Many years ago, Crane Brinlon distinguished between two types of knowledge: knowledge that is cumulative and knowledge that is noncumulative. The contributions of science are characteristic of cumulative knowledge. The physical and biologic sciences are essentially an accumulation of observations tested and re tested over many centuries.
Noncumulalive knowledge is best illustrated from the field of literature. Over 200Ü years ago, men of letters were writing about men, their ideas and practices, and their relationships with other men. Contemporary men of letters are writing about the same things, essentially with no accumulated body of knowledge about these matters.1 This distinction is clearly evident in the difference between the traditional noncumulative body of knowledge about medical ethics, reached through deductive means with the attempts on the part of those who use scientific thinking, thus creating a common method for science and values. The latter uses inductive methods to accumulate knowledge.
In an earíicr study, an attempt was made to recount historically the several dramatic incidents that have led to the remarkable increase in interest in the field of medical ethics.2 In the past 2 decades, there has been an exponential increase in the number of published essays and studies. In spite of all this, one is reminded of André Gide's remark, "It has all been said before, but it must be said again, since no one listens." In this issue oí Psychiatric Annals, the contributors, each in his or her way, present succinct and vigorous statements in supporting a scientific approach to medical ethics.
Joseph FIetcher can lay claim to being the original pioneer of secular medical ethics, although his initial work was as a Protestant theologian. Before his work, there was a long tradition of Roman Catholic medical ethics based on the theological perspective that combined, through Thomas Aquinas, early Christian beliefs and the philosophy of Aristotle; but except for medical codes of ethics which emphasize the obligations of physicians to colleagues, and the Hippocratie corpus, which had not been systematically applied to modern medicine, there was no body of literature that theoretically and practically addressed the problems of medicine from a nonreligious perspective.
In this issue, Flcteher submits a ease history in which he outlines the moral guideline, which he calls "situation ethics." The decision as to what is good or right is dependent upon what the actual situation indicates for the mosi beneficial course to follow. In this sense it is an inductive approach, dependent upon the accumulation of informed data. This differs from the traditional method, which would apply some abstract principle derived from a generalization about what is usually, or typically, the right thing io do in a class or category of similar cases.
Colleen Clements, a philosopher with considerable scholarship in the field of medical ethics, draws attention to the origin of the specialty of secular medical ethics in the 1950s. She emphasizes the noncumulalive and deductive nature of traditional ethics. She points out that biological science is value-free in the sense that it is a method for correcting prejudice and error and, furthermore, thai science is value-generating because it can give us an understanding of what is good specifically for human beings.
J. Richard Ciccone, from his extensive experience in psychiatric forensic work, outlines clearly the issues relating to the insanity defense. He, too, emphasizes the need for an inductive and cumulative acquisition of data that will enable the psychiatrist to advise a court concerning the responsibility of the accused. Perhaps more than other physicians, the psychiatrist has not only learned the prodigious variability of human behavior, but also the need tu learn the significant events in the life course of the person that contribute to current behavior. It is for this reason thai the psychiatrist has had to develop modes of observation appropriate to the task of understanding behavior. Many years ago, David Shakow pointed out that medicine, as it includes biology and behavioral science, involves the observation of human beings by other human beings. This makes necessary not only the need to acquire skills in traditional objective observation, but also in those of" participant, subjective, and self-observation.5
Van Rensselaer Potter insists that the bottom line in all of the cases involving issues of applied bioethics is responsibility. More particularly, he emphasizes most sensibly that decisions made on behalf of t cluses or newborn infants should be shared by physicians and parents who have been properly and adequately informed as to the biological facts in the individual ease.
Kenneth Mark Colby, a psychiatrist and pioneer in the field of artificial intelligence, gives the coup de grâce to the notion that the method of computerassisted psychotherapy is dehumanizing. He has found that the use of this method is consistent with the ethics of helping professions that attempt to provide effective and up-to-date care exiendible to everyone in our society. Somewhat wryly, he states, "In the long run. it is what patients and therapists find acceptable and valuable that will determine the adoption of an innovative technology, regardless of what 'humanists' may decry (often, ironically on television)."
Roger Sider, in his major concern with the education of our medical students and tomorrow's psychiatrists, describes eloquently the confused setting in which f he psychiatric resident attempts to determine the proper management and care of his patient as the latter comes to. or is brought to, the emergency room. He believes thai much of medical ethics over the past 2 decades has been principally concerned with the fundamental reshaping of the patient-physician relationship in which the physician is viewed as (he purveyor of technical services, with the patient as the client. Sider describes the current model, an egalitarian consumer model, which is used to secure the value of patient autonomy and is supported by appeals to "right of treatment," "right to refuse treatment." and the specification of informed consent, He presents in detail the basic assumptions of the model.
There is no question that there has taken place an erosion of the authority, and with it the responsibility and accountability of the physician. The pervasive consumer movement, as well as the residuals of the student anti-authority, anti-intellectual movement of the late 1960s, has contributed to this state. As Sider points out, the current movement insists on the existential freedom and autonomy of the person (in this ease, the patient) in making his own decisions about his health care. This had led to what Trosko has called the "Pontius Piiate" syndrome of the physician; he washes his hands of responsibility.4
Quite understandably, the determinants of this movement are complex and manifold. Let me cite briefly the social and scientific forces that have brought about these changes in our prolession and in our society: the increase in the relative and absolute number of specialists; the exponential development of new medical technology; the rise of medical insurance and reimbursement by third parties; the increase in the total number of doctors due to the expansion of medical schools and the parallel increase in the paraprofcssional and nonprofessional participants in the health field; the recent government sanction of professional advertising; and the takeover of medicai control by a new industry of for-profit health care conglomerates. With the considerable burden of indebtedness of medical students upon graduation and with the spectre of oppressive malpractice insurance premiums, there is a tendency to choose specialty careers that will ensure high income or to look to the security of salaried positions with guaranteed practices and income, which is available in a broad repertory of incorporated structures. Furthermore, there are continuing probing inquiries that ask whether the high cost of health care is yielding a proportional benefit in health.
Public skepticism of the highly technical nature of medical practice and the emotional distance that has grown between the patient and the doctor as the technology has become more powerful also contribute to a new focus on functional objectives and the concept of the quality of life. Through public education, the public is told that its everyday behavior is related to major causes of morbidity and mortality: excessive cigarette smoking, heavy alcohol use, risky driving, peculiar and junk food diets, indiscriminate use of drugs (prescribed, overthe-counter, and under-the-counter), lack of or excessive physical excercisc. and narrowing of the social network of the person. All these are behavioral phenomena, now taddishly called "lifestyle." This movement stresses individual responsibility for help. Some are concerned that the more one looks at the individual's responsibility for his state of health (and no one else's). the less there appears to be a rationale for a collective response for the provision of medical care.
The psychiatrist is in an advantageous position to contribute toward a more scientific bioethics because of his encompassing interest in human as well as infrahuman biology. As Colleen Clements concludes, the psychiatrist's science and his values can be integrated in a common life science method that gives probable truth in an interdiscipline of medico-biocthics.
1 Brinton C: Ideas and Men A History of Western Man. New York Prentice-Hall. 1950.
2. Romano J: Reflections on informed consent. Arch Gen Psychiatry 1474: 30: 129-135.
3. Shakow D. m Cope O: Man. Mind, and Medicine. Philadelphia. J.B. Lippincott Co., 1968, p 133.
4 Trosko JE: Scientific views of human nature Implications for the ethics of technological intervention, in Broch DH (ed); The Culture of Biomedicine; Studies in Science und Culture. Cranberry. New Jersey, University of Delaware Press. 1484. vol 1.