Symposium on Psychiatry in Internal Medicine
The Ethics of Personal Medicine Chase Patterson Kimball, M.D.*
In this paper, I shall discuss the subject of medical ethics in terms of those values and qualities that are intrinsic to the profession of medicine and the individual engaged in its practice. Whereas we may find that there exist some similarities to the ethics of other professions and disciplines as well as to all aspects of human life, this emphasis on the intrinsic values may give us a better idea of what medical ethics is, as opposed to the application of moral and ethical systems derived from other disciplines, including theology and philosophy. Such traditions touch on the ethics of a specific profession to a limited extent. Within each profession, a value system unique to that profession evolves on the basis of the specific experiences of the generations that constitute that profession.
PERSONAL MEDICINE VERSUS PUBLIC MEDICINE With respect to medical ethics, there are two major parallel divisions within the health field, personal medicine and public medicine (health).5 Personal medicine is that aspect of medical practice that is based upon the personal rendering of care, diagnosis, and treatment, for the individual with a self-identified health problem. It is personal and most frequently conducted between a physician and a patient. Public medicine, on the other hand, is a corporate enterprise that includes, and at one time or another has been identified as, public health, preventive medicine, epidemiology, community health, environmental medicine, and, more recently, medical ecology. At this point in history, what has always been a tenuous balance between personal medicine and public medicine is emerging as a central issue in both areas, if only because they share increasingly the public concern and the health dollar. This concern is reflected further in the differences in ethical orientations between personal medicine as opposed to public medicine. In Western society at least, it has become increasingly obvious that private medicine occurs at an expense to the public sector. This issue is demonstrated both in what has become the public education of the physician as well as in the public support of many of the facilities that personal medicine utilizes in diagnosis and treatment. Consequently, the *Professor of Psychiatry and Medicine, University of Chicago, Chicago, Illinois
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increasing intrusion of public medicine into personal medicine is inevitable and will result in an increasing societal influence over what goes on in the personal sector. The issues of the regulation and distribution of health and medical resources, including the production and dispersement of physicians, have become issues of public concern and legislation. 3 These issues, including those such as population control, either by limited production or the limitation of life support systems, become issues of societal values as distinct from the values of the individual physician and his patient. These issues, which deserve more public debate, are often resolved by legislation on the basis of what has spontaneously evolved, rather than by deliberate attention to the ethics of the evolving problem, e.g., abortion. The resolution is based less on individual ethical concerns and is dictated more by societal exigencies out of which a new social morality may develop. Although this is not the major thesis of this paper, the ethics of personal medical care needs to be viewed against this backdrop. Specifically, the so-called ethics of medicine is being redressed by an impersonal social system concerned with statistics and numbers. The value system of the social system is frequently out of step with the ethics of personal medical care which is concerned with the individual ethical values of a patient coming with a specific need to a caring physician.
THE PHYSICIAN Since both the physician and the patient are also members of the larger society, it is inevitable that each alone and sometimes both together will find themselves in conflict between the ethics of personal medicine and the ethics of public medicine. For the emerging student of medicine today, a major ethical dilemma can be that of deciding toward which end of the spectrum his own values lead him. He needs to question which is most in accord with his own system of values, an orientation and investment in the personal care of the individual as opposed to involvement in a larger sphere where decisions based on problems affecting the lives of great numbers may only indirectly and nonspecifically touch upon the life of a given individual. This is perhaps the most vital decision that the emerging physician needs to make. It is a decision which is based primarily upon an individually derived ethics. Thus, the first ethical task of the physician is to review his or her own value system. This begins with a review of his own moral development and an acceptance of the point at which he has settled along a hypothetical evolutionary continuum of moral development. Piaget 8 has initiated such a scheme based upon his empirical observations of children, which Lawrence Kohlberg 6 has discussed in his paper. Such a scheme is not unlike that of Erickson's maturational one. 2 These stages of moral development are: 1. Orientation to punishment and reward and to physical and material power. 2. Hedonistic orientation with an instrumental view of human relations. Beginning notions of reciprocity, but with emphasis on exchange of favors-"You scratch my back and I'll scratch yours."
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3. "Good boy" orientation: seeking to maintain expectations and win approval of one's immediate group: morality defined by individual ties of relationship. 4. Orientation to authority, law, and duty to maintaining a fixed order, whether social or religious, which is assumed as a primary value. 5. Social-contract orientation, with emphasis on equality and mutual obligation within the democratically established order; e.g., the morality of the American Constitution. 6. Morality of individual principles of conscience that have logical comprehensiveness and universality. Highest value placed on human life, equality, and dignity.6
My own predilection is such that I see these essentially socially and cognitively conceptualized schemes as incomplete, as they do not include an affectually conceptualized scheme. An individual's value system is derived only in part from the external environment. It is the individual's personality which gives structure to his cognitive processes and conative acts. Whether one reaches a greater or lesser psychosexual stage of development, cognitive stage of abstraction, or social interactive stage of related ne ss with others will individually and together determine the level of maximum ethical functioning. Further research into the multiple factors affecting ethical development in the individual, as well as within a society, will assist us globally as well as individually to know the ethical base from which we start in our approach to both personal and public medicine. This, I submit is the primary ethical principle for the physician. It is not dissimilar to the old maxim, Physician, Know thyself!
PERSONAL MEDICINE Since the practice of personal medicine essentially involves two individuals, the possible interaction of two potentially different value systems must be considered. Perhaps this is what is hinted at, but not directly discussed, in our controversies about minority groups being treated by its own members. The assumption is that personal medicine is more likely to be more caring and, hence, more effective when the value systems of the physician and patient are more nearly the same. Whether or not this works out in practice may be another matter; personal medicine or even public medicine cannot be practiced without an intimate knowledge of the individual's background and personal habits.
