Scot. med. J., 1977, 22: 248
MEDICAL ETHICS TODAY
Until comparatively recently 'medical ethics' -if thought about much at all-seems to have been regarded as the exclusive domain of doctors, a matter of the profession regulating the conduct of its members to ensure that patients and colleagues are honourably dealt with. Perhaps such a proclivity for washing dirty linen in private offers some justification for Shaw's jibe that professions are a 'conspiracy against the laity', but it is also quite understandable that the relevance of non-medical opinion is not perceived so long as the problems of medical ethics are seen solely in relation to the development of a professional ethos. 'Good professional conduct' is a somewhat intangible thing and is acquired (rather than explicitly taught) through contact in the clinical years with experienced members of the profession. In the minds of Englishmen (I say nothing of the Scots!) it is connected in some obscure way with cricket, with that intuitive sense of 'fair play' which eludes precise definition. Thus only those who know from experience the subtleties of the medical 'game' can help others to play it well. But the restriction of medical ethics to the self-regulation of professional conduct evades the discussion of more fundamental questions about the goals and the limits of medical care. In past generations it was felt to be antitherapeutic to raise doubts about the effectiveness of the doctor's ministrations. The required aura of godlike omniscience is well captured in the following instructions for professional conduct given in the American Medical Association's Ethical Code of 1847: 'Physicians should study also their deportment so as to unite tenderness with firmness and condescension with authority, so as to inspire the minds of their patients with gratitude, respect and confidence.' In our own time such self-confident paternalism is rare indeed. Not only are patients more articulate and better informed but doctors are becoming more aware of the limitations of purely medical interventions and many are willing to look outside their own profession for help in dealing with the increasingly difficult moral choices with which they are faced. When this happens, 'medical
ethics' is seen as a much broader subject and one which requires contributions from a variety of disciplines and perspectives. Over the past 10 years organisations have sprung up in both the U.K. and the U.S.A. devoted to the cause of the interdisciplinary study of medical ethics. As is usual in these cases, it is in the United States that the most luxuriant growth has occurred. There are 3 major organisations in the field (Towers, 1976): The Kennedy Centre for Bioethics (Georgetown University, Washington, D.C.), The Hastings Centre (623 Warburton Avenue, Hastings-on-Hudson, New York) and the Society for Health and Human Values (723 Witherspoon Building, Philadelphia). Moreover, in American medical schools and 'liberal arts' colleges, lectures, seminars and full courses in medico-moral problems are increasing to the point where there are already several hundred formal courses (Veatch & Fenner, 1975). In Britain developments have been slower and more tentative. The pioneering work of the London Medical Group in providing extra-curricular lectures and symposia in 'the moral issues arising from the practice of medicine' led to the gradual formation of similar groups in other medical centres. In 1972 the Society for the Study of Medical Ethics (Tavistock House East, Tavistock Square, London) was formed to act as the postgraduate section of the London Medical Group, and in April 1975 it commenced publication of the Journal of Medical Ethics. (The journal has theologians, lawyers, philosophers and sociologists on its editorial board, as well as a strong medical representation.) Interest in the teaching of medical ethics appears to be increasing in British medical schools. In its most recent questionnaire to deans the General Medical Council included a section specifically on this subject, and in Edinburgh a number of pilot schemes have already been launched by the Edinburgh. Medical Group Research Project in Medical Ethics and Education. To what extent is such a heightened interest in medical ethics likely to improve the quality of decision-making by those with whom clinical responsibility ultimately rests? Some aspects of the new-look inter-
Comments
disciplinary discussion suggest the need for caution. In the first place there is a danger that the new interest will merely spawn neologisms which do no more than describe old problems in impressive sounding jargon. In the USA 'bioethics' is the most common description for the subject area. The boundaries of this term are extremely ill-defined. If we take its root seriously it should embrace all life (bios), but it presumably intends to refer only to ethical issues in the 'life sciences' (a term which also lacks precision!). The problem of such neologisms is that they designate such a broad area of investigation that one is at a loss to know what are the appropriate methods of handling any particular issue. A related danger is that one academic method will make a takeover bid for this ill-defined interdisciplinary field. A likely reason for the medical reaction against 'bioethics' in the USA (see Clouser, 1975) is that philosophers and theologians have tended to dominate the discussion. As a result there has been a feeling that the subject is an alien, if