigurements), the person simply is going to look better, and is not incapable in any sense of acting in accordance with his genetic potential. But again, this type of surgery involves the same kind of knowledge and skill as that involved in restoring people to health, and so it is a branch of the profession.

So far, then, the definitions seem to hit the kind of thing we want to discuss; so let them stand as given.

6.3. The provider's own humanity

Let us just briefly state what certainly should be obvious, but what turns out sometimes to be violated in the course of medical practice:

The health-care provider cannot be willing to do any harm to himself for the sake of restoring others to health.

More specifically, this means:

The provider must not put his life or health in danger except when the Double Effect can apply.

For instance, the practice of making new residents in hospitals work insanely long hours is morally wrong, not only for the residents but for the people they treat. This kind of "hazing" might "toughen" them for hard times ahead, but the end does not justify the means. Further, tired physicians have impaired judgment, which implies that their decisions about treatment will be apt to be harmful to the patients.

Now working when tired is not evil in itself, and so there are times when the Double Effect can apply: when there are so few doctors that the patients will be harmed by not being treated, so that there is a good effect (second rule). Obviously, the harm to the doctors that comes from working when tired (or the harm to the patients) is not the means for the patients' getting treated (fulfilling the third rule); no one wants harm to either doctor or patient (fourth rule). But only when the harm to the patients by not being treated now would be at least as great as the harm to the doctors and the potential mistreatment of the patients from the doctors' impaired state can this be allowed morally, because otherwise the fifth rule is violated.

Similarly, doctors and nurses can treat patients with leprosy, bubonic plague, ebola and other dangerous, even deadly and highly infectious diseases, insofar as (a) they take whatever precautions reason demands not to become infected themselves, and (b) the harm from the danger of their own infection is not greater than the harm that comes from letting the sufferers go untreated. (Note that it is the harm from the danger--the harm of the actual infection minus the likelihood of getting it--that is what is to be compared with the harm of letting the patients go untreated.)

NOTE that a health-care provider must be more willing than the average person to put his own life or health in danger for the sake of restoring others to health.

The reason for this is that, since diseases are apt to be infectious (and insanity, in the mental-health field, is apt to involve violent people), then health-care delivery itself as a profession is a more or less risky business. Thus, when you choose it, you are already willing to run the risks involved.

That is, it is inconsistent with a person to choose the health-care profession and say, "I'll be a doctor, but I don't want to run any risk of getting sick myself."

Still, the point here is that this willingness must not turn into reckless disregard of one's own health.

NOTE also that harm to one's health, however slight, may never be chosen as a means to the benefit of patients.

Thus, if infecting yourself with a disease in a controlled way would allow you to discover the agent that causes the disease and so find a cure for it, and if this meant that you actually had to catch the disease to learn what you needed to know, you couldn't do it--even if this would merely mean that you would get sick, and your knowledge would subsequently save millions of lives.

It was in this way, in fact, that the causative agent for malaria was discovered. The doctors involved in the research each inoculated themselves with different components of mosquito venom, and the one who got malaria showed what it was that caused it. The result was the cure; but however we may applaud the good that came out of this evil, such a course of action still may not morally be chosen.

The reason is that it would be by getting sick that you saved the others' lives; and so you would have to choose the harm to yourself. So even though it is disproportionately small compared to the harm that you would be protecting people from, you couldn't do it.

Before you bristle at this, remember that a willed harm has eternal repercussions, and harm in this life stops at death. If what I said here is not true, the end justifies the means, and the whole moral enterprise, as I have so often repeated, is a waste of time.

So you can't hide behind the "altruism" of the health-care profession as an excuse for actually choosing harm to yourself.

6.3.1. Lying

[This topic is also covered in Modes of the Finite, Part 5, Section 2, Chapter 5, and in Human Conduct, section 6.3.2. ]

There is one moral issue that is actually a violation of the provider himself, but since it deals with communication, it can act as a transition between the provider and the patient: the issue of lying.

DEFINITION: Lying is the act of communicating as a fact what is believed not to be a fact.

The essence of the wrongness of the lie is that the act of factual communication is contradicted in the very exercise of the act. So even if it's a "white lie" that doesn't do any harm to the hearer (even if it's beneficial to the hearer), you are still pretending that your act is not what it is.

Any harm that may come to the hearer because of or in addition to the fact of his deception is an added evil to the essential moral wrongness of the act of lying.

Note that in lying, you expect the hearer to believe you (i.e. to take what you say as your idea of what is really the case). But on what grounds do you have this expectation? Because the nature of this kind of activity (factual communication) is such that it reveals what you think is the case. Thus, you can't lie to someone unless you know that you are acting inconsistently with what you are doing.

NOTE, however, that not every false statement is a lie. Lies must have the intention of communicating (making the hearers believe) that what is not a fact is a fact.