Knowing The concept of empathy is a difficult one, and it is fiercely abused by many using it. It is perhaps important to pause here to consider it because I submit that it is intrinsic to the values of personal medicine. The standard definition of empathy involves the ability to put oneself in the other's shoes in an attempt to experience what he feels. I would rather see this complex term defined more in terms of the ability of the physician to sense and bring out the feelings of his patient and to communicate to his patient a sense of himself as also mortal and subject to similar discomforts. This is, of course, difficult to achieve and frankly ludicrous
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when there is a marked discrepancy between cultural and social backgrounds. In personal medicine, empathy is perhaps the third ethical principle, for without it, there can be no relationship and little attending.
Confidentiality With empathy and attending, the patient has the opportunity for expression of concerns and ventilation of feelings which are done with increasing freeness when the physician and patient are able to relax within the confidentiality of the relationship. This serves to overcome the initial reticence and inhibitions of each and provide an intimacy rare in most other human contacts. The stuff about which medical communications are made is entirely personal, whether factual, such as the description of a mass or pain, or subjective, such as a feeling. They are of the patient and belong to him; they are shared with the physician in the strictest confidence, without which they could be used wittingly or unwittingly to assure his vulnerability. This concept of confidentiality goes beyond signed permission to relate information communicated by the patient to the physician to others. Such consent must in no way lead to the compromise of confidentiality. What is communicated in a consent release must be objective and totally satisfactory to the patient. Furthermore, it is incumbent upon the physician to make his patient aware of any possible harm that the release of the information might cause him. Facilitation of Emotional Expression Part of the physician's duty is to release anxiety and fear that the suffering patient brings with him in his concern about himself. Part of this relief is obtained through the physician's ability to attend and empathize, and in so dOing, bring out as complete a story about the patient and his complaint as possible in an intimate and confidential setting. Through this opportunity, the patient not only more clearly identifies to the physician what his complaint is, but also does this for himself. The patient also begins to express his feelings, the anxieties, fears, sadness, guilt, and shame that are associated with illness. This aspect of the relationship is intrinsic to the ethical dimensions of the physician's role, for it is part of caring for the whole individual. It is a component that is increasingly compromised in the dilemma between public and private medicine.
Teaching When the relationship between patient and physician has evolved on the basis of the above dimensions, a new role is afforded the doctor, that of teacher.1° His obligation as a teacher becomes a fourth intrinsic ethical dimension. Health education is one of the areas in which personal medicine bridges with public medicine. It is a further way of alleviating anxiety by identifying for the patient what is known, regardless of the severity of the disorder. The identified illness then become something tangible with which the patient, in therapeutic alliance with the physician, can objectively approach and contend. What is ofimportance in the
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ethical conduct of the doctor is that both the physician and the patient see him as a teacher who can skillfully educate and instruct the latter in understanding the illness in terms of: Ca) those things that will affect it adversely or propitiously; Cb) what changes may be necessary in his personal, social, and professional life; and Cc) the effects this illness may have on significant others.
Informed Consent The role of physician as teacher is intimately related to informed consent. 1 Rather than using it as a defense, the physician uses education to inform the patient about the patient's illness and counsels him as to the directions or alternatives to follow. This is a mutual process inasmuch as the physician cannot lead unless the patient is willing to follow. The patient is not willing to follow unless he has developed confidence in the physician through the patient-physician relationship. This confidence will depend on the basic trust that each is capable of and which is intrinsic to the development of each. It is further nurtured or deviated by experiences with significant other helping individuals over the course of a life time. Trust and confidence rest on a candor and truth that is delivered in a neutral and appropriate way for the individuals involved. In the ideal situation, informed consent should represent not just the requisite signature of the patient on a piece of paper, but rather the mutual agreement of patient and physician to follow a course of action in terms of an illness that makes not only appropriate medical sense in terms of the biological considerations, but social and psychological sense in terms of the intrinsic responsibilities, goals, and other values of the individual.
Continuity The subsequent tasks of the doctor in his relationship with the patient which have ethical dimensions involve the maintenance of medical care through whatever adversities affect the relationship until the responsibility is transferred by mutual consent to another individual. Such maintenance of care implies availability, notification to the patient at times of absences, providing for an acceptable physician to substitute during these absences, and follow-up of the patient periodically whether or not the patient explicitly requests it. Whereas these might be considered part of the technical aspects of practice, they are based on an ethical commitment of the physician not only to the patient, but also to himself or herself.
ETHICS AS A CONCEPTUAL APPROACH The ethics of personal medical care represent an intrinsic part of the contract between patient and physician. As such, they represent an approach, rather than a rigid, systematic set of rules. The approach involves the posing of significant hypotheses as the relationship unfolds and the obtaining of objective data that will confirm or negate these hypotheses. In this way, the scientific method is an integral aspect of
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medical practice and its use is a fifth major ethical principle intrinsic to personal medical practice. It seems necessary at this time in history to stress that the scientific method is not nearly so much that of a process occurring at the wet bench in the laboratory where the emphasis is on a different kind of observational technique as it is a process of thinking about a patient at the bedside, in the consulting room and for many long hours thereafter.