not hostile, intruder on medical territory. This suspicion is increased by the emergence of a new profession, 'medical ethicist', with philosophers and theologians largely filling its ranks. In order to avoid these dangers 'medical ethics' should, in my opinion, always be seen as a description of a range of topics rather than as a name for a new academic discipline. This allows each participant to play a full part in the discussion without the need for some unifying 'metalanguage'. The language used must in fact continuously change depending on whether the topic is being viewed from the perspective of clinical practice, of philosophical analysis, or of ideas derived from law, theology or social work. The discussion can then be a genuine interdisciplinary exercise rather than the creation of some false synthesis. A consequence of such an approach to medical ethics is that the range of topics dealt with may be wide ranging, but the discussion will always retain a focus on decision-making in a clinical context (see Thompson, 1976). The current interest in the subject undoubtedly owes its origins to a
rising tide of concern about 'issues of life and death'. Changes in abortion laws and new techniques for prolonging life have brought with them decisions which are not purely technical. Doctors are looking for guidelines in an area full of fundamental questions: When does human life begin and when does it cease? Does the fetus have rights? Should the lives of severely deformed neonates be maintained? Should a person be entitled to authorise euthanasia for himself? A new set of questions, which raise broader social issues, are also coming to the forefront of the debate. These have been provoked by a growing awareness that no health service, however well organised and financed, can possibly meet the constantly expanding demands for health care (see Maxwell, 1975; Abel-Smith, 1976). Thus priority decisions must be made, and these in turn raise moral questions concerning the just distribution of a society's resources. Many doctors are unwilling to regard such political questions as relevant to medical ethics as such, arguing that the doctor's primary responsibility is to achieve the best possible treatment for those patients directly under his care. Yet it is becoming increasingly difficult to isolate clinical decision-making from its sociopolitical context. Since doctors are in a unique position to see the outcome of political decisions about health care priorities they have much to offer to the current debate. The participation of the profession in such discussions within the interdisciplinary context of medical ethics may take away from the suspicion that such canvassing for health priorities is merely a form of self-interested trade unionism. Conclusions It is undeniable that the subject matter of medical ethics is both expanding and changing at the present time. Some of these changes may not be for the better, if they result merely in the emergence of yet another speciality with its own private language. It is essential that medical ethics remain closely in touch with the realities of clinical decision making. On the other hand, the opening up of the subject to disciplines outside the medical curriculum may enrich the character 249
Comments
FURTHER READING SUGGESTED Journals Hastings Centre Report. (Bi-monthly). Institute of Society, Ethics and the Life Sciences, 360 Broadway, Hastings-on-Hudson, N.Y. 10706, U.S.A. Annual subscription: $18 (includes annual bibliography-see below). Journal of Medical Ethics (Quarterly). Society for the Study of Medical Ethics, Tavistock House East, Tavistock Square, London WCIH 9LG. Annual subscription: £12. Journal of Medicine and Philosophy (Quarterly). Society for Health and Human Values. Publisher: University of Chicago Press, 11030 Langley Avenue, Chicago, Illinois 606, U.S.A. Annual subscription : $15. Bibliographies New College, Mound Place, Edinburgh EHI 2LX Bibliography of Bioethics (Annual). (Complete listing and cross-referencing of all English language materials, including cassettes and films, commencing REFERENCES calendar year 1973). Compiled by Centre for BioAbel-Smith, B. (1976). Value for Money in Health ethics, Kennedy Institute, Georgetown University, Services. London: Heinemann Washington, D.C. Publisher: Gale Research Co., Detroit, U.S.A. Clouser, K. D. (1976). Medical ethics: some uses, Bioethics Digest (Monthly). (Summaries of current abuses and limitations. Arizona Medicine, 33, 44 literature in books, journals, newspapers and official reports). Information Planning Associates: P.O. Box Maxwell, R. (1974). Health Care: The Growing 1523, Rockville, Maryland 20850, U.S.A. Dilemma. New York: McKinsey & Co. Bibliography of Society, Ethics and the Life Sciences (Annual). (Selected bibliography of books and journal Thompson, I. E. (1976). Implications of medical ethics articles, with some annotations). Hastings Centre, 360 for ethics in general. Journal of Medical Ethics, 2, 74 Broadway, Hastings-on-Hudson, N.Y. 10706, U.S.A. General Textbooks Towers, B. (1976). Report from America. Journal of Campbell, A. V. (1975). Moral Dilemmas in Medicine Medical Ethics, 2, 97 Second edition. Edinburgh: Churchill Livingstone. Haring, B. (1973). Medical Ethics. Slough: St. Paul Veatch, R. M., Fenner, D. (1975). The teaching of Publications. medical ethics in the USA. Journal of Medical Ramsey, P. (1970). The Patient as Person. New Haven: Ethics, 1, 99 Yale University Press.
