Common Sense

The Principle of Moral Proximity

Issue: November/December 2021

Author: Lisa A. Moreno, MD MS MSCR FAAEM FIFEM
President, AAEM

A character in a novel I recently read learned that a colleague was making defamatory statements about a senior member of their profession who had not selected the colleague for an important  committee. The statements were untrue and were damaging to the senior person’s reputation. Should she, the novel’s protagonist, confront her colleague, who was making these statements? Should she tell the person who was being gossiped about unfairly? What was her moral obligation? Is this her business?

After the Allied Forces liberated the Schutzstaffel camps, allied soldiers were assigned to take local citizens on mandatory tours of the camps. The soldiers reported that many of the citizens cried, but some others held their heads high, with defiance in their eyes, and challenged the soldiers to blame or shame them. How, the soldiers wondered, could people have lived with the smell of burning human flesh, in a village where grey ash fell from the sky almost daily, and not have questioned what was going on in these camps?

More proximal geographically and temporally, an American court will be considering whether Alex Kueng, Thomas Lane, and Tou Thao had a moral obligation to act to attempt to stop the murder of George Floyd by Derek Chauvin. Even more proximal are the daily questions that we are confronted with as emergency physicians. What is my obligation to treat the patients lingering at the border between Afghanistan and Pakistan, begging to enter Pakistan for necessary medical care? What is my obligation to treat patients in Haiti who have been struck by another earthquake? What is my obligation to act when my colleague has been terminated without due process and escorted out of the hospital by security staff and a Team Health executive? What is my obligation when the admitting team refuses to admit my homeless patient with second degree burns and no access to water, wound care materials, or transportation to the clinic? What is my obligation to intercede when I hear a patient call a female resident “dumb bitch”?

A colleague of mine who worked in a Pakistani refugee camp years ago told the story of a mother of six whose husband had died. She had lost track of her extended family and his, due to migration during the political turmoil. She had no work skills and she and her children were facing starvation. A 60-year-old widower offered a bride price for the woman’s 12-year-old daughter that would allow her to feed her other five children for at least another three years. She sold her 12-year-old daughter. “How,” my friend asked, “could any mother condemn her little girl to that life? I don’t understand how a mother could do that to her own child.” “Indeed, you don’t understand,” I told her. “And I pray you never have to, but she chose to sacrifice one child to save five.” And then we discussed our moral responsibility to eliminate situations in which mothers are forced to make such decisions.

We all know the words of the confession of the Reverend Martin Niemöller, and I have quoted his confession in this column before. Niemöller was a German Lutheran pastor and theologian born in Germany. In 1892, the Reverend was an anti-communist and so he supported Hitler’s rise to power. But he quickly realized the evil where Niemöller was imprisoned, he wrote this confession:

First, they came for the Communists, and I did not speak out—
Because I was not a Communist.
Then, they came for the socialists, and I did not speak out—
Because I was not a socialist.
Then they came for the trade unionists, and I did not speak out—
Because I was not a trade unionist.
Then they came for the Jews, and I did not speak out—
Because I was not a Jew.
Then they came for me—and there was no one left to speak for me.

His message, clearly, is that we must speak for others, most especially those who cannot speak for themselves. The message deeply touches the core of what we do for emergency patients and what AAEM does for emergency physicians. There is so much to be done, and often, it feels overwhelming, which leads to feeling ineffectual, which leads to burnout. So, as we strive towards self-care and work to avoid burnout, balancing that with our sense of responsibility to the platform and privilege that we have as emergency physicians, and as we strive to protect ourselves from moral injury, how do we decide where our responsibility lies and how can we exercise our privilege in a way that is effective?