PERSONAL VERSUS SOCIET AL ETHICS These questions, as I have indicated above, involve not only those relating to the biological problem, but those relating to all aspects of the life of the patient. A patient is only arbitrarily conceptualized in terms of various disciplines. Medicine uses these orientations in attempting to analyze the problem. But in approaching a problem medicine becomes synthetic and directs its treatment in terms of the patient. The individual's value system, which is as intrinsic a part of his life as any other arbitrarily isolated part, needs to be addressed in terms of what is acceptable or unacceptable in his life. In this situation, the physician, having instructed and aided the patient in analyzing, becomes a counselor who assists the patient in a decision-making process. One is reminded of the Hippocratic statement in Hippocrates' book of Aphorisms: "Life is short and the (healing) art is long; the opportunity (to administer remedies) fleeting, experiment is dangerous, the decision difficult" ... "One must not only do the right thing oneself, but make the patient and all about him concur" ... "You must not only do the proper thing, but do it at the right time."9 Such an approach introduces an uncomfortable relativism into medicine which will often lead to discomfort on the parts of both the physician and the patient. In order to avoid this, at least in the moments of illness, the physician first needs to be objective and comfortable with this relativism. He needs to see this as deriving from the situation at hand rather than in terms of prejudgments. In other words, he cannot assist in an individual decision regarding the care of an aged patient on the basis that he feels a useful life ends at 70. Such a bias, whatever its basis or potential merit in other considerations, is anathema to the resolution of the individual case in terms of the physician's ethic of conduct. On the other hand, this physician's view might have an ethical basis in a public medicine (health) policy in which a society or a world bases its potential for survival or some other derived value on the optimal care of the young, essentially at the expense of the aged patient. Many of the problems that have been identified as problems of medical ethics relate to a public medicine as opposed to personal medicine. They are not really intrinsic to personal medicine but derive from the values of a society that change over time and are ultimately based on the survival of that group or society (itself an ethical value). Thus, while there are ethical bases for the attitudes adopted toward population control (whether these be contraception, abortion, euthanasia for the defec-
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tive or aged, selection of patients for scarce resources, distribution of physicians, or suicide) these are of a societal nature and are only partially reflected, if at all, in the doctor-patient relationship and contract. The values reflected by a society's approach to such issues only indirectly reflect those of its individual members. They are pragmatic for that society's survival (in one sense or another) in the same way in which an individual's values may ultimately derive from a sense pragmatic for his own survival. It is of the utmost importance that neither the physician nor the patient confuse what might be identified as his societal ethic from that of a personal ethic that is based in a patient-doctor relationship. This is an ethic based on a fundamental belief in the autonomy of the life of the individual which is necessarily compromised in a social situation. This is not to say that there is no place for altruism in the individual's personal life in terms of decisions made about himself. There is every place for altruism and such an issue needs to be evaluated objectively with the physician in this relationship. This altruism, however, must be seen not only as derived partially from the sense of a societal altruism 10 but also as derived from an ethic based on the sense of self-integrity. It is when the patient's personal ethic comes in conflict with a societally derived ethic that the greatest dilemma for the physician is posed. In such situations, there inevitably comes a time when the physician draws the line between his actions based on a commitment to the patient and those based on his membership in society. Legal formulations aside, which is not to say they are without merit and do not reflect a societal position, the resolution remains that of the physician. Societally derived resolutions of ethical dilemmas may be more clearly addressed, especially if it is possible to derive the history of their ethical development. In the democracies of Western society, the evolution of ethics is toward allowing the maximum autonomy for individual decision-making which is compatible with equal autonomy for other affected or potentially affected individuals. There is, of course, more restraint than license in such a formulation. The ethics of a society, as I suggested before, probably relate to its (majority opinion) survival. Thus, ethics will reflect the changing values of a society based on its accommodation to a survival principle with as little (in a democratic society) imposition as possible on individual autonomy. On this level, a public medicine policy will be determined on the basis of broad social and political factors occurring over time, effecting change, first in societal and second in individual values. I do not believe that a humane physician cannot take part in these discussions of a public medicine policy. However, it should be apparent to him and to the public that this is at a different level and of another order than the ethics of personal medical care.
Value of Philosophical and Theological Contributions to Medical Ethics The practitioner of personal medicine may occasionally utilize the analytic modes fashioned by philosophical and theological traditions in
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exammmg some of the factors operating in his personal medicine decision-making activities. For instance, in personal medicine, it is questionable to what extent "a greatest good for the greatest number" principle should operate, if at all. In other words, the consequences of action based on such a principle would often be distinctly different for the individual vis Et vis the society.lo Similar, though more complex, is "the sanctity oflife" principle. One cannot go very far with this concept until such questions as the definition of humanness and the quality of life are raised. Immediately, we are on the verge of discordance between the possible answers forthcoming in terms of the quality of life of the individual in terms of the patient and the quality of that life as viewed in societal terms. We might extend this to suggest that we have little, if any, empirical data on the quality of life of the comatose individual inasmuch as we do not know what is going on in that life (mind). Yet we are influenced by societal definitions in accepting a value system that may frequently be at odds with that of the individual and of a personal medicine. Societal values place higher evidence on achievement, specific ages, health as opposed to illness, status (social, economic, position), creativity, fame, productivity, all of which may have little to do with a personal medicine which most often addresses individual illness, in the povertystricken and the disenfranchised. The physician may be frequently influenced in his care of patients by other factors such as pain and the degree of suffering. Particularly in our society, there is a sense that one should not have to suffer although other societies have acknowledged suffering as an obligatory part of daily living. However, around the patient with chronic illness, we have often developed a concept that one should not have to suffer and should be relieved of and even helped out of his misery. There is the possibility that such an emphasis may operate to a greater extent than it is generally thought to in the care of the patient. Most recently, we have before us the idea of a living will, defining under what circumstances the writer would no longer want to live. Beneath its candor is a certain absurdity in that until one has lived through something, one can not know it. There are many situations I have observed or been told about that I would not desire to live through, but as a physician caring for severely ill patients, I know that patients have had similar thoughts in a well state. This does not mean that they have the same thoughts in the present state or would have the same thoughts two weeks or six months from the present time in a partially rehabilitated state. A corollary of this type of thinking is the physician who would do for his patient what he would do for a member of his family or would want done for him. In the first instance, we need to ask how he can presume to know what another would want in terms of himself. In the second, we would need to ask, how does he know what he would want. A final ethical value for the physician is humility.
SOCIET AL VERSUS INDIVIDUAL ETHICS There is another area in which ethically derived principles of society conflict with individual ones. This dilemma is perhaps best joined in the
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issue of suicide in Western society. (In some societies, suicide has been societally accepted and probably reinforced.) The question of suicide as an individual right is, of course, first one based on legal rights. However, whether it is ethically right for one to commit suicide is another matter, inasmuch as suicide directly affects significant others as well as society as a whole. From a psychological perspective, we know that suicide frequently is directed at others as a way of bringing them discomfort. The consequences frequently are longer lasting and greater than one might suspect. The question here is not whether the individual needs to protect himself, in this case, his rights of autonomy, but whether society has a need to protect itself and others from the consequences of such an act. To what extent does society have a right to protect itself from an act of one of its members when that act may grievously distort the social structure by leading, as experience has shown in some instances, to a "wave of suicides" or a devaluation of life within that society? In a somewhat similar way, the societal attitudes toward abortion may be at variance with a personal ethics based on consequences, definitions of life, quality of life, etc., when abortion might threaten directly the survival (economic or actual) of a society or the "reverence for life" that society needs in order to conduct its affairs humanely. In these and other situations, the dilemma for the physician in personal medicine is frequently great, regardless of what his own value system may be inasmuch as at what point he can (should) desist from being the counselor of the patient and the protector of the state.
