A Time for Dirty Hands? Clinical Practice, Clinical Ethics, & the Evolving Legal Landscape

Daniel Kim, PhD – Clinical Ethics Consultant & Faculty, Alden March Bioethics Institute, Albany Medical College

Abstract: In this presentation, we argue that Michael Walzer’s notion of dirty hands can deepen our understanding of the moral predicament of clinicians and clinical ethics consultants as they seek to respond to the legal landscape under the Trump Administration. As the administration bans or limits access to medical standards of gender affirming care or abortion, for example, how should the conscientious clinician or consultant respond?

The problem of dirty hands in philosophy names the experience of moral conflict in which the correct political action requires violating or neglecting profound ethical norms. For clinicians or consultants recommending a course of action, the problem exists in one of two ways. (1) They can disobey the law by continuing to provide the medical standard of care to patients, trading off on legal consequences to maintain professional integrity. Or (2) they can comply with the letter of the law and do what they can within its constraints, but thereby compromise on their sense of moral integrity as professionals.

Walzer articulates three distinct responses to this problem of dirty hands. (a) In a Machiavellian approach, justify the means based on the ends; this would downplay the significance of moral integrity. (b) In a Weberian move, embrace personal anguish over the compromise, adopting a self-image as tragic hero. (c) In following Camus, acknowledge responsibility for an ethical violation, paying its price, so as to uphold the integrity of duty and the moral code. We examine these options in the clinical context.

Keywords: Dirty hands, moral conflict, moral integrity