The concept I recently came across is called MORAL PROXIMITY. The principle holds that your moral obligation, first and foremost, is to the person with whom you interact. Moral proximity takes the ethical approaches: VIRTUE ethics (to be good, do good), DUTY ethics (to be good, do your duty/follow the rules), UTILITY ethics (the greatest good for the greatest number), and DISCOURSE ethics (something is good be cause EVERYONE who it effects agrees it is good) and distills them down to the individual relationships we engage in daily. Proximity ethics looks at our duty in the here and the now to the person or people who are here with us. A wonderful article “Between You and Me: A Comparison of Proximity Ethics and Process Education” by Hintze, et al (International Journal of Process Education, June 2015, Volume 7 Issue 1) discusses the implications of moral proximity ethics to health care providers and educators. Many of us are both by profession, but all of us are both in practice since we educate patients, families, and non-physician health care professionals daily. And while I am definitely someone who likes to go way off into the weeds to have discussions about ethics and philosophy, what I found most attractive about this principle is its simplicity and relevance to what we do. Moral proximity ethics is principally based on the works of Martin Buber, Emmanuel Levinas, and Knud Logstrup, if you want to read more, but the article I reference summarizes the core principles elegantly (and I quote):

  1. When interacting with another, we have an ethical obligation to help the other.
  2. What constitutes “helping” can be defined through discourse but must always respect the other’s self-determination.
  3. To interact authentically with the other is to risk ourselves and give up some of our control over where the dialogue between us takes us.
  4. Do what works in the particular situation, taking from any other ethical field (especially discourse ethics, but also virtue, utility, or duty) but always respecting the other as the primary virtue.
  5. In bringing preconceptions and prejudgments to our interaction with the other, we dismiss his needs.
  6. When in a position of power over another, we are obliged to act in his best interest, not our own.
  7. A relationship of caring has as its goal that of helping the other to gain his autonomy.

When we compare the mission and vision of AAEM, and when we compare the work of AAEM to the Ethics of Moral Proximity, it is extremely clear that AAEM operates as an organization of the highest ethical standards. We recognize our obligation to help our fellow emergency physicians and to do so with respect for their autonomy. We authentically engage in dialog exploring controversial and opposing opinions. We regard respect for each other as a primary virtue. We uphold the values of diversity, equity, and inclusion and eschew preconceptions and prejudgments. Unlike the corporate medical groups we oppose, we believe that those in a position of power are obligated to act in the best interests of those we serve, not in our own best interests. And as we support those who have been unfairly terminated without due process, and those who are subjected to metrics and processes not patient outcome focused and not physician led, we work with them to regain autonomy over their professional practices. Yes, we do live in a professional environment that seems to support burnout and sustain moral injury, but AAEM stands firm and true to the ethical principles that only mark a good standard of medical practice, but that also mark a good standard of ethics.

When you move through your workday, reflect on how beautifully emergency medicine creates opportunities for you to practice in a truly ethical way. You come to work to help your patients, and you respect their self-determination through shared decision making. You give up control not only over where the dialog in the ED will take you, but over everything that you will encounter during your shift, and then create order and healing in the environment of the unexpected. You do what works in each situation. You consciously put aside your prejudgments and preconceptions so that you can engage authentically and with respect. You put the patient’s needs above your own. And you strive to give the gift of health and wellness to each patient so that s/he can live as autonomously as possible.

It is easy for us to feel diminished by the loss of autonomy we ourselves feel as we see our meaningful work impeded by corporate medical groups, private equity, and regulations createdby non-physicians. I urge you to look at these basic principles of moral proximity ethics periodically and remind yourself that you belong to an organization that holds itself to the highest ethical standards, even if our position is not supported by those who put profit over patient and who find it in their best financial interests to provide inferior care or inadequately trained non-physician practitioners for their patients. Thank yourself each day for the work that you do, with the highest level of integrity, ethics, and authenticity, to serve those individuals who are frightened, in pain and in the most need of help. We have your back, so that you can continue to have their back in the way that only a board certified, residency trained emergency physician can. Thank you for all you do each and everyday to make your shop, the Academy, our nation, and our world a better place because you are in it.

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