RETURNING TO PERSONAL MEDICINE In closing this deliberation, I return to the intrinsic ethics of personal medicine and consider the matter of intimacy. Perhaps, in no other relationship, is there the potential for as much intimacy as there is in the relationship of doctor and patient. Our attention is drawn to the Hippocratic Oath, a most contemporary document; it addresses the excesses and abuses of a personal medicine that are still with us. I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation: to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not in connec-
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tion with it, I see or hear, in the life of men, which ought not be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!9
Intimacy allows for the maximum of communication between physician and patient necessary for the accumulation of the empirical data upon which medicine is practiced. The physician has more access to the patient's mind and body than any other individual. This occurs at a time of distress when the patient is especially vulnerable. Such an individual is at maximum risk and vulnerable (willingly or unwillingly) to another. This intimacy is essential to the therapeutic situation if the patient is to receive maximum care and attention. Only in such a situation based on trust and confidence can the patient divulge the data necessary for the physician to attend to his needs. In doing so, the patient knowingly places himself at maximal risk. Essentially, he is exposing his defects and deficiencies which can be used by the physician in his societal role, wittingly or unwittingly to take advantage of the patient. This may occur through carelessness in matters of confidentiality, whether these be by leaving records around or by careless remarks. This degree of intimacy between physician and patient may take many forms. A physician can become overinvested in a patient's personal life and take it upon himself to advise in matters that go beyond his concern, knowledge and competence. Physicians may promise more than they or perhaps anyone else can realistically give in the way of emotional and social support. Physical intimacy with a patient is not uncommon, nor is it not understandable. Its roots are based on a mutuality between an individual (physician) wishing to give something "substantive" and a patient wishing to receive a tangible expression of care. The classical characterization of it is the laying on of hands. More rarely this may intimate and evolve into something more in terms of a fantasied or actual sexual activity. This was not unforeseen by Hippocrates and is still a matter of contemporary controversy in our profession. Despite attempts by some to give a therapeutic and even an ethical basis for such actions, it seems to me that this remains in complete violation of the implicit and explicit trust invested in the concept of the patient-physician relationship by all parties concerned, patients, physician and society. Intimacy is not one only of the physical but is one that transcends the usual ego boundaries between the individuals involved and, as such, again may appear seductive in promising more involvement than can possibly be maintained and/or infringes upon areas outside the competent concern of the physician. On the other hand, a patient in the course of treatment may violate the unwritten ethic of the relationship by intruding in one way or another into the personal life of the physician, a problem that always requires maximum delicacy and firmness in resolving. Over time it behooves the physician to acquire the experience and skill that will assist him in negotiating these situations. Lastly, intimacy is a rare privilege. Perhaps only the physician has the opportunity to share this relationship with many individuals. It
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serves to enhance his view of humanity and consequently has the potential for increasing his own humanity.
SUMMARY In this discussion, I have suggested that the ethics of personal medicine is intrinsic to the patient-physician relationship in matters of health and illness. In so doing, I have suggested that an ethical basis for a personal medicine is: (1) an awareness by the physician ofhis(her) motivations, abilities and competence; (2) the physician's ability to get to know as much about his/her patient as a person as he would about the complaint; (3) the physician's capacity for empathy that will facilitate (2); (4) the physician's ability to maintain the confidentiality of the doctor-patient relationship; (5) the physician's obligation to be a teacher to his(her) patient; (6) the physician's obligation to inform the patient of what (s)he is doing and is planning to do; (7) the physician's obligation to continue his (her) care of the patient; (8) the physician's commitment to a scientific (or analytic) approach to the patient and his(her) problems; (9) the physician's capacity for helping his (her) patient reach decisions most appropriate for that individual's illness and life; and (10) the physician's awareness of his (her) own humanness and limitations. Thus, I propose that medicine is a matter of ethics. Ethics in terms of the individual (patient or physician) is not a matter of cognitive processes alone, but also of an emotional tolerance of the individual for internal conflict between the cognitive and emotional aspects of the self as well as the external conflict between the resolved individual position, its conative acts, and society's.
REFERENCES 1. Beecher, H. K.: Medical research and the individual. In Life or Death: Ethics and Options. Seattle, University of Washington Press, 1968. 2. Erikson, E.: Eight ages of man. In Childhood and Society. New York, W. W. Norton & Co., 1963. 3. Hardin, G.: The tragedy of the commons. Science, 162:1243-1248,1968. 4. James, W.: The will to believe. Essays in Pragmatism. Hafner Publishing Co., New York, 1948. 5. Kass, L. R.: Regarding the end of medicine and the pursuit of health. The Public Interest, 40:11-42, Summer 1975. 6. Kohlberg, L.: A cognitive-developmental approach to moral education. The Humanist, Nov.lDec. 1972, pp. 13-16. 7. Mill, J. S.: Utilitarianism. In The English Philosophies From Bacon to Mill. The Modern Library, New York, 1939. 8. Piaget, J.: The Moral Judgment of the Child. Free Press, Glencoe, Illinois, 1948. 9. Taylor, H. 0.: Greek Biology and Medicine. Boston, Marshal! Jones, 1922, pp. 32, 34-36. 10. Tosteson, D.: The Right to Know: Public Education for Health. J. Med. Educ., 50:117123, 1975. 11. Wilson, E. 0.: Sociobiology: The New Synthesis. Cambridge, Harvard University Press, 1975. Department of Psychiatry 950 East 59th Street Chicago, Illinois 60637
The Ethics of Personal Medicine Chase Patterson Kimball, M.D.*
In this paper, I shall discuss the subject of medical ethics in terms of those values and qualities that are intrinsic to the profession of medicine and the individual engaged in its practice. Whereas we may find that there exist some similarities to the ethics of other professions and disciplines as well as to all aspects of human life, this emphasis on the intrinsic values may give us a better idea of what medical ethics is, as opposed to the application of moral and ethical systems derived from other disciplines, including theology and philosophy. Such traditions touch on the ethics of a specific profession to a limited extent. Within each profession, a value system unique to that profession evolves on the basis of the specific experiences of the generations that constitute that profession.
