When Medicine, Morality, and Ethics Collide

Medicine isn’t just about lab values and treatment plans. Sometimes it drags you into places where science, morality, and ethics all collide — places where the old promise to “do no harm” doesn’t give a clear answer. These are the questions that keep me up at night.

Medicine is full of puzzles with no easy answers. One of the hardest is what happens when morality, ethics, and medicine all run head-on into each other. These are the kinds of things that creep into your brain late at night. To even think about them, you almost have to strip away your own convictions — forget everything you think you know about right and wrong — and try to look at the problem scientifically. But science by itself doesn’t cut it. You still have to wrestle with the moral and ethical boundaries that hang over every decision we make.

Take the Hippocratic Oath. It tells us: “First, do no harm.” But what exactly counts as harm?

If someone with terminal cancer is suffering in agony, and even sky-high doses of narcotics don’t touch the pain, am I doing harm by letting them live through that? Or am I doing harm by helping end the suffering?

Or think about a person in a persistent vegetative state. No higher brain function, no real awareness — just a body being kept alive by tubes and wires. Muscles wasting away, skin breaking down, dignity slipping away. Is it harm to keep that going? Or is it harm to say, “enough”?

I don’t have an answer. I’m not especially religious, but I like to think of myself as a moral person. And I’ll tell you this: it bothers me even when I stitch up a cut and realize my anesthetic wasn’t quite enough. If something that minor nags at me, how in the world am I supposed to sit comfortably with choices that literally decide whether a person lives or dies?

And then there’s the big question: who gets to decide?

In some countries, assisted dying is legal under very strict safeguards. And it isn’t always limited to terminal cancer or ALS — in places like the Netherlands and Belgium, even certain severe, treatment-resistant psychiatric illnesses can qualify. That means a person with profound, unrelenting mental suffering — not just physical disease — might be eligible after multiple evaluations and reviews. Switzerland also allows assisted suicide in some psychiatric cases.

But that’s not the norm. Here in the United States, every “medical aid in dying” law ties eligibility to a terminal physical illness with a life expectancy of six months or less. Mental illness by itself does not qualify. Even in countries where psychiatric euthanasia exists, it remains rare, controversial, and tightly regulated.

I took the Oath. I believe in it. I try every day not to hurt people. But the longer I practice, the more I realize that some questions just don’t have clean answers. Sometimes “do no harm” isn’t a command at all — it’s a riddle you’ll never fully solve.

How I Try to Think Through the Impossible

Over the years, I’ve learned that the best I can do is slow down and lean on a process:

Nail down the facts: what’s really going on medically, what’s the prognosis, how much suffering are we actually talking about.
Center the patient’s wishes: if they can’t speak, find their advance directive, or talk to the people who know them best.
Weigh “helping” against “not harming” — and admit that those two aren’t always the same thing.
Bring in palliative care, ethics consults, family voices. Don’t try to carry it alone.
Remember that sometimes the goal isn’t to fix everything — it’s just to make the suffering less.

Even then, you’re often left with more questions than answers.

And maybe that’s the point. In medicine, the hardest problems aren’t meant to be tied up in a neat bow. They’re meant to be struggled with — case by case, patient by patient, family by family. Sometimes the best we can do is walk into the storm with them and keep asking the questions, even when the answers never come.

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How I Try to Think Through the Impossible

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