Joumnal ofmedical ethics, I982, 8, 122-127 J Med Ethics: first published as 10.1136/jme.8.3.122 on 1 September 1982. Downloaded from
Symposium In defence of clinical bioethics
John D Arras Montefiore Hospital and Medical Center, New York Thomas H Murray The Hastings Center, Hastings-on-Hudson, New York
In the course ofhis attack on the discipline ofbioethics The nature of ethics Professor Swales attempts to establish two con- clusions. First, he argues that medical ethics cannot be First we should simply say that the opposition por- dissociated from clinical decisions and should not, trayed between medicine and medical ethics as parallel therefore, be taught as a separate subject in the medical to that between science and religious ethics amounts to curriculum. Medical ethics is 'too important', he says, a caricature ofboth the latter enterprises. Science is not to have its own separate place in the curriculum. Given merely an inductive ingathering of empirical facts, but this ringing affirmation of the importance of ethics for an immensely more complex and more interesting clinical practice, one would reasonably expect Swales's affair, bristling with idiosyncratic hypotheses and second conclusion to be that we must now proceed to other 'subjective' elements. Many eminent develop a clinically-based medical ethic - ie an philosopher-historians of science have argued that all that would combine the conceptual of our theories necessarily presuppose a certain pre- approach sophisti- - of the cation of contemporary ethical theory with an appreci- scientific parti pris a certain way viewing worldcopyright. ation of the empirical details of clinical practice. It - and have consequently ruled out the very possibility comes as something of a surprise, then, when Swales's of any clear 'direct observation' of nature un-mediated attack on the alleged separatism of bioethics turns into by the tinted 'lenses' of our competing theories (i). an attack on the very possibility of applying ethics to Science is not nearly as concrete and anti-metaphysical medicine. Since ethics in the world according to as Swales's outdated portrait of it suggests. Good sci- Swales is generally regarded as nothing more than ence requires the same sorts of judgments and rational sectarian, non-scientific speculation, he concludes that arguments as good work in ethics. bioethics cannot be fruitfully applied to the moral Likewise, Swales does little justice to theological dilemmas that beset contemporary medical practice. ethics by portraying it as amounting to nothing more http://jme.bmj.com/ Lest today's physician be left without a moral compass than a dogmatic appeal to indefensible sectarian of any sort, however, Swales hastens to add that a beliefs. At the least, this caricature ignores the extent hard-headed, pragmatic utilitarianism - seasoned by to which secular and theological ethics have converged years of medical experience - can serve as a guide to in defence of similar (but not identical) values, such as the perplexed physician. This endorsement of an fidelity between physician-researchers and patients, instrumentalist ethical theory meshes nicely with the fostering of patients' welfare, and the rights of patients to self-determination and autonomous Swales's conviction that all ethical questions in medicine on October 2, 2021 by guest. Protected are ultimately reducible to questions of technical decision-making. Swales consequently obscures the expertise. enormous contributions of theological, ethicists (such Although Professor Swales's unfavourable portrait as Paul Ramsey, Joseph Fletcher, James Gustafson and of medical ethics bears scant resemblance to the disci- Richard McCormick) to contemporary secular debates pline of bioethics as we know it, his dichotomous dis- over such issues as genetic engineering, human tinction between the 'two cultures' of medicine and experimentation, and the cessation of so-called 'extra- ethics is sufficiently widespread in the medical com- ordinary' medical treatments. If medical ethics munity to merit a reply. Swales's indictment of con- amounted to nothing more than the recitation of inde- temporary ethics founders on a misunderstanding of fensible maxims, and if ethical expertise were equival- the nature of ethics, of the interrelation of ethical and ent to the skills ofthe advertising man who cons us into scientific considerations in clinical judgment, and of baying one kind of soap rather than its indistinguish- the role of the medical ethicist in the clinical setting. able competitor, then Swales would be correct, and the ethicist would have no more business in the clinic than the carnival barker. But religious medical ethics and, a Key words fortiori, contemporary secular ethics amount to much Medical ethics; bioethics; medical education; patients' more than Swales would have us believe. autonomy; ethicists. In fairness to Professor Swales and those who share Symposium: in defence ofclinical bioethics 123 J Med Ethics: first published as 10.1136/jme.8.3.122 on 1 September 1982. Downloaded from