First, it is obvious that mistaken statements are not lies. If you think something is the case and it actually isn't, you have issued a false statement, but you have not been willing to communicate what is false; and so you haven't lied.

Second, there are non-factual utterances, such as questions or exclamations or commands. You can't lie by saying "Are you sick?" or "What a beautiful day!" or "Go shut the door" unless the expression implies a "fact" that is known actually not to be a fact. For instance, "What a beautiful day!" implies the fact, "The day makes me feel great," and so you might be lying if you said it intending to deceive someone about the state of your mind. But in general, since these things express attitudes and not facts, you aren't lying when you utter them.

Third, there are factual statements which do not communicate what the words literally mean. For example, (a) there are ironic statements such as, "You certainly studied hard last night," spoken by the teacher to the student who is falling all over himself answering a question. In this case, what is communicated is the exact opposite of what is said. Such things are actually more forceful means of communicating a fact than a literal statement (and the meaning actually communicated is often reinforced by the tone of voice and so on). Hence, the teacher is not lying when making such a statement.

Also, (b) there are also conventional statements such as the secretary's "Mr. Smith is not in at the moment," when a visitor asks to see him. These statements are understood by everyone to not to mean a literal indication of Mr. Smith's whereabouts, but to be a way of saying, "You can't see him at the moment" without communicating the implied insult "You are not worthy of speaking to Mr. Smith." That is, if the secretary answered, "He's in, but he won't see you," this conveys an implied insult that might be false. Just as the visitor's question, "Is Mr. Smith in?" is not actually a request for information about Mr. Smith's physical location, the answer does not communicate information about his location, but answers the implied request.

So No, Virginia, the secretary is not lying when she makes that answer; and anyone who accuses her of doing it does not understand the difference between what you say and what you communicate.

Fourth, strictly speaking you can't lie by making value statements, since values depend on subjectively set standards, and the only fact involved is whether the situation in question meets the standard you set up to evaluate it--and only you can know that.

So, for instance if you go into a hospital room to visit a friend, and you say, "You look fine," when he looks a wreck, you're not really lying--on two counts. First of all, what you're trying to communicate is "I sympathize with you and want you to feel good" without saying it in an insulting way, which you would do if you said those words (since you as a healthy person would come across as condescending to the sick one). But secondly, you can also mean, "You look fine in comparison to what I would have expected," or "in comparison to someone who is at the last stages of cancer" or whatever--which is perfectly true.

And the patient generally takes these sympathetic remarks for what they are; because later on in the conversation, he might say, "Okay, now tell me how I really look," meaning that now he wants an evaluation plus the standard you are using. In that case, you'd have to say, "Well, based on what you've been through, you look pretty good," or you'd be lying--because if you now made the unqualified statement, "You look fine" when you think he looks terrible, you'd be communicating as your value judgment the opposite of what it really is, which is what he's asking you for.

NOTE that the moral obligation does not extract from you the positive duty of telling the truth, but the negative one of not communicating the opposite of what you think the truth is.

That is, there is nothing morally wrong with leaving someone uninformed, unless he has a right to know the facts; but it is always wrong to misinform someone deliberately. Lying by implication: the placebo

The distinction between what is said and what is communicated is a two-edged sword, however, and you can sometimes lie by telling what is factually true, but which you know the hearer will take in a false sense.

For instance, Anacin for years advertised that it "contains the pain-reliever doctors recommend most," implying that it had some kind of fancy prescription drug in it, when all it was was aspirin and caffeine.

One particular case of this type of lie is called the placebo (from the Latin word meaning "I will please [you]."

DEFINITION: A placebo is a medically inert substance that is made to look like a pill or a medicine capsule. The "placebo effect" consists in the fact that often if a patient believes a certain thing will make him feel better, he feels better.

Placebos are sometimes the only thing that will work with hypochondriacs (people who imagine they have diseases). Since "it is all in their head" anyway, you can't give them the standard treatment for the disease they don't have but are convinced they have; but if you give them a placebo, then the "disease" gets "cured."

Often enough also, real medical problems can get cured by placebos, since basically the body cures itself, and the mind can do wonders at directing this curing mechanism if its power is unleashed by suggestion (as hypnosis demonstrates). Just as there are real psychosomatic diseases, real physical diseases whose cause is the mind, so there are psychosomatic cures; and placebos can sometimes bring these about.

The trouble is that administering the placebo is a lie, because the act of giving to a patient sugar that looks just like a pill communicates the idea that this pill is medically effective and will cure him when it isn't and it can't. If he gets better, it isn't the pill that cured him, but his belief that it would. That is, the pill is just an occasion for his belief to effect the cure; it itself is not the cause.

Since in administering the placebo, it is the deception that effects the cure, this is using a morally wrong means for a good purpose, and is morally wrong.

Some have tried to get around this by alleging that when the physician says, "Take this and you'll feel better," he is telling the truth, because when the person takes it, he will in fact feel better. But this statement is not the lie; the lie consists in the fact that "this" is assumed by the patient to be medicine which will cure him, and it isn't.

