Psychiatric Annals

Psychiatry in the Land of Ethics: Landmarks and Landmines

Colleen D Clements, Phd

Abstract

Physicians, because they practice an applied biological science, arc used ?? the responsibilities and accountability of the expert role. They are inclined to grant experts in medical ethics the same acceptance as medical colleagues. They trust that ethical knowledge and medical knowledge are arrived at in the same tested, verified way, They are wrong.

Ethics does not use a scientific standard for knowledge or truth, Ethics, like much of the humanities, rejects the scientific criterion for probable truth. Psychoanalysts may be familiar with this issue since there is a current interest in "hermeneutics" and an argument that hermcneutic thinking can replace scientific thinking in psychoanalysis.1 Hermeneutic truth is an internally coherent story. The story can be based on a text of language (the Oxford English Dictionary], a text of history, or a text of intuitions. Clinicians may wonder what such abstract airy-fairy ideas have to do with good patient care or clinical practice. It turns out that they have a great deal to do with it. For practicing psychiatrists, there are landmines hidden in medical ethics and medical humanities.

AN ALTERNATIVE BIOETHICS

It has only been since the 1950s that the humanities produced the specialty ol secular medical ethics and that medical schools began to pay attention to it.2 Before that, Roman Catholic medical ethics had been an important part of the Catholic physician's practice.'·4 But Catholic medical ethics did not redefine the profession of medicine, and its Aristotelian background was usually compatible with the basic biological values of medicine (survival, well-functioning, and appeal to biological knowledge}.5 That is not true of current medical ethics. 1 want to offer a map of" the territory oí current ethics, with landmines posted, and landmarks pointing to an alternative medical bioethics.

I. Ethical Knowledge is "Foolish Consistency."

Because current ethics is hermeneutics, it has only one standard for truth about what is good medical practice: coherence. If all assumptions hang together without internal contradictions, like the internally coherent story of an intelligent schizophrenic, then the ethical assumptions or guidelines are true. Values are an internally consistent story, a well-done piece of fiction. More thinkers than Emerson have problems with foolish consistency. The life sciences have a standard of truth that requires both internal consistency and some correspondence to external experience, Things not only have to be consisten!, they have to work in the world around and within us. Ideas about growing grass and cutting machines have to actually mow the lawn. Physicians have to verify or throw out assumptions, correct for cultural and individual biases, and confirm hypotheses by pragmatic testing. A very strange thing is now going on in medicine. Well-told stories about values arc replacing scientific understanding of the human organism and physicians, to be considered ethical, are changing their practice of medicine to fit those stories.

II. Values are Individual and Cultural Stories.

If consistency is the only current standard for ethical truth (and it is), values can be anything we like as long as they are consistent stories. Since values come from our assumptions about value, they can reflect our individual prejudices or our culture's conventions. How do such personally relative or culturally relative stories affect psychiatrists? For one thing, from the 1960s on, medical ethics has over-valued patient autonomy and informed consent, condemned physician paternalism, and insisted that medical-biological knowledge could not generale values (the science/value split). These value assumptions were used to justify significant changes in how psychiatrists could practice based not on what is good medicine (scientific ethics), but what is the patient's choice (the individual's story about ethics). In a culture where legai institutions are…

Physicians, because they practice an applied biological science, arc used ?? the responsibilities and accountability of the expert role. They are inclined to grant experts in medical ethics the same acceptance as medical colleagues. They trust that ethical knowledge and medical knowledge are arrived at in the same tested, verified way, They are wrong.

Ethics does not use a scientific standard for knowledge or truth, Ethics, like much of the humanities, rejects the scientific criterion for probable truth. Psychoanalysts may be familiar with this issue since there is a current interest in "hermeneutics" and an argument that hermcneutic thinking can replace scientific thinking in psychoanalysis.1 Hermeneutic truth is an internally coherent story. The story can be based on a text of language (the Oxford English Dictionary], a text of history, or a text of intuitions. Clinicians may wonder what such abstract airy-fairy ideas have to do with good patient care or clinical practice. It turns out that they have a great deal to do with it. For practicing psychiatrists, there are landmines hidden in medical ethics and medical humanities.

AN ALTERNATIVE BIOETHICS

It has only been since the 1950s that the humanities produced the specialty ol secular medical ethics and that medical schools began to pay attention to it.2 Before that, Roman Catholic medical ethics had been an important part of the Catholic physician's practice.'·4 But Catholic medical ethics did not redefine the profession of medicine, and its Aristotelian background was usually compatible with the basic biological values of medicine (survival, well-functioning, and appeal to biological knowledge}.5 That is not true of current medical ethics. 1 want to offer a map of" the territory oí current ethics, with landmines posted, and landmarks pointing to an alternative medical bioethics.

