September 1982 IV/1
MASKING ETHICAL DILEMMAS IN MEDICINE
"Confusion has risen in some professional circles and the public mind about the proper role of the psychiatrist in medicine and society. Being an expert in the science of human behavior tends to be equated with knowing which behavior is morally right. Psychiatrists are customarily called in to render opinions on what are in fact ethical and legal questions in schools, in courts, in prisons, and the military."
The above quotation summarizes a recent article in the New England Journal of Medicine. (1) According to the authors, primary physicians often call in psychiatrists for consultation, not realizing that the issues which prompt the call for consultation are ethical rather than psychiatric. Two serious difficulties result: 1) "In the process, unfortunately, a moral consideration of the proposed or expected actions and considerations of ethical dimensions of the case are often overlooked or ignored by both primary physician and psychiatrist;" and 2) "there is a danger in artificially demarcating physicians' roles in this way.. ...Such a approach militates against rather than in favor of, the biopsychosocial unity of medicine." While the clinical cases presented in the article illustrate that the aforementioned difficulties do at times occur, there are some ethical guidelines which will help both primary physicians and psychiatrists avoid these difficulties.
Identifying Ethical Issues
First of all, physicians must become adept at identifying medical decisions which have ethical implications. Lo and Schroeder offer an operational definition of an ethical issue in medicine: "one that involves a question of what one ought to do, rather than what is usually done or can be done, and that requires a resolution of value choices, as opposed to resolving merely factual or scientific matters." Another word for value is basic human need; thus a value choice involves or affects such things as health, love, life, truth, friendship, freedom, security, self-esteem, the ability to work, to relate to others, to serve others, and other important human goods. Hence, whenever a medical decision will affect a basic human need, then the medical decision implies a value or ethical decision. Clearly, there are few medical decisions of consequence which are value free.
Many of the ethical issues that arise in medicine are known to primary physicians as well as to other members of the medical team. Thus, discerning the presence of ethical issues is not always difficult, especially for health care professionals who follow the current literature. In the cases presented in the aforementioned article, the medical team seems to have called in a psychiatrist because there were differences of opinion between physician and patient in regard to the proper procedures. In all three cases, the primary physician attributed the difference of opinion to psychological problems. Actually, the differences were due to differing values on the part of the physician and the patient. Hence, the first task for the physician or medical team when differences of opinion arise is to determine whether it arises because of differing values. If this seems to be the case, then an ethical consultation is needed.
The Goal of the Ethical Consultation
In the case of the divergent opinions between physician and patient, the purpose of the consultation is not to make the patient agree with the opinion of the physician; rather, the purpose is to help the patient make a decision in accord with the patient's value system. Hence, ethical consultation must first of all aim at creating an atmosphere in which the patient's freedom is maximized. Unless the patient is freed from coercion and psychological determination, ethical discussion is useless. Until such an opening is achieved, the consultant must strive to keep value discussions at a minimum and not waste time with what seems to be ethical arguments but which in fact are only the expression of emotional conflict. Once the consultant is assured that the patient is sufficiently free to deal with an ethical decision, the next objective is to help the patient arrive at a decision which is at least subjectively good; that is, a decision in accord with the patient's honest conscience. If the consultant is convinced that this decision is not objectively good, that is, in accord with accepted conclusions of medical ethics, then he or she must help form such a decision.
The reason the consultant should first of all help the patient come to a subjectively honest decision is twofold: (1) because the patient always retains primary responsibility for health decisions; and (2) because the proximate norm of all moral decisions is the conscience of the person acting. The task of the consultant, however, does not stop with helping a person arrive at subjectively conscientious decisions. The fact that a decision is honest does not prevent it from being harmful to others or even to one who makes the decision when in fact it is an objectively wrong decision. Honest mistakes do not injure moral integrity, but they do have consequences which might injure the actor or others. Consequently, the consultant cannot be content simply to ratify decisions made by a patient if the decisions are clearly injurious to the patient or to someone else (for example, in decisions of suicide or murder). In such cases, the consultant has to do what is possible to help prevent harm, especially through discussion with the patient, even though the consultant must raise disturbing questions which ultimately go to the root of the patient's value system. Obviously the consultant must be very cautious about disturbing sick people in this manner, yet he or she should have the courage to do so when the patient's own behavior signals that such probing is necessary.
Selecting the Consultant
Given the goals of ethical consultation, a variety of competent people might perform the task. The primary physician might be the ethical counselor, the advantage being that the biopsychosocial unity of medical care would be evidenced. A psychiatrist might be called upon, the advantage being that he or she would be more adept by training at establishing the atmosphere of freedom that is needed in order to make conscientious ethical decisions. A member of the pastoral care team, trained in counseling, might be called upon, the advantage being that he or she is able to help the patient make value decisions in accord with conscience. Perhaps in some cases, all three persons might work in unison to help a patient and family reach a difficult decision. In any case, it seems that the recognition by the medical team that an ethical issue exists and the realization of the limited goals of ethical counseling are more important than which health care professional is chosen to act as ethical consultant.
Kevin O'Rourke, OP
Footnotes 1. "Psychiatric Consultation Masking Moral Dilemmas in Medicine," NEJM Sept. 2, 1982; Vol.307, N.10; pp.618-621.
2. "Frequency of Ethical Dilemmas in a Medical Inpatient Service, " Arch. Intern. Med. ; V.141, July 1981; pp.1062-1064.
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