"Ethicogenesis": Response to the Articles "Consultation-Liaison
Psychiatry and the Teaching of Ethics," by J. R. McCartney, and "Consultation-Liaison
Psychiatry and Clinical Ethics," by J. R. Hayes
Harold Bursztajn, M.D.
Assistant Clinical Professor of Psychiatry, Harvard Medical School;
Co-Director, Program in Psychiatry and the Law, Massachusetts Mental
Health Center
General Hospital Psychiatry, 8, 422-424, 1986
Drs. Hayes and McCartney in their articles have performed a vital service
in, respectively, clarifying the depth of the wish for clinical certainty
in ethically conflictual decisions and the cost of attempting to attain
it. Before commenting on their work, I want to state that the compassion
and concern of each for the patient and doing what is ethical and clinical
comes across loud and clear. Such compassion and concern deserve to be
nourished by any academic department of psychiatry, especially one involved
in training residents as consultants to other health care professionals.
Dr. Hayes takes up the challenge, so importantly elucidated by Dr. Perl
in his earlier work, of how should the psychiatrist respond when the
request for consultation masks a request for help in resolving a moral
dilemma [1]. Although finding the earlier answer suggested
by Dr. Perl and his colleague "inadequate" insofar as it focuses
on the suggestion that "the psychiatrist's appropriate role is in
facilitating autonomous decision-making by the patient," Dr. Hayes
chooses to remedy the situation by identifying "the emotional tension
behind the consult ... [as being] because physicians and patients have
no knowledge of a process whereby the most ethically sound decision can
be made" [2]. Unfortunately Dr. Hayes's good intentions
founder as on further reading we find that in his wish to offer concrete
solutions, leading to definitive answers, he reduces the richness of
process, of the necessary dialogue involving the building of a therapeutic
doctor-treatment team-patient-family alliance, which must evolve during
the exploration of the ethical conflict, to a series of stepwise considerations
according to one of two models. For Dr. Hayes the psychiatrist's function
is to "insist on stepwise consideration of the categories" [2].
No doubt, such an approach "often restores order, calms emotions
and allows acceptable resolution" [2]. And no doubt,
from the standpoint of the treatment team, busy as it is with the problems
of treating all patients on a unit, such a solution has the prima facie
virtues of certainty, decisiveness, and expediency as far as allowing
the team to come together, and turn its attention to the treatment of
other patients. However, the costs of such an approach are paid by the
way the patient is experienced. We can see this by looking at the case
example selected by Dr. Hayes.
Dr. Hayes's example is that of an elderly comatose woman. We are told
that her husband disagrees with the treatment team and there are no other
psychosocial data included. Why not? Is it perhaps because in the formal
schemata advocated, there is little room for individuality, for particularity,
if certainty is to be achieved? Moreover, although process is emphasized
in the introduction, the case description neglects to mention time! This
timelessness, a characteristic of formal systems in the natural sciences,
leaves little room for the dynamism of the human drama to which the psychiatrist
is called on as a participant-observer. Dr. Hayes's psychiatrist is more
of a classical mathematician, offering a timeless proof bereft of intuition,
designed to calm the emotions by offering a solution arrived at in a
stepwise fashion, which others can accept or reject, but not create.
The system of proof itself is given by the models, and the sequence of
steps they suggest is not open to question, challenge, or intuition.
We now know that even the process of mathematical proof does not have
the degree of timelessness, certainty, or impoverishment of intuition
that Dr. Hayes offers us in his application of the schematas to the case
example! [4]
Dr. Hayes proceeds to reassure us that "with supportive interventions
the husband accepted the medical decision. His mental capacity was not
an issue in this decision" [2]. Indeed! The husband
is treated in the case description as having only two mental capacities—to "disagree
vehemently" or to "accept." Nowhere do we hear about his
pride, courage, grief, or the capacity to experience conflict and mourning.
He comes across as an object, to be manipulated, and presented with a
mechanistically derived solution, which offers with it the promise of
moral certainty, rather than as a subject who together with other subjects,
the treatment team, can engage in a dialogue where all understand that
the point is to create a climate where moral choice can be made while
the burden of moral uncertainty is shared [5,6].