his views, we must concede that some of the literature or at least greatly oversimplified. Our clearest and on medical ethics does seem to portray the enterprise as surest ethical judgments, they claim, are often about a facile invocation of remote and abstract ethical prin- cases. In fact, novel cases often cause us to modify our ciples to specific issues: G E Moore on informed con- principles; this is how much argument actually sent, Leviticus on prenatal surgery, or, as Professor proceeds, even in theoretical ethics. If we understand Swales appears to prefer, Bentham on terminating Jonsen and Toulmin correctly, they conceive of ethics treatment. His remarks on the meaninglessness of in practice as a dialectical process of 'casuistry', ethical expertise - or at best its irrelevance to clinical wherein principles are fashioned and modified largely practice - would be well taken if medical ethicists did in response to their ability to articulate our intuitive nothing more than recite from grand theories. But responses to particular cases. Once again, the working sound ethical inquiries in medicine are not like this at principles are at the middle level; much of the work of all. practical ethics consists in identifying which principle Consider, for example, the nature of the principles or principles are most important or fruitful in the that bioethicists habitually apply to the doctor-patient particular case. Whether we prefer principle-ethics or relationship. In response to an antiquated and nar- case-ethics (approaches that might well merge in rowly professional Hippocratic ethic, contemporary practice), both require careful attention to concrete bioethicists have enshrined the 'principle ofautonomy' details, and both involve more than the vacuous incan- as the centrepiece of their emerging theory of how tations of abstract principles that Swales mistakenly patients and physicians should relate to one another. identifies as ethics. A firm principle has gradually emerged from the convergence of various ethical traditions to the effect The intersection ofclinical judgment and moral that medical decisions concerning the lives of judgment patients properly belong to those patients, and not to Assuming that ethics is not the spooky metaphysical physicians, no matter how knowledgeable or well- business that Swales makes it out to be, exactly how are intentioned the latter might be. This principle of self- we to conceive of the relationship between clinical determination draws support from a wide variety of judgment and moral philosophy? disparate ethical and religious traditions: from Kantian Swales appears to be of two minds concerning the copyright. notions ofautonomy and dignity, from the Utilitarians' possibility of a fruitful collaboration between morals conviction that the greatest good is best served by and medicine. In the first part of his essay, he main- allowing each person to decide what is in his or her best tains that ethical decisions in medicine cannot be dis- interests, from the Lockean theory of natural rights, sociated from clinical decisions, adding (rather disin- and from the Judeo-Christian teaching on the unique- genuously, in our opinion) that medical ethics is 'too ness and preciousness ofeach individual human being. important' to be taught separately. But in the remain- Diverse as their ultimate first principles might be, each der of his essay, Swales adamantly declares that of these 'grand theories' lends support to the more medicine is science, medical ethics non-science, and modest middle-level proposition that, in the absence of never the twain shall meet. One is left wondering how http://jme.bmj.com/ compelling countervailing reasons, individual self- two inseparable subjects can have nothing to do with determination should prevail, even in the face of con- one another. Perhaps our perplexity will abate upon trary medical advice. closer examination of Swales's (apparently) contradic- Although the principle of autonomy occupies by far tory assertions. the most important place in the constellation of bio- First, what does Swales mean when he claims that ethical principles, several other middle-level principles medical ethics cannot be dissociated from clinical deci- been articulated to the moral deliberations The he have guide sions? least could be claiming is that medical on October 2, 2021 by guest. Protected of health professionals and health planners. These ethics necessarily or essentially concerns itself with include the principles of non-maleficence, benefi- medical decisions, just as business ethics is about cence, justice, veracity, and confidentiality (2). Thus, business, or engineering ethics about engineering. one perfectly respectable view of this emerging field This claim is true, but only because it is a tautology; as holds that 'doing medical ethics' should (and often such, it does not tell us whether it is either possible or does) consist in the identification, articulation, and desirable to teach medical ethics as a separate subject. application of such convenient middle-level principles A more interesting interpretation of the essential to concrete situations. connection between medical ethics arnd clinical deci- This conception of the relationship between ethical sions would assert that theory construction in medical theory and practical application has undoubtedly ethics must draw on a knowledge of medical facts and achieved the status of a reigning paradigm in the bio- medical practice. Few, if any, practising bioethicists ethics community, but it is by no means the only would take issue with this claim. Indeed, they would available self-understanding of what bioethics is or assert that good work in bioethics must be firmly should be about. An intriguing alternative is currently anchored in the medical facts. Still, this belief in no being explored by Albert R Jonsen and Stephen way implies that the theories and methods of