This can be seen from the fact that if the doctor says, "This is actually just a sugar pill; but it'll cure you if you believe it will," then the cure won't happen, because the patient will realize that it itself won't do anything for him. So it's only when the patient is deceived into thinking that the pill is medicine that it will work.

In this connection, there is nothing morally wrong with "faith healing," in which someone like Oral Roberts lays hands on sick people telling them that if they have faith, they will be cured. This is not a lie. First of all, God can and sometimes does produce miraculous cures (there's certainly objective evidence that medically--and even psychosomatically--unexplainable cures have occurred in a religious context). Secondly, even when God is not involved, an unwavering belief that the cure will happen can produce a cure by the placebo effect. So in this case, it is precisely the belief that does the curing, and this is what the faith healer says. So there's no deception involved here. This applies to the kind of thing that medicine men do as well as what is done in a Christian context. Obviously, if the treatment by medicine men didn't work quite often, they would not be sought out.

There is a legitimate use for placebos, however. In testing drugs, one wants precisely to eliminate the placebo effect as the reason for the apparent ability to cure the patient. So what is done is that subjects of the testing are divided into two groups, one of which receives the medicine, and the other a placebo of identical appearance. Subjects are told beforehand that they may be receiving the medicine, and they may be receiving simply a placebo (so there's no deception involved here); and since everyone knows that he might simply be taking an inert pill, this kills the belief necessary for the placebo effect to work; and so if the medicine is really effective, a significant difference will show up between those who took the medicine and those who took the placebo.

It can happen that if the person who administers the pills knows which is real and which is the placebo, his body language can convey this information to the subjects; and so to avoid this, "double blind" studies are used, in which those who administer the pills are given them in such a way that they don't know whether they're giving a placebo to the patient or not. Public-health propaganda

A situation similar to that of the placebo is the manipulation of scientific data to influence the public to take steps to be healthy. The motivation for such things is noble, since people are often doing things which are harmful to their health without fully realizing the risks, and they don't tend to change their behavior unless the risks are "brought home" to them by exaggeration. Thus, data which prove a slight risk are interpreted as establishing a serious danger, evidence on one side of the issue is presented without evidence which supports the other side; and so on. Again, what is said is not false, exactly, as stated, but it communicates, for a good purpose, a false idea of what the facts are. This is a lie.

"Fudged" or misleading data must not be used to persuade people to do something which is beneficial to them. If they cannot be persuaded by the truth, then the chips must fall where they may.

This sort of thing is counterproductive, actually. To the extent that the public begins to realize that it is the victim of a propaganda campaign, it tends to be skeptical of all pronouncements from the office which issues such information, and becomes like the people who heard the boy cry "Wolf!"

Recent instances of this are the outrageous exaggeration of the dangers of second-hand smoke (for which there is no credible evidence that it is harmful to people's health); the scare about the chemical Alar which was sprayed on apples and is perfectly safe; concerns expressed about the dangers of radon gas (which are infinitesimal); the so-called "disaster" of global warming (which hasn't been established even to be occurring, let alone to have disastrous effects); and most of all, the myth that AIDS is a disease that "anybody" can get.

To show you how this works, in the last instance it is true that anyone can get AIDS; but the chances of getting it from ordinary heterosexual intercourse even with someone infected with the virus (provided the parties do not have other sexually transmitted diseases, especially those which cause lesions) is on the order of one in ten thousand. The problem is that the odds are very high (e.g. one in three) for things like anal intercourse with infected people and for sharing with them needles used for drugs; but being honest with the information gives the impression that the disease is a gay men's and drug users' disease, and to a somewhat lesser extent a prostitute-client disease; and that will make the public complacent.

One side-effect of the AIDS scare has been the touting of condoms as "safer sex." They used to be called "safe sex" until the falsity of this became so obvious it had to be changed. Using a condom during sexual intercourse does (in the "real world": that is, in the way condoms are actually used) tend to cut the transmission of sexually transmitted diseases about in half; so it sounds like a good idea to promote them. But (a) cutting the odds of getting AIDS in half (one in ten thousand to one in twenty thousand) is like thinking you're "more likely" to win the lottery if you buy two tickets instead of one; (b) some STD's, like gonorrhea, have a ninety per cent transmission rate, and so the odds are reduced to a little less than fifty-fifty for a single act. With five such acts, the odds of getting the disease using condoms each time is over ninety per cent. Thus, people who are safe anyway from AIDS are given a false sense of security against other STD's and are confidently having "protected" sex which in fact is not much of a protection.

The point is that well-intentioned falsehoods are not only morally wrong but can sometimes exacerbate the problem they are trying to solve.

6.4. Relations to others: rights

[This topic is treated also in Modes of the Finite Part 6, Section 1 and Human Conduct, Chapter 8.]