Such a striking omission alas curtails the capacity of the family or
the treatment team to mourn and grow, perpetuates the myth of medical
science omniscience in the guise of ethical systems omniscience. The
cost of such a mechanistic view of science and the ethical life extends
to the breakdown of trust and dialogue when magical wishes for omniscience
come to founder against the frailty and uncertainty of our all too mortal
flesh and vision. This breakdown, this failure to share uncertainty leads
to an adversarial doctor-patient relationship at the root of the "malpractice
crisis" and other manifestations of "critogenesis" [7]. "Critogenesis" (from
crites, the term for an Athenian jurist) occurs most often when jurists
disregard the possibility that legal interventionism in the name of patient "rights" may
lead to patient harm. It is parallel to the iatrogenesis that occurs
when medical technology is used uncritically. The rush to ethical certainty,
and the consequent impoverishment of the clinical case presentation of
process, brings to mind the warning sounded in the seminal article
"Legal defense as ego defense" [8]. One is
left to wonder whether what we are seeing is "ethical defense as
ego defense," a defense against bearing, sharing, and putting into
perspective the pain at recognizing our limitations.
Ethicogenesis, to parallel iatrogenesis and critogenesis, can be avoided.
That it can is adumbrated in Dr. McCartney's article, where we find ourselves
being able to identify with the plight of the comatose 20-year-old patient
by virtue of the psychosocial details included in the case presentation
[9]. Somehow, the fact that she was, before the accident,
by her family, "viewed as an outcast and often contrasted with her
older successful brother and sister," the family being "very
involved ... in search of a miracle as twice a day they performed passive
movements" adds the details that allow us to understand how "after
500 days in the ICU the family suddenly announced they wanted her taken
off the respirator." The family's inability to articulate the conflict
of values in the process becomes far more understandable, and their actions
far more viewable as the actions of moral agents in intrapsychic conflict
when seen in the perspective of the moral history and life of the individual
and the family. Rather than attempting to shear away these details for
the sake of the certainty promised by the analytic processes advocated
by Hayes, McCartney's description actively engages the intuition, thereby
keeping the process of ethical decision making in contact with its clinical
context [10].
These, and the family's and treatment team's emotional reactions, are
presented in the context of time, an unfolding drama alive with the anguish
and conflict by which ethical ideals come, as in great literature, to
be lived. Helping this process be bearable is the ethical work of a psychiatrist
[11,12].
References
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Perl M, Shlep E: Psychiatric consultation
masking moral dilemmas in medicine. N Engl J Med 307:618-621, 1982
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Hayes JR: Consultation-liaison psychiatry
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Psychiatry 8:415-418, 1986
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Bruner J: Actual Minds, Possible Worlds. Cambridge,
MA, Harvard University Press, 1986
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Madjid H, Myers JM: On the formal expression
of intuition in mathematical logic. Gordon McKay Laboratory, Harvard
University, Cambridge, MA 1986. Unpublished
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Bursztajn H, Feinbloom RI, Hamm RM, Brodsky
A: Medical Choices, Medical Chances: How Patients,
Families and Physicians Can Cope with Uncertainty. New York,
Delacorte, 1981
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Gutheil TG, Bursztajn H, Brodsky A: Malpractice
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the therapeutic alliance. N Engl J Med 311:49-51, 1984
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Bursztajn H: More
law and less protection: "Critogensis," "legal iatrogenesis," and
medical decision making. J Geratr Psychiatry 18:143-153, 1985
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Gutheil TG: Legal defense as ego defense:
A special form of resistance to the therapeutic process. Psychiatr
Q 51:251-256, 1979
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McCartney JR: Consultation-liaison psychiatry
and the teaching of ethics. Gen Hosp Psychiatry 8:411-414, 1986
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Hamm RM: Moment by moment variation in experts
analytic and intuitive cognitive activity. Working paper series No.
86-15, University of Iowa, Iowa, 1986
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Williams M: The Velveteen Rabbit. New York
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Conrad J: Lord Jim. London, J. B. Dent,
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