Dr. Robert Shabanowitz’s “Clinical Ethical Decision Making”

by Nathan Derstine

Dr. Robert Shabanowitz began his presentation on Clinical Ethical Decision Making in Science Center 106 after a brief tension-breaking introduction from EMU professor Dr. Roman Miller. After informing the audience of Dr. Shabanowitz’s title as Director of ART/Andrology Laboratories at Geisinger Medical Center and his position as Chair of the Bioethics committee since 1996, Dr. Miller also revealed that he was a long time friend, having attended graduate school at Kent State University with Dr. Shabanowitz.

Dr. Shabanowitz opened by emphasizing the challenges and importance of having intentional bioethical discussions, especially with the recent shift from a paternalistic concept of health care (where patients do what the doctor orders without question), to one that values patient autonomy. This issue is compounded by the increasingly pluralistic nature of our society (one with diverse values, and moral and political rights to live according to those values). He explained how the claims we make in moral arguments are based on factual, conceptual and moral components. More often than not, moral issues arise from differences of concept than of fact.

He explained codes of ethics as one attempt to standardize these decisions; a familiar example would be the Ten Commandments. Dr. Shabanowitz stressed, however, that having an ethical code does not necessarily mean that it is followed or even respected by others. To illustrate this point and “poke fun at everyone” he gave an example of the Taliban’s Code of Ethics regarding suicide bombers, and then showed a graph representing those responsible for all the deaths in the Bible, with God far surpassing anyone (including Satan) and clearly breaking his own “Thou shalt not kill” mandate. Dr. Shabanowitz then attempted to summarize two ethical frameworks: principle-based and narrative based ethics.

Principle-based ethics espouses adherence to specific guiding principles. He described the principles of biomedical ethics as patient autonomy, non-malfeasance (don’t do bad), beneficence (do good), and justice. Dr. Shabanowitz quickly added that principle-based ethics can easily lead to oversimplification and have no hierarchy or formula for prioritizing a given set of principles. He also wondered how, in a biomedical setting, “do we do justice in a world of limited resources?”

Moving into a concept of narrative ethics, Dr. Shabanowitz implied that we are naturally imbued with ethical principals based on the various narratives we’ve interacted with in life. To do this he displayed several media clips, drawing on TV shows “Family Guy” and “Seinfeld” and movies “The Savages” and “Spirited Away.” The clips depicted common ethical dilemmas diffused with humor, or the case of “Spirited Away” the young age at which we learn certain virtues. This view suggests that narrative is a tool for sorting out the principles already present in ethical views.
Unabashed about his cynicism, Dr. Shabanowitz concluded the seminar with a retreat into the uncertainty with which ethical decisions must be faced. In reference to the general situation of biomedical ethics he ended with a Mark Twain quote, “I was gratified to be able to answer promptly, and I did. I said I didn’t know.”

After the presentation, the time was opened up for audience questions and EMU President Loren Swartzendruber was the first to respond. He inquired as to what degree health insurance companies influence a bioethics committee, a question that drew directly on Dr. Shabanowitz’s work experience. Cynicism showing through, Dr. Shabanowitz gave the simple version of his answer first, saying, “It’s a big mess.” He then described the ingrained nature of injustice in the current system of health insurance coverage.

Dr. Shabanowitz gave a good background and summary of the various ethical options available in a health care setting. On the whole, I thought his talk was informative, but it lacked what I wanted to hear most, unique personal insights from someone with extensive knowledge and experience in bioethical decision making. I wanted to know where he places himself among the various principal-based or narrative approaches to ethics. I went into the seminar thinking clinical ethical decision making is difficult and complex…and for better or worse, that is exactly how I left.