PERSONAL MEDICINE VERSUS PUBLIC MEDICINE With respect to medical ethics, there are two major parallel divisions within the health field, personal medicine and public medicine (health).5 Personal medicine is that aspect of medical practice that is based upon the personal rendering of care, diagnosis, and treatment, for the individual with a self-identified health problem. It is personal and most frequently conducted between a physician and a patient. Public medicine, on the other hand, is a corporate enterprise that includes, and at one time or another has been identified as, public health, preventive medicine, epidemiology, community health, environmental medicine, and, more recently, medical ecology. At this point in history, what has always been a tenuous balance between personal medicine and public medicine is emerging as a central issue in both areas, if only because they share increasingly the public concern and the health dollar. This concern is reflected further in the differences in ethical orientations between personal medicine as opposed to public medicine. In Western society at least, it has become increasingly obvious that private medicine occurs at an expense to the public sector. This issue is demonstrated both in what has become the public education of the physician as well as in the public support of many of the facilities that personal medicine utilizes in diagnosis and treatment. Consequently, the *Professor of Psychiatry and Medicine, University of Chicago, Chicago, Illinois
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increasing intrusion of public medicine into personal medicine is inevitable and will result in an increasing societal influence over what goes on in the personal sector. The issues of the regulation and distribution of health and medical resources, including the production and dispersement of physicians, have become issues of public concern and legislation. 3 These issues, including those such as population control, either by limited production or the limitation of life support systems, become issues of societal values as distinct from the values of the individual physician and his patient. These issues, which deserve more public debate, are often resolved by legislation on the basis of what has spontaneously evolved, rather than by deliberate attention to the ethics of the evolving problem, e.g., abortion. The resolution is based less on individual ethical concerns and is dictated more by societal exigencies out of which a new social morality may develop. Although this is not the major thesis of this paper, the ethics of personal medical care needs to be viewed against this backdrop. Specifically, the so-called ethics of medicine is being redressed by an impersonal social system concerned with statistics and numbers. The value system of the social system is frequently out of step with the ethics of personal medical care which is concerned with the individual ethical values of a patient coming with a specific need to a caring physician.
THE PHYSICIAN Since both the physician and the patient are also members of the larger society, it is inevitable that each alone and sometimes both together will find themselves in conflict between the ethics of personal medicine and the ethics of public medicine. For the emerging student of medicine today, a major ethical dilemma can be that of deciding toward which end of the spectrum his own values lead him. He needs to question which is most in accord with his own system of values, an orientation and investment in the personal care of the individual as opposed to involvement in a larger sphere where decisions based on problems affecting the lives of great numbers may only indirectly and nonspecifically touch upon the life of a given individual. This is perhaps the most vital decision that the emerging physician needs to make. It is a decision which is based primarily upon an individually derived ethics. Thus, the first ethical task of the physician is to review his or her own value system. This begins with a review of his own moral development and an acceptance of the point at which he has settled along a hypothetical evolutionary continuum of moral development. Piaget 8 has initiated such a scheme based upon his empirical observations of children, which Lawrence Kohlberg 6 has discussed in his paper. Such a scheme is not unlike that of Erickson's maturational one. 2 These stages of moral development are: 1. Orientation to punishment and reward and to physical and material power. 2. Hedonistic orientation with an instrumental view of human relations. Beginning notions of reciprocity, but with emphasis on exchange of favors-"You scratch my back and I'll scratch yours."
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3. "Good boy" orientation: seeking to maintain expectations and win approval of one's immediate group: morality defined by individual ties of relationship. 4. Orientation to authority, law, and duty to maintaining a fixed order, whether social or religious, which is assumed as a primary value. 5. Social-contract orientation, with emphasis on equality and mutual obligation within the democratically established order; e.g., the morality of the American Constitution. 6. Morality of individual principles of conscience that have logical comprehensiveness and universality. Highest value placed on human life, equality, and dignity.6
My own predilection is such that I see these essentially socially and cognitively conceptualized schemes as incomplete, as they do not include an affectually conceptualized scheme. An individual's value system is derived only in part from the external environment. It is the individual's personality which gives structure to his cognitive processes and conative acts. Whether one reaches a greater or lesser psychosexual stage of development, cognitive stage of abstraction, or social interactive stage of related ne ss with others will individually and together determine the level of maximum ethical functioning. Further research into the multiple factors affecting ethical development in the individual, as well as within a society, will assist us globally as well as individually to know the ethical base from which we start in our approach to both personal and public medicine. This, I submit is the primary ethical principle for the physician. It is not dissimilar to the old maxim, Physician, Know thyself!
PERSONAL MEDICINE Since the practice of personal medicine essentially involves two individuals, the possible interaction of two potentially different value systems must be considered. Perhaps this is what is hinted at, but not directly discussed, in our controversies about minority groups being treated by its own members. The assumption is that personal medicine is more likely to be more caring and, hence, more effective when the value systems of the physician and patient are more nearly the same. Whether or not this works out in practice may be another matter; personal medicine or even public medicine cannot be practiced without an intimate knowledge of the individual's background and personal habits.