Of course, lying is generally not simply the contradiction of the liar's act of communicating, it also involves deception of another person, who in engaging in conversation has a presumptive right not to be deceived; so lying is also unjust. But this brings up the question of what rights are.

DEFINITION: A right is a social power to do something (or to refrain from doing something).

DEFINITION: a social power means that it is morally wrong for anyone else to try to stop you from doing the act in question.

That is, if you have a right, you don't necessarily have the physical skill to be able to perform the act. You may own an oboe, for instance, which gives you the right to play it; but you may not in fact be able to make any sound come out of it.

The way I learned about rights was that they were moral powers, implying not only that it is wrong for anyone else to prevent you from doing the act, but that it is not morally wrong for you to do it. I think this view is mistaken, because it implies that we would have no right to do what is morally wrong (and which harmed only ourselves), which would mean that others could morally intervene to stop us. I now think that this is false. If you want to harm yourself (by smoking, say), and it does no harm to anyone else, it is a violation of your command over yourself if someone else can prevent you from doing what you want with yourself.

This, I take it, would follow from the fact that God does not force people not to damn themselves if they want to (which can be inferred from the fact that if he did, the moral obligation would collapse into meaninglessness, as we saw in Chapters 2 and 3). The fact that God respects our self-determination even to allowing us to set and keep deliberately self-frustrating goals is an indication that self-determination is the true essence of a person. So it is a violation of self-determination for anyone to interfere in a person's living of his own life (as long as it doesn't affect anyone else).


You can have a right to do wrong and to harm yourself; you can be persuaded not to do so, but not forced, as long as the harm you do does not violate anyone else's right.

It therefore follows that it is morally wrong to "save someone from himself" if he knowingly and freely is choosing his own harm.

Now then, the fundamental reason we have rights is that we are persons, not that we are "equal" to other people (in spite of what Jefferson wrote in the Declaration of Independence). This is a complex issue, and I am going to oversimplify it for our purposes.

DEFINITION: a person is a free being: a being who can set goals for himself and direct his behavior toward achieving them.

As far as we know, human beings are the only living bodies who are persons. The other animals engage in goal-directed behavior, but they give no clear evidence of being able consciously to set the goal. Their attention is directed by what their genetic "program" assesses as most "beneficial" to them at the moment, based on the condition they are in. They give no evidence of being able simply to imagine themselves as different, to compare the imaginary state with their present condition, and opt for the imaginary one over either the one they are now in or the one their emotions incline them towards.

Experimenters in this field demonstrate the intelligence of chimpanzees and other highly developed animals, but they have never been able to show that they understand what the symbols they use mean, as opposed to being able to manipulate them. That is, it is one thing to make a connection (this house reminds you of Mr. Smith), and to understand what the connection is (he owns the house). The difference is extremely subtle, and setting up an experiment that would clearly reveal it is exceedingly difficult--and none so far have succeeded.

Nor, I am sorry to say, are they likely to. The difference between children and apes becomes quickly apparent as each learns words. The ape manipulates the symbols he is given, but evinces no curiosity to find what other symbols go with the objects in his world. But once a two-year-old catches on to language, he is constantly pestering people with trying to find out what names to give to the objects around him--and in fact, he makes up his own names when no one tells him. This clearly indicates more than that he knows how to use language; he knows what it does. Animals so far have given not the slightest hint of this.

But the point for our purposes is that in order to set a goal to be achieved, one must understand the relationship between the real state and the imagined one; and for this one needs the capacity that we find only in humans.

Note that persons are moral agents; that is, since they are free, they are responsible. Animals are not. It can also be shown that free beings have immortal souls, and are therefore subject to eternal reward or frustration for what we do.

So the implications of saying that animals have rights are significant. It means you can't neuter them, chain them up against their will, "put them to sleep" when it is the humane thing to do, have them medically treated when they don't want it, and so on. The "animal rights" activists understand neither animals nor rights. They want them to have "rights" only when it is convenient.

This is not to say that we don't have moral obligations toward animals; it is just that these obligations do not correspond to rights in them.

The moral implications of rights are that it is inconsistent with a person to use his self-determining activities to prevent another person from determining himself. That is, if you don't want others fulfilling themselves at your expense, then you are inconsistent if you fulfill yourself at their expense.

Thus, rights imply a reciprocity: I will let you alone if you let me alone. And since animals can't enter into such an agreement (since they can't (a) understand the meaning of such an agreement, or (b) consciously refrain from doing what the strongest influence tells them to do), that is why they cannot be the subjects of rights.

Now, to make a very long story short, even though the basis of our having rights in general is freedom, and becoming what you want to be in the future,

the basis of a given rights claim is damage to your present condition.

What this means is the following. A rights claim imposes a moral obligation on everyone else to let you do whatever it is you claim a right to do. So it restricts the freedom of everyone else. Hence, the mere fact that you want to do something does not give you sufficient grounds for preventing other people from doing what they want. So you have to show that if you can't do the action you claim a right to, you are somehow harmed. That is, that they are somehow contradicting what you now are by preventing you from doing the act.