of the discussion and broaden its range to include some of the more intransigent questions of social policy which underlie the provision of medical care in modern society. In whatever direction the subject goes, one may hope that it will help to achieve that end laid down as long ago as Hippocrates: the benefit of patients. However complex the means now employed in medical practice, this must remain the aim of all medical interventions. REV. DR. A. V. CAMPBELL,
250
MEDICAL ETHICS TODAY
Until comparatively recently 'medical ethics' -if thought about much at all-seems to have been regarded as the exclusive domain of doctors, a matter of the profession regulating the conduct of its members to ensure that patients and colleagues are honourably dealt with. Perhaps such a proclivity for washing dirty linen in private offers some justification for Shaw's jibe that professions are a 'conspiracy against the laity', but it is also quite understandable that the relevance of non-medical opinion is not perceived so long as the problems of medical ethics are seen solely in relation to the development of a professional ethos. 'Good professional conduct' is a somewhat intangible thing and is acquired (rather than explicitly taught) through contact in the clinical years with experienced members of the profession. In the minds of Englishmen (I say nothing of the Scots!) it is connected in some obscure way with cricket, with that intuitive sense of 'fair play' which eludes precise definition. Thus only those who know from experience the subtleties of the medical 'game' can help others to play it well. But the restriction of medical ethics to the self-regulation of professional conduct evades the discussion of more fundamental questions about the goals and the limits of medical care. In past generations it was felt to be antitherapeutic to raise doubts about the effectiveness of the doctor's ministrations. The required aura of godlike omniscience is well captured in the following instructions for professional conduct given in the American Medical Association's Ethical Code of 1847: 'Physicians should study also their deportment so as to unite tenderness with firmness and condescension with authority, so as to inspire the minds of their patients with gratitude, respect and confidence.' In our own time such self-confident paternalism is rare indeed. Not only are patients more articulate and better informed but doctors are becoming more aware of the limitations of purely medical interventions and many are willing to look outside their own profession for help in dealing with the increasingly difficult moral choices with which they are faced. When this happens, 'medical
ethics' is seen as a much broader subject and one which requires contributions from a variety of disciplines and perspectives. Over the past 10 years organisations have sprung up in both the U.K. and the U.S.A. devoted to the cause of the interdisciplinary study of medical ethics. As is usual in these cases, it is in the United States that the most luxuriant growth has occurred. There are 3 major organisations in the field (Towers, 1976): The Kennedy Centre for Bioethics (Georgetown University, Washington, D.C.), The Hastings Centre (623 Warburton Avenue, Hastings-on-Hudson, New York) and the Society for Health and Human Values (723 Witherspoon Building, Philadelphia). Moreover, in American medical schools and 'liberal arts' colleges, lectures, seminars and full courses in medico-moral problems are increasing to the point where there are already several hundred formal courses (Veatch & Fenner, 1975). In Britain developments have been slower and more tentative. The pioneering work of the London Medical Group in providing extra-curricular lectures and symposia in 'the moral issues arising from the practice of medicine' led to the gradual formation of similar groups in other medical centres. In 1972 the Society for the Study of Medical Ethics (Tavistock House East, Tavistock Square, London) was formed to act as the postgraduate section of the London Medical Group, and in April 1975 it commenced publication of the Journal of Medical Ethics. (The journal has theologians, lawyers, philosophers and sociologists on its editorial board, as well as a strong medical representation.) Interest in the teaching of medical ethics appears to be increasing in British medical schools. In its most recent questionnaire to deans the General Medical Council included a section specifically on this subject, and in Edinburgh a number of pilot schemes have already been launched by the Edinburgh. Medical Group Research Project in Medical Ethics and Education. To what extent is such a heightened interest in medical ethics likely to improve the quality of decision-making by those with whom clinical responsibility ultimately rests? Some aspects of the new-look inter-
Comments
disciplinary discussion suggest the need for caution. In the first place there is a danger that the new interest will merely spawn neologisms which do no more than describe old problems in impressive sounding jargon. In the USA 'bioethics' is the most common description for the subject area. The boundaries of this term are extremely ill-defined. If we take its root seriously it should embrace all life (bios), but it presumably intends to refer only to ethical issues in the 'life sciences' (a term which also lacks precision!). The problem of such neologisms is that they designate such a broad area of investigation that one is at a loss to know what are the appropriate methods of handling any particular issue. A related danger is that one academic method will make a takeover bid for this ill-defined interdisciplinary field. A likely reason for the medical reaction against 'bioethics' in the USA (see Clouser, 1975) is that philosophers and theologians have tended to dominate the discussion. As a result there has been a feeling that the subject is an alien, if not hostile, intruder