Knowing The concept of empathy is a difficult one, and it is fiercely abused by many using it. It is perhaps important to pause here to consider it because I submit that it is intrinsic to the values of personal medicine. The standard definition of empathy involves the ability to put oneself in the other's shoes in an attempt to experience what he feels. I would rather see this complex term defined more in terms of the ability of the physician to sense and bring out the feelings of his patient and to communicate to his patient a sense of himself as also mortal and subject to similar discomforts. This is, of course, difficult to achieve and frankly ludicrous
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when there is a marked discrepancy between cultural and social backgrounds. In personal medicine, empathy is perhaps the third ethical principle, for without it, there can be no relationship and little attending.
Confidentiality With empathy and attending, the patient has the opportunity for expression of concerns and ventilation of feelings which are done with increasing freeness when the physician and patient are able to relax within the confidentiality of the relationship. This serves to overcome the initial reticence and inhibitions of each and provide an intimacy rare in most other human contacts. The stuff about which medical communications are made is entirely personal, whether factual, such as the description of a mass or pain, or subjective, such as a feeling. They are of the patient and belong to him; they are shared with the physician in the strictest confidence, without which they could be used wittingly or unwittingly to assure his vulnerability. This concept of confidentiality goes beyond signed permission to relate information communicated by the patient to the physician to others. Such consent must in no way lead to the compromise of confidentiality. What is communicated in a consent release must be objective and totally satisfactory to the patient. Furthermore, it is incumbent upon the physician to make his patient aware of any possible harm that the release of the information might cause him. Facilitation of Emotional Expression Part of the physician's duty is to release anxiety and fear that the suffering patient brings with him in his concern about himself. Part of this relief is obtained through the physician's ability to attend and empathize, and in so dOing, bring out as complete a story about the patient and his complaint as possible in an intimate and confidential setting. Through this opportunity, the patient not only more clearly identifies to the physician what his complaint is, but also does this for himself. The patient also begins to express his feelings, the anxieties, fears, sadness, guilt, and shame that are associated with illness. This aspect of the relationship is intrinsic to the ethical dimensions of the physician's role, for it is part of caring for the whole individual. It is a component that is increasingly compromised in the dilemma between public and private medicine.
Teaching When the relationship between patient and physician has evolved on the basis of the above dimensions, a new role is afforded the doctor, that of teacher.1° His obligation as a teacher becomes a fourth intrinsic ethical dimension. Health education is one of the areas in which personal medicine bridges with public medicine. It is a further way of alleviating anxiety by identifying for the patient what is known, regardless of the severity of the disorder. The identified illness then become something tangible with which the patient, in therapeutic alliance with the physician, can objectively approach and contend. What is ofimportance in the
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ethical conduct of the doctor is that both the physician and the patient see him as a teacher who can skillfully educate and instruct the latter in understanding the illness in terms of: Ca) those things that will affect it adversely or propitiously; Cb) what changes may be necessary in his personal, social, and professional life; and Cc) the effects this illness may have on significant others.
Informed Consent The role of physician as teacher is intimately related to informed consent. 1 Rather than using it as a defense, the physician uses education to inform the patient about the patient's illness and counsels him as to the directions or alternatives to follow. This is a mutual process inasmuch as the physician cannot lead unless the patient is willing to follow. The patient is not willing to follow unless he has developed confidence in the physician through the patient-physician relationship. This confidence will depend on the basic trust that each is capable of and which is intrinsic to the development of each. It is further nurtured or deviated by experiences with significant other helping individuals over the course of a life time. Trust and confidence rest on a candor and truth that is delivered in a neutral and appropriate way for the individuals involved. In the ideal situation, informed consent should represent not just the requisite signature of the patient on a piece of paper, but rather the mutual agreement of patient and physician to follow a course of action in terms of an illness that makes not only appropriate medical sense in terms of the biological considerations, but social and psychological sense in terms of the intrinsic responsibilities, goals, and other values of the individual.
Continuity The subsequent tasks of the doctor in his relationship with the patient which have ethical dimensions involve the maintenance of medical care through whatever adversities affect the relationship until the responsibility is transferred by mutual consent to another individual. Such maintenance of care implies availability, notification to the patient at times of absences, providing for an acceptable physician to substitute during these absences, and follow-up of the patient periodically whether or not the patient explicitly requests it. Whereas these might be considered part of the technical aspects of practice, they are based on an ethical commitment of the physician not only to the patient, but also to himself or herself.
ETHICS AS A CONCEPTUAL APPROACH The ethics of personal medical care represent an intrinsic part of the contract between patient and physician. As such, they represent an approach, rather than a rigid, systematic set of rules. The approach involves the posing of significant hypotheses as the relationship unfolds and the obtaining of objective data that will confirm or negate these hypotheses. In this way, the scientific method is an integral aspect of
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medical practice and its use is a fifth major ethical principle intrinsic to personal medical practice. It seems necessary at this time in history to stress that the scientific method is not nearly so much that of a process occurring at the wet bench in the laboratory where the emphasis is on a different kind of observational technique as it is a process of thinking about a patient at the bedside, in the consulting room and for many long hours thereafter.