Thus, if I am a citizen, you are contradicting my reality as a citizen by keeping me from voting. If I have a driver's licence, you contradict me as a driver if you won't let me drive my car. You contradict me as a human being if you try to kill me (since human beings are living beings, whatever their goals may be). If I enter into a contract with you and do the work you agreed to pay me for, you contradict me as a party to the contract if you don't pay me. And so on.

DEFINITION: The title to the right is the particular aspect of your reality that is contradicted if you are prevented from performing the act in question.

Thus, we have human rights, whose title is our humanity, civil rights, whose title is our citizenship, and various acquired rights like those arising from a contract or getting a licence to drive, and so on.

There are three especially important points to consider about rights:

First point: Whenever something is a human being, that something is a person, and so a possessor of all his human rights.

Why is this, if the human being is not always something that can in fact make choices? Fetuses, even if they can make choices, can't carry them out; and there has to be some stage between the fertilization of the egg and birth where the organism is incapable of making any choice at all. So how can that thing be a person?

Because he is a self-determining kind of thing, and personhood and rights do not depend on (a) whether you actually are making a choice, or even (b)whether in practice at the moment you can make a choice. They depend on whether you are a "choice-maker."

Consider the implications of denying this. If you lost your personhood when you lost your ability to make a choice, you would lose your rights along with it. Then, since you can't in practice make any choices when you are asleep, robbing you or even killing you during your sleep would not be immoral, because it wouldn't be a violation of your right to ownership or life. But that is ridiculous.

For those who argue, "But you still can make choices, because at any moment you can wake up and make them. But that would mean that people who are given drugs that render them unconscious and incapable of being awakened for, say, the next four hours are not persons during that time, and so can be killed--because they "can't" wake up and make choices in the sense that the sleeping person can. But that is also absurd.

But since there is no empirical difference between a person who has been knocked out and, say, a fetus who can't yet make choices because of the state of his body or a person in a coma who can't any longer make choices for the same reason, if you exclude these two classes of humans from personhood, then logically, you would have to exclude anyone who is unconscious, which is ridiculous.

Therefore, as long as the body is organized dynamically in a human way (as long as it is functioning as a human unit), it is a person.

Second point: Rights never extend to the violation of someone else's right.

This should be obvious. No one's right ever "trumps" another person's, no matter how "important" or "unimportant" either of them is, because rights are not based on equality or superiority or inferiority, but on the fact that a person is a free being. Rights basically are negative: you may not fulfill yourself by doing damage, however slight, to anyone else.

This is the basis of the saying, "Your right to swing your arm stops at my nose." So if you have a right to do something, you can exercise this right only to the extent that your exercise of it doesn't violate any right of anyone else.

Third point: Rights can be defended by force, by using the Double Effect.

The reasoning goes this way: Since a right is a power to do it, if I can't prevent someone from violating my right, I don't in practice have the power to do the act in question--which contradicts the right as a power.

But my act of using force, of course, does damage to the violator, and so (by definition) violates some right of his. Hence, there is a bad effect of my defending myself: harm comes to the violator. So we have a double effect.

Now the act I take to defend myself is innocent in itself (since if the violator ducks and then runs away in fear, nothing bad happens) (First rule.) It has, as I said, a good effect: my right is protected. (Second rule.) The damage done to the violator is not what protects my right, since, as I said, he may evade the damage and stop his violation, meaning that the good effect can happen without the bad one. So even if the damage actually occurs, it is not what produced the protection. (Third rule) I do not want the harm to the violator, but only the protection of my right (Fourth rule.)

Then as long as the harm to the violator is not greater than the harm I am preventing to myself (fifth rule), I can defend a right I have. That is, I cannot kill someone to prevent him from stealing my wallet, or maim him for insulting me. The damage must be proportionate to what I am protecting myself from or I also wish him harm, and this makes me the violator of his right, and not simply the protector of my own.

Note that the fact that "he asked for it" or "he deserves it" may never be the motive for doing damage to someone (however he may actually deserve it), because it violates the fourth rule. You may never morally choose harm to another human being. The double effect allows you to do the harm, but only unwillingly.

6.4.1. The right to privacy

Now then, what rights does the patient have that the provider must respect? Obviously, there are the normal human rights to life, physical integrity, and so on, which we will discuss at length later. But now let me concentrate on a few that deal with the patient as a patient.

First of all, the patient has a right to privacy: that is, to be able to conceal information about himself from other people.

To show that this is a right and not simply a desire, you have to show how the mere fact of others' knowing information about a person does damage to his human condition, whether that information is used against him or not.

