Psychiatric Annals

Applied Bioethics and the Crisis in Health Care

Van Rensselaer Potter, PhD

Abstract

Triage is a French word meaning sorting, sifting, or selecting. Il was applied in military medicine, where it involved "The sorting and firstaid treatment of battle casualties in collecting stations at the front before the evacuation to hospitals in the rear."1 It was understood that for some casualties nothing could be done, for some others treatment was feasible, while still others were considered able to walk to the rear unaided. The triage nurse in the emergency room of a modern hospital, however, makes decisions on a different basis. Medical care is given first to the most serious (and perhaps unsalvagcable) eases. Health insurers also suggest a triage decision in which psychiatrie care will be available to the most ill (usually psychotic). but not to those mildly dysfunctional from the typical problems of ordinary life (the moderately depressed and the personality disorders).

Bioethics is a word that was coined in 1970 and defined as an interdisciplinary effort that combines biological knowledge and human values into a long-range perspective that calls for measures that would promote the survival of the human species.2· 5 Although originally cast in ecological terms, it was later defined more narrowly by Walters as "the branch of applied ethics which studies practices and developments in the biomédical fields."4 Somehow the short-term needs of individuals must be brought into balance with the long-term needs of the species; for example, the production of children (procreation) as a human value has to be examined in the light of genetics and demography. Applied bioethies now demands the consideration of available biological facts in all ethical decisions based on human values. It is a matterò!" situation ethics, with the "situation" adequately described in terms of available biological knowledge.1' Each case will involve unique individuals in unique circumstances and the oversimplified use of universal principles needs to be reexamined. The point has been made by Clements and Ciccone, who concluded that:

... all attempts lo derive medically useful values from inielleciuiil or cultural biases tnow labeled values) involve us in circular rcasuning . . . We urge luoking at the real world of consequences, at the individual situation, and at what we know scientifically about purpose and functions.6

It is not clear how triage was carried out in the mass bombings of World War II or in natural catastrophes. The process of triage was certainly carried out, but not designated as such, in an entirely different context just prior to 1973 when two pediatricians reported on their decisions tu withhold treatment in the ease of certain ncwborns.7 After noting that between 1940 and 1970 there was a 58111O decrease in the infant death rale in the United States, which they attributed to the installation of neonatal intensive care units (NICUs). they reported lhat of 299 consecutive deaths in a special care nursery 43 (14%) were related to withholding treatment. They described the kinds of defects and stated that parents and physicians concluded thai prognosis Cor meaningful life was extremely poor or hopeless. Their decision to report the data was based on the conclusion that (he issue had ?? be faced "for not to decide is an arbitrary and potentially devastating decision of default." Biological facts were used to help delineate the boundaries of "meaningful life." The same biological knowledge has applicalion lo psychiatric issues involving lowering of therapeutic goals and expectations in chronic schizophrenia, aggressive suicide prevention with Alzheimer's and Huntington's patients, and management of severe personality disorders.

Triage in the NICU suddenly changed in 1982 when one doctor and one set of parents decided in one particular case that a defective newborn infant…

Triage is a French word meaning sorting, sifting, or selecting. Il was applied in military medicine, where it involved "The sorting and firstaid treatment of battle casualties in collecting stations at the front before the evacuation to hospitals in the rear."1 It was understood that for some casualties nothing could be done, for some others treatment was feasible, while still others were considered able to walk to the rear unaided. The triage nurse in the emergency room of a modern hospital, however, makes decisions on a different basis. Medical care is given first to the most serious (and perhaps unsalvagcable) eases. Health insurers also suggest a triage decision in which psychiatrie care will be available to the most ill (usually psychotic). but not to those mildly dysfunctional from the typical problems of ordinary life (the moderately depressed and the personality disorders).

