"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].


  1. Perl M, Shlep E: Psychiatric consultation masking moral dilemmas in medicine. N Engl J Med 307:618-621, 1982
  2. Hayes JR: Consultation-liaison psychiatry and clinical ethics: A model for consultation and teaching. Gen Hosp Psychiatry 8:415-418, 1986
  3. Bruner J: Actual Minds, Possible Worlds. Cambridge, MA, Harvard University Press, 1986
  4. Madjid H, Myers JM: On the formal expression of intuition in mathematical logic. Gordon McKay Laboratory, Harvard University, Cambridge, MA 1986. Unpublished
  5. 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
  6. Gutheil TG, Bursztajn H, Brodsky A: Malpractice prevention through the sharing of uncertainty: Informed consent and the therapeutic alliance. N Engl J Med 311:49-51, 1984
  7. Bursztajn H: More law and less protection: "Critogensis," "legal iatrogenesis," and medical decision making. J Geratr Psychiatry 18:143-153, 1985
  8. Gutheil TG: Legal defense as ego defense: A special form of resistance to the therapeutic process. Psychiatr Q 51:251-256, 1979
  9. McCartney JR: Consultation-liaison psychiatry and the teaching of ethics. Gen Hosp Psychiatry 8:411-414, 1986
  10. Hamm RM: Moment by moment variation in experts analytic and intuitive cognitive activity. Working paper series No. 86-15, University of Iowa, Iowa, 1986
  11. Williams M: The Velveteen Rabbit. New York Doubleday, 1925
  12. Conrad J: Lord Jim. London, J. B. Dent, 1900