The way to show this is that, as we saw, a person has a moral obligation not to misinform people about himself. But since everything you do gives some information about you to others, and since partial information can easily be misleading, then are misinforming the people around you unless (a) you fill in all the information they need to be able to make a correct judgment of your character (which is impossible in practice) or (b) it is known by everyone that you have the right to conceal information about yourself and therefore, any judgment they make based on what they have observed is based only on partial evidence. (Hence, if they judge you based on their observation, they should know they are making a rash judgment, which is their fault, not yours.)

Some of my second-semester students, for instance, get a shock when May comes and I enter class with a short-sleeve shirt, displaying the tattoo of a snake on my forearm for the first time. The don't think of the old philosophy professor as the kind of person who would have got a tattoo, let alone one of a snake. But that's part of my personality also.

So the only way in practice that you can interact with other people and not misinform them as to the kind of person you are is if you can conceal information about yourself. Therefore, you have the right to do so.

But the health-care provider has a right to do his job; and to do it, he needs information--sometimes information of the most intimate and personal nature--about the patient. Therefore., the patient has no right to conceal relevant personal information from the provider.

NOTE that only relevant information can be demanded from the patient. The health-care provider has no right to know all personal details about the patient, even those which "might conceivably" have a bearing on treating him. The provider has to have some reason to believe that the information he extracts actually does have a bearing on treatment before he has a right to expect to have it.

Providers may bristle at this, on the grounds that "there's always a chance" that information, say about a person's sex life might be pertinent to some treatment in the present or the future. But health-care providers are not God, and are not expected to be omniscient. The patient has right to privacy, and just because the doctor is treating him, that does not mean that his life has to be an open book every page of which is subject to the doctor's scrutiny. If, of course, the patient (on the grounds that he wasn't asked) conceals information which is relevant, but which the doctor wouldn't have any reason to suspect either exists or is pertinent to the case, then this is the patient's problem. He can't expect the doctor to ferret out details about his life.

The point is that, because of the provider's right to know pertinent information the patient has the obligation to freely reveal all the details of his life that he thinks might be relevant to the treatment in question.

To the extent that he doesn't do this, he can't hold the doctor responsible for acting on insufficient information.

But just because of the patient's right to privacy, the patient has a right to confidentiality of the information he reveals.

That is, information revealed to a health-care provider must not be revealed to anyone not involved in the treatment of the patient; and the more sensitive the information, the fewer people involved in the treatment have a right to know it.

Obviously, this has practical as well as moral implications. To the extent that a person knows that some socially damaging information he gives to his doctor might find its way into the general public, to that extent he is going to be motivated not to reveal it--with the resulting harm that can come from the provider's acting on insufficient information.

This is one of the problems connected with the confidentiality of testing for the AIDS virus. The mere fact that a person gets tested for HIV implies that he has done something (either committed adultery or used intravenous drugs) which put him in danger of contracting it. Very often it can be socially or personally disastrous if this impression is given; and so "mandatory testing" programs where the fact of being tested can be found out are bound to decrease the number of at-risk people who come to be tested.

Can confidential information ever be revealed? Suppose some third party will be damaged if it is not revealed, and yet the patient says he doesn't want the information to get out.

Since damage to a third party implies the right for that third party to know the information, and since no one's right extends to the violation of anyone else's right, then using the Double Effect the provider may reveal the information to the third party when the damage done by not revealing it is as great as the damage done to the patient by its revelation plus the damage done to patients in general from the undermining of confidentiality this will produce.

NOTE that since undermining confidentiality can be very serious, the damage to the third party must be extreme in order to justify the breach of confidentiality.

The point is that morally speaking, you can't say that confidential information can never be revealed; but in practice it is almost never.

That is, doctors are not like Catholic priests. Catholics believe that serious sins are not forgiven unless the sinner confesses them to a priest (or intends to do so; there's a loophole if he can't, in practice). Thus, he has to reveal it under pain of eternal damnation. If penitents believe that the priest can reveal this information under any circumstances whatever, this will motivate some to choose not to confess their sins, which will damn them--and this must be avoided at all costs. Hence, a priest may never under any circumstances whatever even act as if he knows any information about a penitent, no matter even if it is a matter of life or death or the averting of war or destruction of whole civilizations. The "seal of confession" is absolute, and breaking it is the most serious sin a priest can commit. The "seal" of the provider-patient relationship is not that serious.

NOTE that confidentiality is not breached when a person speaks (1) of what is already public knowledge, even though he has learned of it in his practice, (2) in general terms about a case, in such a way that the person involved cannot be identified, or (3) of what the provider has reason to believe the patient would want him to reveal, when the patient can't actually give permission (e.g. because he is unconscious).

6.4.2. Concealing information

Let me now put this obligation the provider has of confidentiality together with the obligation not to lie. How do you keep information secret if you can't lie to protect it.

First, the way to conceal information that must be kept secret is to keep silence or make some remark like "no comment." This must be used unless the silence or noncommittal remark in fact tends to communicate (by implication) the information.

