The Role of the Clinician II
Michael A. Gillette, Ph.D.

Recall the following scenario from last month's Centerline. Ms. P is a 17 year woman with moderate retardation who was transferred to a state MR facility upon discharge from a pediatric care center. She is identified under new guidelines as an individual who should be moved into a community based living arrangement. However, the treatment team in this case feels that sending Ms. P to a group home might result in physical and psychological harm for her. Ms. P functions on too high a level to remain in the MR facility, too low a level to go home to her family, and too low a level to succeed in a group home. The ethical question posed in last month's issue concerned the ethical responsibility that a professional might bear if he/she were to follow the policy of his/her working environment and send Ms. P into a less than optimal situation.

In last month's column I suggested that it might be possible to show that while the decision to move Ms. P out of the MR facility might not be best for her, all other things considered it might still be morally appropriate. This argument is based on the idea that decisions must often be made which bring about bad consequences for some people, but that at times it is necessary for those decisions to be made nonetheless. It might turn out, for instance, that the financial or social costs involved in keeping Ms. P in the MR facility are extreme. They may be too extensive for our society to accept.

As I suggested last month, however, it would be useful to determine exactly what the responsibility of a health care professional would be when he/she disagrees with the above argument. What if I, as a member of Ms. P's treatment team and the person who is primarily responsible for discharge planning, feel that society ought to accept the burdens of continuing to care for Ms. P in her present setting? If my facility or my legislature orders me to discharge my client, should I do so?

There are several possible arguments to be made in this situation. One is known as the 'No Difference Argument'. This argument states that I have no moral reason to refuse to discharge Ms. P into the community when it is the case that if I do not do so then someone else will.

While the exact structure of the No Difference Argument is somewhat complicated, it is worth describing in some detail. The argument begins by admitting that there is some action, call it action X, and it would be better if X were not done. Second, the world just is the sort of place where my refusal to do X will not result in X's not being done since if I don't do X someone else will. From these two points it is concluded that my choice to do or not do X does not make a moral difference in the world, sincewhether or not I refuse to do X, X will still be done.

Next, the argument maintains that an act which makes no moral difference cannot be wrong. In other words, in order for an act to be wrong, the act must make the world a worse place. Since my doing X does not make the world a worse place (remember that the world will be an equally bad place whether I do X or someone else does X), my doing X cannot be morally wrong. If my doing X is not morally wrong, then I have no moral reason not to do X.

To apply this argument to the present case simply replace 'X' with 'placing Ms. P in the community'. The argument would state that if I refuse to place Ms. P in the community, someone else will place her in the community. The fact that according to my point of view Ms. P belongs in the Training Center is morally irrelevant. Whether I place Ms. P in the community or not, she will be placed there. Since who does the discharge makes no moral difference to the outcome, and since I cannot change the outcome by refusing to be involved, I have no moral reason to refuse to be involved.

This is a very clever version of the famous 'If I Don't Do It Then Somebody Else Will' argument. The interesting question is, does it work? I would like to claim that it does not.

The fourth step in this argument is that if an action makes no moral difference in the world, then it cannot be wrong for me to do that action. This is the point with which I most clearly disagree. According to this step in the argument, every moral issue should be approached from a disinterested perspective. In order to determine whether an action is wrong for me to do, I am supposed to ask whether the world would be worse off in the long wrong if I were to do it.

But this is already problematic. The question that I would most probably ask in a situation such as that of Ms. P is not just whether Ms. P should be transferred to another living arrangement, but whether I should transfer her. I would not merely ask 'is it wrong for someone to transfer Ms. P', I would ask 'is it wrong for me to transfer Ms. P'? I am not just concerned about general outcomes, but for my own actions.

Moral decision making is a personal matter and I have a special moral responsibility for what I do. If you perform an action that it would be better to avoid, then I might condemn you but I am not responsible for you. If I perform such an action then I am responsible. This personal responsibility is not easy to escape and the 'No Difference Argument' does not seem to help. Next month we will look elsewhere for other possible solutions.