I. Ethical Knowledge is "Foolish Consistency."

Because current ethics is hermeneutics, it has only one standard for truth about what is good medical practice: coherence. If all assumptions hang together without internal contradictions, like the internally coherent story of an intelligent schizophrenic, then the ethical assumptions or guidelines are true. Values are an internally consistent story, a well-done piece of fiction. More thinkers than Emerson have problems with foolish consistency. The life sciences have a standard of truth that requires both internal consistency and some correspondence to external experience, Things not only have to be consisten!, they have to work in the world around and within us. Ideas about growing grass and cutting machines have to actually mow the lawn. Physicians have to verify or throw out assumptions, correct for cultural and individual biases, and confirm hypotheses by pragmatic testing. A very strange thing is now going on in medicine. Well-told stories about values arc replacing scientific understanding of the human organism and physicians, to be considered ethical, are changing their practice of medicine to fit those stories.

II. Values are Individual and Cultural Stories.

If consistency is the only current standard for ethical truth (and it is), values can be anything we like as long as they are consistent stories. Since values come from our assumptions about value, they can reflect our individual prejudices or our culture's conventions. How do such personally relative or culturally relative stories affect psychiatrists? For one thing, from the 1960s on, medical ethics has over-valued patient autonomy and informed consent, condemned physician paternalism, and insisted that medical-biological knowledge could not generale values (the science/value split). These value assumptions were used to justify significant changes in how psychiatrists could practice based not on what is good medicine (scientific ethics), but what is the patient's choice (the individual's story about ethics). In a culture where legai institutions are so important, iI is also not surprising that medical ethics often became medical law. This has affected psychiatry severely.6 Only a scientific standard of truth for ethics can avoid this. Instead of being relativistic stories, values could then be working rules coming from the world around us, from our human nature, and from a standard of thinking that allowed for correction of error and bias. There could be a real content to medical ethics.7,10

III. The Moral Agent is Not the Human Organism.

A second difficulty with medical ethics is that it separates the human moral agent and his autonomous choice from the biological organism and natural causes. Autonomy is the patient's full story. Psychiatrists understand autonomy as a goal of treatment, so they may feel comfortable with autonomy language. That is also a mistake. The ethicist's moral agent is a cognitive-only decision maker, purely logical, in need of all the information, whose free choice is by definition what is good." The moral agent has "reasons" for acting: his action is not caused. The moral agent is nonbiological - a storyteller, not a biological system. Many of the current arguments in psychiatry reflect this mentation/organic dualism. Psychiatry is particularly sensitive to the mind/body dualism, and current ethics is based on that dualism. It is an ethics for the "mind." Only a bioethics can be an ethics for the complete human biological system - the total patient.

IV. Stories are Not the Standards of Critical Thinking.

Psychiatrists are accustomed to credentialing, certification, peer review, and the generally rigorous standards of accountability in medicine. They practice critical thinking in very pragmatic terms. Physicians are also consensus-builders, and are almost required to be eclectic, combining elements from many incompatible theories, as long as things work clinically. There are scientific safeguards to ensure lhat consensus does not simply become the might of the establishment, and that eclecticism remains a stop-gap tool which has to be justified in practice. That is not true of ethics. Ethics has not made slow progress over time to a reasonably validated consensus. It takes a physician interested in philosophy as an avocation to realize that the perennial problems of philosophic ethics remain the current problems of philosophic ethics, and that the skeptic can rightfully claim that no current ethical theory is reasonable.12 i4 The physician also has to have a working expertise in inductive logic so he can identify the informal fallacies of which medical ethics makes use: Slippery Slope (make one decision and slip to depravity). Circular Argument (assuming what is to be proved), Ad Hominem (if you don't have a case, personally attack ihe opposition), Authority (if Galen believed it, it has to be true), and Ad Populum (counting noses to see if the earth is flat). Because ethics is by current definition deductive reasoning, it docs not have the safeguards built into medicine. The scientific method, inductive reasoning, does have safeguards deliberately built in. It also has outcome criteria, which ethics does not have. If medical ethics discussion were left in academia, where academic philosophers conducted only "thought experiments." lhcre would be little concern; but ethics is rapidly becoming guidelines for case management, and patients' morbidity and mortality are now at stake. That requires more than analysis of ideas, thought experiments, and intuition.