The reason this is the primary way to conceal the information is that the methods we are going to discuss involve the possibility of misinforming as well as not informing, and so they have a bad effect.

Secondly, if simply keeping silence in fact reveals information, then you must say something which leaves the hearer uninformed.

There are various ways of doing this.

You can make a partial or an ambiguous statement (i.e. a statement that either contains only part of the truth, or one that means more than one thing), not with the intention of having the hearer take it in the wrong sense, but with the intention of having him not know which sense you intended.

Thus, if a doctor is questioned as to whether a patient of his requested an HIV test, he can say, "Look, he was here to have a heart problem checked." (Which was true, but he also asked for the HIV test) or "He's not the kind of person who would make a request like that." (True, he's not the kind of person that would do so, even though he in fact uncharacteristically did do so.) This is not a lie, because (a) there is a sense in which the statement is true, and (b) a reasonably astute hearer would realize that it doesn't really answer the question.

This kind of thing is sometimes called "mental reservation" (in which you "reserve to yourself" which of the meanings is the true one) or "equivocation" (meaning that you've voiced something with "equal" meanings). It is the reason why in law courts you swear to tell "the truth, the whole truth, and nothing but the truth." At that point, you have sworn that you will not conceal relevant information, or give partial or ambiguous statements. If you have to conceal information here, you have to inform the Court that the information you have is confidential. If the Court refuses to admit this, then you have to reveal it, because the act now of concealing it contradicts itself in violating the oath you took, and so the first rule of the Double Effect is violated.

In the case of doctors, lawyers, and priests, however, this concealment is legal. Such information is called "privileged," meaning that government cannot legally force the person to reveal it.

There was a notorious case recently in which a prosecutor in Oregon taped a criminal's confession to a priest (obviously, without the knowledge of either of them) and was going to use it in a trial, on the grounds that it wasn't "lawyer-client" information, and was only "religion," and presumably by separation of church and state, it shouldn't be privileged. The uproar at this was so enormous that (fortunately) it was not admitted (and I believe the tape was ordered destroyed. If not, it certainly should have been).

Finally, if neither concealment nor partial nor ambiguous statements can leave the hearer uninformed (since he might be clever enough to deduce from your remark what you are trying to conceal), you can sometimes make a false statement that you realize will not be believed.

"Oh, so it's all right to lie, sometimes, then." No. Remember, lying involves communicating false information. In the situation I am talking about, you are in a context where you know that the hearer will not believe your false answer "because it's the only thing you could say if you didn't want to reveal the information," and so he doesn't know any more after the interview than he did before. If this sounds "Jesuitical," remember that the moral obligation simply forbids contradicting yourself; and the closer you get to the line between contradiction and non-contradiction, the finer the distinctions you have to make.

To take our HIV case a bit further, suppose the patient is a prominent moral leader of the community, and the questioner is a reporter who wants to discredit him. He asks, "Did Reverend Smith ask for an HIV test?" (because he's heard a rumor that he did). You answer, "He came to my office to have a heart murmur checked," and he says, "But did he ask to be tested for HIV?" and you answer, "He's not the kind of person that would make such a request," and he (realizing that you're evading the issue) persists, "But did he actually ask for one, because I've heard that he did." You answer, "No, he didn't," and he (as you expect) says, "I don't believe you, Doctor."

In this context anything but "No, he didn't" (i.e. any evasion of the question) is going to reveal that he actually did ask for the test; and so "No, he didn't" now is an ambiguous statement. It would be what you would say if in fact he didn't ask for the test, and also the only possible thing you could say to conceal that he asked for the test. So the false statement is not a lie, because it communicates no information at all.

Summary of Chapter 6

An act is morally wrong if it contradicts your genetically given humanity or modifications of it that you have made by promises. We are now going to apply ethics to the human being as a health-care provider.

Note that many apparently "difficult" moral problems are morally simple, and only "difficult" in that being moral involves difficulties in this life. But it doesn't matter how much you suffer for being moral in this life, because there is an afterlife, in which you will suffer more for taking the immoral course. Either that, or all moral investigation is a waste of time.

Health is the ability to act in accordance with one's genetic potential: what you could be expected to be able to do because of your genetic structure. Unhealth is the inability to do so, because of something inside you (if you are tied up, you are not unhealthy) If you have defective genes, then strictly speaking you are handicapped, not unhealthy (i.e. you can't do what practically every other human being can do). You are mentally unhealthy if your choices can't control your acts or access to information stored in your brain. You are spiritually unhealthy if your idea God makes you think he is telling you to do something inhuman. You are socially unhealthy if your "acculturation" is maladaptive to the society you happen to be in.

A health-care provider is a person who serves others by attempting to restore them to health. Sometimes the person you serve is other than the patient, as in the case of child or animal patients.