Bioethics is a word that was coined in 1970 and defined as an interdisciplinary effort that combines biological knowledge and human values into a long-range perspective that calls for measures that would promote the survival of the human species.2· 5 Although originally cast in ecological terms, it was later defined more narrowly by Walters as "the branch of applied ethics which studies practices and developments in the biomédical fields."4 Somehow the short-term needs of individuals must be brought into balance with the long-term needs of the species; for example, the production of children (procreation) as a human value has to be examined in the light of genetics and demography. Applied bioethies now demands the consideration of available biological facts in all ethical decisions based on human values. It is a matterò!" situation ethics, with the "situation" adequately described in terms of available biological knowledge.1' Each case will involve unique individuals in unique circumstances and the oversimplified use of universal principles needs to be reexamined. The point has been made by Clements and Ciccone, who concluded that:

... all attempts lo derive medically useful values from inielleciuiil or cultural biases tnow labeled values) involve us in circular rcasuning . . . We urge luoking at the real world of consequences, at the individual situation, and at what we know scientifically about purpose and functions.6

It is not clear how triage was carried out in the mass bombings of World War II or in natural catastrophes. The process of triage was certainly carried out, but not designated as such, in an entirely different context just prior to 1973 when two pediatricians reported on their decisions tu withhold treatment in the ease of certain ncwborns.7 After noting that between 1940 and 1970 there was a 58111O decrease in the infant death rale in the United States, which they attributed to the installation of neonatal intensive care units (NICUs). they reported lhat of 299 consecutive deaths in a special care nursery 43 (14%) were related to withholding treatment. They described the kinds of defects and stated that parents and physicians concluded thai prognosis Cor meaningful life was extremely poor or hopeless. Their decision to report the data was based on the conclusion that (he issue had ?? be faced "for not to decide is an arbitrary and potentially devastating decision of default." Biological facts were used to help delineate the boundaries of "meaningful life." The same biological knowledge has applicalion lo psychiatric issues involving lowering of therapeutic goals and expectations in chronic schizophrenia, aggressive suicide prevention with Alzheimer's and Huntington's patients, and management of severe personality disorders.

Triage in the NICU suddenly changed in 1982 when one doctor and one set of parents decided in one particular case that a defective newborn infant (Baby Doe) should be allowed to die without treatment. M-9 The case was basically no different from the 43 cases reported 9 years earlier, but the decision noi lo lreat is now so constrained by law (hat physicians have been reluctant to do anything other than to proceed with maximum intervention to avoid malpractice suits. Physicians, parents, attorneys, and cthicists all remain sharply divided on when and how to reach a decision noi (o treat.8 ?? Malpractice suils have indeed been brought for the opposite reason, ie, failure to advise abortion, or failure to inform prospective parents of their situation and their options.11

The process of triage represented the fundamental biologizing of medical decision-making and the inapplicabilily of abslract ethical theories. The requirement was to decide what was possible biologically, rather than exerting maximum effort on maximum injuries. Today, lhe medical profession seems to have dropped the concepì of triage completely, and many have adopted the policy of maximum mobilization of medical resources with no judgment of quality of life. This abrogation of responsibility has been forced upon lhe profession by the lay public, operaling without biological knowledge, and by the scrutiny of the legal profession, also without adequate biological knowledge. At the other end of the life cycle, public policy is moving to withhold treatment for the elderly, and is reluctant to pay for palliative care for the severely and chronically mentally ill (deinstitutrcmalization). Psychiatrists will be involved much more frequently in assessing an elderly patient's competence to refuse treatment or request an order not to resuscitate.

The current crisis in health care is made worse by increased malpractice suits coupled with increased monetary awards, either in the case of outright death, or in the case of handicapped life. Trieresponse of the medical profession has been to practice defensive medicine, which means to carry out all procedures that could possibly be relevant and to avoid the discussion of meaningful life.

The issue of meaningful life could be approached by applied bioothics if the medical community shared responsibility with the laypersons most closely in vol ved, and i I the lall er were more responsible.

The issue is relatively straightforward in the case of individuals making decisions about their own condition. If the prognosis is poor, the patient or failing elderly person should be given an honest description of the biological facts and the kind of life that is in prospect if maximum effort is expended. Patients should be given the option of no treatment and even the option of painless suicide if they are still able to make decisions for themselves. Psychiatric knowledge is very important in this process, as consult and liaison, to identify, eg, ambivalence, feelings of rejection, depression, or denial. Certainly the medical profession should noi proceed with maximum technology, taking no responsibility while at the same time noi sharing responsibility with the patient or those who want the best possible treatment for loved ones.