V. Medical Ethics is a Political Story.

A funny thing happened to ethics on the way to the hospital. H became government policy-making, agency regulation, and statutory law. Ethical case management became legal case management. It also became bureaucratized, fitting patients into policies and procedures. Ethicists went to Washington. But all this politicking is occurring in elhics language, not politics language. Legal decisions on informed consent, laws about ECT, right to refuse medication, and the civil rights of the chronically mentally ill have become morality. We have people on the side of the angels in some cosmic battle between light and darkness on the plains of psychiatry." A good political debate transmutes into a doctrinal dispute; in fact, medical ethicists routinely call informed consent the "doctrine of informed consent." Medical bioethics distinguishes between political autonomy-civil rights and the broad range of human values. It is a minimalist ethics, stressing biological values basic to human nature and required for continuing function. Because it talks about the human organism's well-functioning, it needs the knowledge of biological psychiatry, ethological psychiatry,15 and psychodynamic psychiatry. It supplies a means for choosing values in specific situations. It is a unified ethical theory, not an eclecticism. What the President's Commissions on medical ethics issues have given us is an eclectic combination of incompatible universal principles (autonomy, beneficence, truth telling, etc.) with no way to tell which to choose in what case - the standard problem of eclecticism.16

VI. Medical Ethics is an Economic Story.

Deinstitutionalization came in under the cloak of medical ethics, but soon showed its face of costcontainment. Ethical words like "patient autonomy," "death with dignity," and "right to die" are inadvertently covering another agenda of saving money on the health care of the elderly and dying, which has co-opted those terms. CAT scans were criticized as too high-tech - the intrusion of scientific machinery into proper bedside medicine - when the real agenda was to cut costs by limiting the number of scanners and the utilization of them. Ethics language advanced cost-containment agcndas in artificial heart research and in vitro fertilization. Psychiatrists, who are often called upon to determine Jl a patient refusing life-saving treatment is competent (legally), will be caught in this doubletalk. There are valid issues in the good use of resources;17 but these questions need to be answered by careful ecological studies. Medical bioethics can separate economic prioritizing from the actual ethics issues involved in conservation of resources. It can supply a framework for looking at the conflicts between individual good and the ecosystem good, a framework that will not automatically assume that the elderly patient has a moral duty to die and get out of the way, or that psychiatric treatment of the everyday unhappiness of life wastes resources, or that 10.8% ui" the GNP is a magical "bad" number.

CONCLUSION

Biological science is value-free in the sense that it is a method of correcting for prejudice and error, unlike current medical ethics, which is valueloaded because it does not have a method for correcting false value assumptions. Science is valuegenerating because it can give us an understanding of what is good specifically for human beings, unlike current medical ethics, which is value-empty since it can have no verified content. Inductive science deals with purpose and function teleonomically.lw These concepts arc the ground of ethics. Bioethics is derived from our scientific knowledge about the world in which we live. The psychiatrist's science and values can be integrated in a common life science method, which gives probable truth in an interdiscipline of medical bioethics.

REFERENCES

1. Spence DP: Narrative Truth and Historical Truth: Meaning and Interpretation in Psychoanaly, New York. Norton. 1982,

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4. Burke EF: Acute Canes in Moral Medicine. New York, Macmillan. 1925.

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11. Moore MS: Psychiatry and Law: Rethinking the Relationship. New York. Cambridge University Press, 1984.

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13, Murphy JG: Evolution, Mortality and the Meaning of Life. TOtowa, New Jersey, Rowan & Littlefield, 1982.

14. Clements CD: Medical Genetics Casebook: A Clinical Introduction to Medical Ethics Systems Theory. Clifron, New Jwersey, Humana, 1982.

15. McGuire MT. Fairbanks LA: Ethological Psychiatry: Psychopathology in the Context of Evolutionary Biology. New York, Grune & Stratton, 1977.

16. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research: Screening and Counseling for Genetic Conditions. Washington, D.C. President's Commission for the Study of Ethical Problems in Medicne and Biomedical and Behavioral Research, 1983.

17. Clements CD: 'Therefore choose life': Reconsiling medical and environmental bioethics. Perspect Biol Med 10985: 28:407-425.

18. Lorenz KZ, in Lorenz KZ. Kickert RW (trans): The Foundations of Ethology New York, Springer, 1981.

10.3928/0048-5713-19860701-06

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