A provider must not be willing to harm himself for the sake of his patients; he may put his health or life in danger only when the Double Effect applies. Making residents work insanely long hours in hospitals is thus morally wrong in general (and bad for the patients too). A provider, however, must be more willing than an ordinary person to run risks in treating people, because he chose to get into an inherently risky business. Note that the harm to one's health may never be the means to the benefit for people.

Lying is communicating as a fact what is known not to be a fact. Harm to the hearer is an evil in addition to the contradiction of the act itself of communication. But not every false statement is a lie. Mistakes aren't, because there is no intention to misinform. Non-factual utterances such as questions or exclamations can only be lies except insofar as they imply that you are communicating a state of mind you don't have. Factual statements may also not communicate what they actually say, such as ironic statements (which communicate the opposite) or conventional statements (which are understood to mean something other than what the words say). You don't have a positive moral obligation to communicate the truth, but simply not communicate the opposite of it. You may leave people uninformed, but not misinformed.

You can lie by implication. The placebo is an inert substance which is disguised as a medicine. If the doctor gives it to a patient, his statement, "Take this and you'll feel better," is true, because the "placebo effect" means that a person's belief that he get well makes his own mind cure him. But the belief is the result of the deception that the pill is medicine when it isn't. Thus, the act of giving the placebo is the lie, which is the means to the cure; and the end does not justify the means. Faith-healing is legitimate, because in this case, it is the belief that effects the cure. Placebos can be used in experiments when all the subjects know they might be given a placebo instead of medicine, because then they are uninformed, not misinformed, about what they are taking.

Analogous to the placebo is misleading public-health propaganda, in which scientific evidence of dangers is exaggerated in order to scare the public into avoiding acts they wouldn't otherwise take much trouble to avoid. First, the end does not justify the means; and second, such misleading information is apt to backfire, with the result that the problem becomes worse, not better.

A right is a social power to do something: no one may morally stop you. Because you are master of your life, you have the right to do harm to yourself if you want. Others can persuade you, but not force you, unless someone else's rights are involved. Rights in general come from our personhood: our freedom to direct our lives by making choices. Human beings are the only known living bodies who are persons; thus, animals do not have rights, even though we may have obligations toward them. It is inconsistent with a person to fulfill himself by preventing another person from doing so. The basis, however, of a given rights claim is a title: an aspect of your present reality which is contradicted if you can't do the act in question. Thus, you may prevent another from doing what he wants to do, but you can't do harm to him. Whenever something is a human being, he is a person, and has all his human rights. A human being is a person as long as his body is organized in a human way. Rights never extend to the violation of another person's right; no right ever supersedes another. Rights can be defended by force when the Double Effect applies: the actual harm cannot be the means to the protection of your rights, and the harm you do can't be greater than the harm you are protecting from.

Patients have a right to privacy: to prevent other people from knowing facts about themselves. If they didn't have this right, then they could not in practice avoid misinforming people about the kind of people they are (because everything they do gives information about themselves); and thus they would be lying. But the provider often needs to know intimate details about patients in order to treat them, and so the right to privacy yields to the provider's right to know. Patients must reveal all pertinent information, but have no obligation to reveal irrelevant facts about themselves. This obligation to reveal private information to providers implies confidentiality: the obligation of the provider to conceal this information from everyone not involved in the treatment of the patient. Using the Double Effect, if the concealment of the information does serious damage to a third party, it may be revealed, provided the damage would be greater than both the harm done to the patient and the harm resulting from the undermining of confidentiality (which can be very, very great). Thus, confidentiality in practice can almost never be violated. Confidentiality is not violated by speaking of information already public, by speaking in general terms so that the patient can't be identified, or by saying what the provider can presume the unconscious patient would want revealed.

One must conceal information by being silent or noncommittal ("no comment") if that will in fact conceal it. If silence reveals (by implication) the information, then something must be said to leave the hearer uninformed. This can take the form of a partially true statement or an ambiguous one, using the Double Effect and intending, not the deception of the hearer, but the fact that he knows no more now than before. If he persists, however, and not even this conceals the information, a false statement may actually be made if there are grounds for believing that the hearer will not believe you (and so will remain uninformed, not be misinformed).

Exercises and questions for discussion

1. If a person's self-determination means that the moral obligation is actually different for different people, how can there be books like this which give rules for everyone?

2. If it is immoral to choose one's own death, then is not the statement, "No one has greater love than this: to give up one's life for one's friend" advice to do what is immoral?

3. A patient claims that he can't go to sleep unless he listens to rock music--which disturbs other patients. You take away his boom box, and he claims you are depriving him of his rights. Are you? What do you do?

4. Why should we respect the rights of a Hitler or a Charles Manson, who has no respect for anyone else's rights?

5. Would a health-care provider have a greater moral obligation than an ordinary person not to smoke?

6. Mr. Clinton complains about the scrutiny every detail of his life gets from the media. Does the fact that he is a "public figure" give him less of a right to privacy (because he has chosen public life, after all) than others? To what extent, and on what grounds, does the "public" have a "right to know"?