PERSONAL VERSUS SOCIET AL ETHICS These questions, as I have indicated above, involve not only those relating to the biological problem, but those relating to all aspects of the life of the patient. A patient is only arbitrarily conceptualized in terms of various disciplines. Medicine uses these orientations in attempting to analyze the problem. But in approaching a problem medicine becomes synthetic and directs its treatment in terms of the patient. The individual's value system, which is as intrinsic a part of his life as any other arbitrarily isolated part, needs to be addressed in terms of what is acceptable or unacceptable in his life. In this situation, the physician, having instructed and aided the patient in analyzing, becomes a counselor who assists the patient in a decision-making process. One is reminded of the Hippocratic statement in Hippocrates' book of Aphorisms: "Life is short and the (healing) art is long; the opportunity (to administer remedies) fleeting, experiment is dangerous, the decision difficult" ... "One must not only do the right thing oneself, but make the patient and all about him concur" ... "You must not only do the proper thing, but do it at the right time."9 Such an approach introduces an uncomfortable relativism into medicine which will often lead to discomfort on the parts of both the physician and the patient. In order to avoid this, at least in the moments of illness, the physician first needs to be objective and comfortable with this relativism. He needs to see this as deriving from the situation at hand rather than in terms of prejudgments. In other words, he cannot assist in an individual decision regarding the care of an aged patient on the basis that he feels a useful life ends at 70. Such a bias, whatever its basis or potential merit in other considerations, is anathema to the resolution of the individual case in terms of the physician's ethic of conduct. On the other hand, this physician's view might have an ethical basis in a public medicine (health) policy in which a society or a world bases its potential for survival or some other derived value on the optimal care of the young, essentially at the expense of the aged patient. Many of the problems that have been identified as problems of medical ethics relate to a public medicine as opposed to personal medicine. They are not really intrinsic to personal medicine but derive from the values of a society that change over time and are ultimately based on the survival of that group or society (itself an ethical value). Thus, while there are ethical bases for the attitudes adopted toward population control (whether these be contraception, abortion, euthanasia for the defec-
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tive or aged, selection of patients for scarce resources, distribution of physicians, or suicide) these are of a societal nature and are only partially reflected, if at all, in the doctor-patient relationship and contract. The values reflected by a society's approach to such issues only indirectly reflect those of its individual members. They are pragmatic for that society's survival (in one sense or another) in the same way in which an individual's values may ultimately derive from a sense pragmatic for his own survival. It is of the utmost importance that neither the physician nor the patient confuse what might be identified as his societal ethic from that of a personal ethic that is based in a patient-doctor relationship. This is an ethic based on a fundamental belief in the autonomy of the life of the individual which is necessarily compromised in a social situation. This is not to say that there is no place for altruism in the individual's personal life in terms of decisions made about himself. There is every place for altruism and such an issue needs to be evaluated objectively with the physician in this relationship. This altruism, however, must be seen not only as derived partially from the sense of a societal altruism 10 but also as derived from an ethic based on the sense of self-integrity. It is when the patient's personal ethic comes in conflict with a societally derived ethic that the greatest dilemma for the physician is posed. In such situations, there inevitably comes a time when the physician draws the line between his actions based on a commitment to the patient and those based on his membership in society. Legal formulations aside, which is not to say they are without merit and do not reflect a societal position, the resolution remains that of the physician. Societally derived resolutions of ethical dilemmas may be more clearly addressed, especially if it is possible to derive the history of their ethical development. In the democracies of Western society, the evolution of ethics is toward allowing the maximum autonomy for individual decision-making which is compatible with equal autonomy for other affected or potentially affected individuals. There is, of course, more restraint than license in such a formulation. The ethics of a society, as I suggested before, probably relate to its (majority opinion) survival. Thus, ethics will reflect the changing values of a society based on its accommodation to a survival principle with as little (in a democratic society) imposition as possible on individual autonomy. On this level, a public medicine policy will be determined on the basis of broad social and political factors occurring over time, effecting change, first in societal and second in individual values. I do not believe that a humane physician cannot take part in these discussions of a public medicine policy. However, it should be apparent to him and to the public that this is at a different level and of another order than the ethics of personal medical care.
Value of Philosophical and Theological Contributions to Medical Ethics The practitioner of personal medicine may occasionally utilize the analytic modes fashioned by philosophical and theological traditions in
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exammmg some of the factors operating in his personal medicine decision-making activities. For instance, in personal medicine, it is questionable to what extent "a greatest good for the greatest number" principle should operate, if at all. In other words, the consequences of action based on such a principle would often be distinctly different for the individual vis Et vis the society.lo Similar, though more complex, is "the sanctity oflife" principle. One cannot go very far with this concept until such questions as the definition of humanness and the quality of life are raised. Immediately, we are on the verge of discordance between the possible answers forthcoming in terms of the quality of life of the individual in terms of the patient and the quality of that life as viewed in societal terms. We might extend this to suggest that we have little, if any, empirical data on the quality of life of the comatose individual inasmuch as we do not know what is going on in that life (mind). Yet we are influenced by societal definitions in accepting a value system that may frequently be at odds with that of the individual and of a personal medicine. Societal values place higher evidence on achievement, specific ages, health as opposed to illness, status (social, economic, position), creativity, fame, productivity, all of which may have little to do with a personal medicine which most often addresses individual illness, in the povertystricken and the disenfranchised. The physician may be frequently influenced in his care of patients by other factors such as pain and the degree of suffering. Particularly in our society, there is a sense that one should not have to suffer although other societies have acknowledged suffering as an obligatory part of daily living. However, around the patient with chronic illness, we have often developed a concept that one should not have to suffer and should be relieved of and even helped out of his misery. There is the possibility that such an emphasis may operate to a greater extent than it is generally thought to in the care of the patient. Most recently, we have before us the idea of a living will, defining under what circumstances the writer would no longer want to live. Beneath its candor is a certain absurdity in that until one has lived through something, one can not know it. There are many situations I have observed or been told about that I would not desire to live through, but as a physician caring for severely ill patients, I know that patients have had similar thoughts in a well state. This does not mean that they have the same thoughts in the present state or would have the same thoughts two weeks or six months from the present time in a partially rehabilitated state. A corollary of this type of thinking is the physician who would do for his patient what he would do for a member of his family or would want done for him. In the first instance, we need to ask how he can presume to know what another would want in terms of himself. In the second, we would need to ask, how does he know what he would want. A final ethical value for the physician is humility.
SOCIET AL VERSUS INDIVIDUAL ETHICS There is another area in which ethically derived principles of society conflict with individual ones. This dilemma is perhaps best joined in the
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issue of suicide in Western society. (In some societies, suicide has been societally accepted and probably reinforced.) The question of suicide as an individual right is, of course, first one based on legal rights. However, whether it is ethically right for one to commit suicide is another matter, inasmuch as suicide directly affects significant others as well as society as a whole. From a psychological perspective, we know that suicide frequently is directed at others as a way of bringing them discomfort. The consequences frequently are longer lasting and greater than one might suspect. The question here is not whether the individual needs to protect himself, in this case, his rights of autonomy, but whether society has a need to protect itself and others from the consequences of such an act. To what extent does society have a right to protect itself from an act of one of its members when that act may grievously distort the social structure by leading, as experience has shown in some instances, to a "wave of suicides" or a devaluation of life within that society? In a somewhat similar way, the societal attitudes toward abortion may be at variance with a personal ethics based on consequences, definitions of life, quality of life, etc., when abortion might threaten directly the survival (economic or actual) of a society or the "reverence for life" that society needs in order to conduct its affairs humanely. In these and other situations, the dilemma for the physician in personal medicine is frequently great, regardless of what his own value system may be inasmuch as at what point he can (should) desist from being the counselor of the patient and the protector of the state.