on medical territory. This suspicion is increased by the emergence of a new profession, 'medical ethicist', with philosophers and theologians largely filling its ranks. In order to avoid these dangers 'medical ethics' should, in my opinion, always be seen as a description of a range of topics rather than as a name for a new academic discipline. This allows each participant to play a full part in the discussion without the need for some unifying 'metalanguage'. The language used must in fact continuously change depending on whether the topic is being viewed from the perspective of clinical practice, of philosophical analysis, or of ideas derived from law, theology or social work. The discussion can then be a genuine interdisciplinary exercise rather than the creation of some false synthesis. A consequence of such an approach to medical ethics is that the range of topics dealt with may be wide ranging, but the discussion will always retain a focus on decision-making in a clinical context (see Thompson, 1976). The current interest in the subject undoubtedly owes its origins to a
rising tide of concern about 'issues of life and death'. Changes in abortion laws and new techniques for prolonging life have brought with them decisions which are not purely technical. Doctors are looking for guidelines in an area full of fundamental questions: When does human life begin and when does it cease? Does the fetus have rights? Should the lives of severely deformed neonates be maintained? Should a person be entitled to authorise euthanasia for himself? A new set of questions, which raise broader social issues, are also coming to the forefront of the debate. These have been provoked by a growing awareness that no health service, however well organised and financed, can possibly meet the constantly expanding demands for health care (see Maxwell, 1975; Abel-Smith, 1976). Thus priority decisions must be made, and these in turn raise moral questions concerning the just distribution of a society's resources. Many doctors are unwilling to regard such political questions as relevant to medical ethics as such, arguing that the doctor's primary responsibility is to achieve the best possible treatment for those patients directly under his care. Yet it is becoming increasingly difficult to isolate clinical decision-making from its sociopolitical context. Since doctors are in a unique position to see the outcome of political decisions about health care priorities they have much to offer to the current debate. The participation of the profession in such discussions within the interdisciplinary context of medical ethics may take away from the suspicion that such canvassing for health priorities is merely a form of self-interested trade unionism. Conclusions It is undeniable that the subject matter of medical ethics is both expanding and changing at the present time. Some of these changes may not be for the better, if they result merely in the emergence of yet another speciality with its own private language. It is essential that medical ethics remain closely in touch with the realities of clinical decision making. On the other hand, the opening up of the subject to disciplines outside the medical curriculum may enrich the character 249
Comments
FURTHER READING SUGGESTED Journals Hastings Centre Report. (Bi-monthly). Institute of Society, Ethics and the Life Sciences, 360 Broadway, Hastings-on-Hudson, N.Y. 10706, U.S.A. Annual subscription: $18 (includes annual bibliography-see below). Journal of Medical Ethics (Quarterly). Society for the Study of Medical Ethics, Tavistock House East, Tavistock Square, London WCIH 9LG. Annual subscription: £12. Journal of Medicine and Philosophy (Quarterly). Society for Health and Human Values. Publisher: University of Chicago Press, 11030 Langley Avenue, Chicago, Illinois 606, U.S.A. Annual subscription : $15. Bibliographies New College, Mound Place, Edinburgh EHI 2LX Bibliography of Bioethics (Annual). (Complete listing and cross-referencing of all English language materials, including cassettes and films, commencing REFERENCES calendar year 1973). Compiled by Centre for BioAbel-Smith, B. (1976). Value for Money in Health ethics, Kennedy Institute, Georgetown University, Services. London: Heinemann Washington, D.C. Publisher: Gale Research Co., Detroit, U.S.A. Clouser, K. D. (1976). Medical ethics: some uses, Bioethics Digest (Monthly). (Summaries of current abuses and limitations. Arizona Medicine, 33, 44 literature in books, journals, newspapers and official reports). Information Planning Associates: P.O. Box Maxwell, R. (1974). Health Care: The Growing 1523, Rockville, Maryland 20850, U.S.A. Dilemma. New York: McKinsey & Co. Bibliography of Society, Ethics and the Life Sciences (Annual). (Selected bibliography of books and journal Thompson, I. E. (1976). Implications of medical ethics articles, with some annotations). Hastings Centre, 360 for ethics in general. Journal of Medical Ethics, 2, 74 Broadway, Hastings-on-Hudson, N.Y. 10706, U.S.A. General Textbooks Towers, B. (1976). Report from America. Journal of Campbell, A. V. (1975). Moral Dilemmas in Medicine Medical Ethics, 2, 97 Second edition. Edinburgh: Churchill Livingstone. Haring, B. (1973). Medical Ethics. Slough: St. Paul Veatch, R. M., Fenner, D. (1975). The teaching of Publications. medical ethics in the USA. Journal of Medical Ramsey, P. (1970). The Patient as Person. New Haven: Ethics, 1, 99 Yale University Press.
of the discussion and broaden its range to include some of the more intransigent questions of social policy which underlie the provision of medical care in modern society. In whatever direction the subject goes, one may hope that it will help to achieve that end laid down as long ago as Hippocrates: the benefit of patients. However complex the means now employed in medical practice, this must remain the aim of all medical interventions. REV. DR. A. V. CAMPBELL,
250