The situation becomes more complex when the decision is made by someone other than the one who will Jive or die. Choosing abortion or nontreatment for a handicapped newborn is a classic example of the controversies surrounding the concept of non-treatment in the absence of prospects for meaningful life.8·4 The present slate of affairs encourages non-decisions by both parents and pediatricians. If the parents and lhe physician shared lhe responsibility for the decision and the parents had to bear lhe major responsibility for the outcome, the common sense delineation uf meaningful life would not be delayed for long.

Going back to the 1973 report, while 43 (14%) of the total of 299 deaths were due to non-trealment, 256 l86í:'íO resulted from pathology that prevailed despite the treatment given. 7 From the standpoint of applied biocthics, the problem is not the 299 newborns (hat died, but the defective newborns that were treated and survived. What kind of survival was given them? An unreporled number of treated surviving infants are severely handicapped by "a myriad of congenital malformations that in previous times would have resulted in early death."7 Various manifestations of brain damage also persist. Al present these cases can be abandoned by their parents, who may have brought on extreme prematurity or defects by lhe use of alcohol, cigarettes, or drugs. Would it not be belter to put less emphasis on maintaining premature and defective infants in NICUs at fantastic cost, with possible abandonment and miserable survival, and stress the knowledge that could bring about a normal birth? Would it not be belter to abort a defective Ictus than to give birth to a permanently handicapped infant? It is time to reach a consensus on the criteria as to which defects can permit meaningful life at home or in an institution and which cannot.12

The bottom line in all of the cases involving issues of applied bioethics is responsibility. Decisions made on behalf of fetuses or newborn infants should be shared by physicians and by parents who have been properly informed as to the biological facts tn the individual case. When public facilities arc available to relieve parents of the responsibility of maintaining a defective child for life, the parents should be IuIIy informed as to the possibilities for meaningful life for their child in the available institution, where life for a severely defective child can come close to "a definition of hell."7·8 Again, the parents should bear the responsibility for their decision or non-decision, and lheir physician should bear the responsibility for advising them of their present and future options. It is here that psychiatric training should develop ways to help the pediatricians and the parents,11 Decisions made by terminally ill patients or their relatives should also take into account the biological facts in the individual case, and physicians have the responsibility of determining what is good medical practice. Again, psychiatric training can supply help to geriatric specialists and family systems. Triage in the field of heallh care may be unpleasant and difficult, but iI has been avoided for too long.

REFERENCES

1. Webster's Third International Dictionary. Springfield, Massachusetts, G & C. Merriam Co., 1965.

2. Potter VR: Bioethics, the science of survival. Perspect Biol Med 1970; 14:127-153.

3. Potter VR: Bioethics. Bridge to the Future. Englewood Cliffs, New Jersey, Prentice-Hall, 1971.

4. Walters L.: Bioethics as a field of ethics, in Beauchamp TL, Walters L (eds): Contemporary Issues in Bioethics, Belmont, California, Wadsworth, 1978. pp 48-51.

5. Fletcher JF: Situation Ethics: The New Morality. Philadelphia, Westminister Press, 1966.

6. Clements CD, Ciccone JR: Applied clinical ethics or universal principles. Hosp Community Psychiatry 1985; 36:121-123.

7. Duff RS, Campbell AGM: Moral and ethical dilemmas in the special-care nursery. N Engl J Med 1973; 289:890-894.

8. Weir RF: Selective Non-Treatment of Handicapped Newborns. Moral Dilemmas in Neonatal Medicine. New York, Oxford University Press, 1984.

9. Lyon J: Playing God in the Nursery New York, W. W. Norton, 1985.

10. Associated Press: Baby Doe treatment ordered. Wisconsin State Journal. Updated ruling as of April 16, 1985.

11. Otten AL: Wrongful life? Parents and newborns win new legal rights to sue for malpractice. Wall Street Journal, June 7, 1985.

12. Engelhardt HT Jr: Euthanasia and children: The injury of continued existence. J Pediatr 1973; 83:170-170.

13. Spitz RA: Hospitalism: An inquiry into the genesis of psychiatric conditions in early childhood. Psychoanal Study Child 1945: 1:53-74.

10.3928/0048-5713-19860701-07

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