RETURNING TO PERSONAL MEDICINE In closing this deliberation, I return to the intrinsic ethics of personal medicine and consider the matter of intimacy. Perhaps, in no other relationship, is there the potential for as much intimacy as there is in the relationship of doctor and patient. Our attention is drawn to the Hippocratic Oath, a most contemporary document; it addresses the excesses and abuses of a personal medicine that are still with us. I swear by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation: to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further, from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not in connec-
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tion with it, I see or hear, in the life of men, which ought not be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!9
Intimacy allows for the maximum of communication between physician and patient necessary for the accumulation of the empirical data upon which medicine is practiced. The physician has more access to the patient's mind and body than any other individual. This occurs at a time of distress when the patient is especially vulnerable. Such an individual is at maximum risk and vulnerable (willingly or unwillingly) to another. This intimacy is essential to the therapeutic situation if the patient is to receive maximum care and attention. Only in such a situation based on trust and confidence can the patient divulge the data necessary for the physician to attend to his needs. In doing so, the patient knowingly places himself at maximal risk. Essentially, he is exposing his defects and deficiencies which can be used by the physician in his societal role, wittingly or unwittingly to take advantage of the patient. This may occur through carelessness in matters of confidentiality, whether these be by leaving records around or by careless remarks. This degree of intimacy between physician and patient may take many forms. A physician can become overinvested in a patient's personal life and take it upon himself to advise in matters that go beyond his concern, knowledge and competence. Physicians may promise more than they or perhaps anyone else can realistically give in the way of emotional and social support. Physical intimacy with a patient is not uncommon, nor is it not understandable. Its roots are based on a mutuality between an individual (physician) wishing to give something "substantive" and a patient wishing to receive a tangible expression of care. The classical characterization of it is the laying on of hands. More rarely this may intimate and evolve into something more in terms of a fantasied or actual sexual activity. This was not unforeseen by Hippocrates and is still a matter of contemporary controversy in our profession. Despite attempts by some to give a therapeutic and even an ethical basis for such actions, it seems to me that this remains in complete violation of the implicit and explicit trust invested in the concept of the patient-physician relationship by all parties concerned, patients, physician and society. Intimacy is not one only of the physical but is one that transcends the usual ego boundaries between the individuals involved and, as such, again may appear seductive in promising more involvement than can possibly be maintained and/or infringes upon areas outside the competent concern of the physician. On the other hand, a patient in the course of treatment may violate the unwritten ethic of the relationship by intruding in one way or another into the personal life of the physician, a problem that always requires maximum delicacy and firmness in resolving. Over time it behooves the physician to acquire the experience and skill that will assist him in negotiating these situations. Lastly, intimacy is a rare privilege. Perhaps only the physician has the opportunity to share this relationship with many individuals. It
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serves to enhance his view of humanity and consequently has the potential for increasing his own humanity.
SUMMARY In this discussion, I have suggested that the ethics of personal medicine is intrinsic to the patient-physician relationship in matters of health and illness. In so doing, I have suggested that an ethical basis for a personal medicine is: (1) an awareness by the physician ofhis(her) motivations, abilities and competence; (2) the physician's ability to get to know as much about his/her patient as a person as he would about the complaint; (3) the physician's capacity for empathy that will facilitate (2); (4) the physician's ability to maintain the confidentiality of the doctor-patient relationship; (5) the physician's obligation to be a teacher to his(her) patient; (6) the physician's obligation to inform the patient of what (s)he is doing and is planning to do; (7) the physician's obligation to continue his (her) care of the patient; (8) the physician's commitment to a scientific (or analytic) approach to the patient and his(her) problems; (9) the physician's capacity for helping his (her) patient reach decisions most appropriate for that individual's illness and life; and (10) the physician's awareness of his (her) own humanness and limitations. Thus, I propose that medicine is a matter of ethics. Ethics in terms of the individual (patient or physician) is not a matter of cognitive processes alone, but also of an emotional tolerance of the individual for internal conflict between the cognitive and emotional aspects of the self as well as the external conflict between the resolved individual position, its conative acts, and society's.
REFERENCES 1. Beecher, H. K.: Medical research and the individual. In Life or Death: Ethics and Options. Seattle, University of Washington Press, 1968. 2. Erikson, E.: Eight ages of man. In Childhood and Society. New York, W. W. Norton & Co., 1963. 3. Hardin, G.: The tragedy of the commons. Science, 162:1243-1248,1968. 4. James, W.: The will to believe. Essays in Pragmatism. Hafner Publishing Co., New York, 1948. 5. Kass, L. R.: Regarding the end of medicine and the pursuit of health. The Public Interest, 40:11-42, Summer 1975. 6. Kohlberg, L.: A cognitive-developmental approach to moral education. The Humanist, Nov.lDec. 1972, pp. 13-16. 7. Mill, J. S.: Utilitarianism. In The English Philosophies From Bacon to Mill. The Modern Library, New York, 1939. 8. Piaget, J.: The Moral Judgment of the Child. Free Press, Glencoe, Illinois, 1948. 9. Taylor, H. 0.: Greek Biology and Medicine. Boston, Marshal! Jones, 1922, pp. 32, 34-36. 10. Tosteson, D.: The Right to Know: Public Education for Health. J. Med. Educ., 50:117123, 1975. 11. Wilson, E. 0.: Sociobiology: The New Synthesis. Cambridge, Harvard University Press, 1975. Department of Psychiatry 950 East 59th Street Chicago, Illinois 60637