medical Toulmin (3). These philosophers take the usual pre- ethics cannot be presented apart from the clinical set- sumed order (from principles to cases) to be mistalen, ting. It may or may not be pedagogically desirable to 1124 John D Arras and Thomas H Murray J Med Ethics: first published as 10.1136/jme.8.3.122 on 1 September 1982. Downloaded from teach medical ethics as a separate subject but it is less, Swales makes other points here that merit a certainly possible to do so. response. While he insists that non-scientific outsiders So we are left with a much stronger and much more can contribute nothing to clinical decision-making, controversial interpretation that alone seems to capture Swales does grant a certain validity to a utilitarian ethic what Swales has in mind: medical ethical judgments espoused by many in the medical community. This cannot be separated from clinical or technical judg- ethic is concerned exclusively with 'doing good' - ie ments because they cannot be distinguished concep- with maximising the welfare of the patient. And since tually as two distinct sorts of judgments. In other an accurate appraisal of the patient's welfare must rest words, medical ethical decisions are clinical deci- upon a knowledge of the medical alternatives, Swales sions. Contrary to the previous interpretations, this concludes (rather hastily) that only physicians are in a one is neither tautologous nor platitudinous; it is, position to make this sort of ethical judgment. however, plainly false. This contention is vulnerable even if we assume the Swales attempts to support this contention by noting validity of an exclusively pragmatic or patient- that ethical and clinical decisions frequently mas- benefiting ethic in the Hippocratic tradition. Such an querade as each other. It is true that a good deal of ethic, ifit is to be anything more than a mere diagnostic masquerading goes on in the hospital setting; doctors and treatment manual, must be geared to the total often cloak their moral advice to patients in the lan- welfare of the patient - not simply to her medical guage of medicine, and bioethicists are often called condition narrowly construed, but also to her emo- upon to discuss problems that turn out, on close tional, psychological, and socioeconomic conditions as examination, to be largely medical (4). But Swales well. Thus, in deciding, for example, whether or not to cannot support his sweeping implication that all medi- tell a cancer patient the truth, the doctor must know cal ethical issues are really clinical by alluding to these about the patient's own hopes, fears, plans and prob- occasional transformations. Although moral concerns lems in order accurately to predict what course will, in pervade clinical decisions, they can nevertheless be fact, maximise her welfare. This sympathetic identifi- distinguished from the merely technical. The occa- cation and weighing ofneeds, preferences, and (some- sional case in which a question ofmedical management times) idiosyncratic values is no doubt a much more
poses as an ethical issue does not demonstrate that all difficult undertaking than Swales would have us copyright. medical ethical issues are really at bottom clinical. No believe; but even more importantly, such a task is amount of medical knowledge can tell us whether the plainly not a matter of medical or technical expertise. Jehovah's Witness is morally entitled to refuse a blood Doctors have no special training to do it; and they are transfusion, whether a woman with breast cancer often pretty bad at it - (not, we hasten to add, because should be able to choose between a radical mastectomy they are unusually insensitive to psychosocial con- and lumpectomy, or whether severely defective neon- siderations, but rather because of their own pre- ates should have to make way for healthier babies in an disposition to treat patients in certain ways and because overcrowded intensive care unit (ICU). Doctors must of the increasingly anonymous character of doctor- provide much-needed medical knowledge bearing on patient interactions in large hospitals and nursing http://jme.bmj.com/ such questions, but medical data alone will never homes today). A knowledge of the technical options is determine the 'solutions' to these moral dilemmas. obviously necessaty to make informed decisions, but it Problems such as these highlight the fact that, while is not sufftcient to calculate the patient's best interests. ethical issues might well be firmly embedded in the To do that, one would have to factorin all sorts ofhazy, clinical setting, these clinical decisions are themselves non-scientific variables such as the patient's attitude embedded in the larger human context where such toward cosmetic appearance, aversion to risk, etc. moral concerns as truthtelling, personal autonomy and Apart from these problems which are internal to justice hold sway. These larger ethical concerns form Swales's pragmatic medical ethic, there are good on October 2, 2021 by guest. Protected the warp and woofofcontemporary biomedical ethics. reasons for rejecting any medical ethic that is blind to After having argued that ethical and clinical such themes as patients' rights, self-determination, decision-making cannot be dissociated, Swales per- truthtelling, and confidentiality. Even if most doctors forms an about-face, declaring that no matter how were to develop the necessary counselling skills to earnestly bioethicists try to acquaint themselves with work up an accurate and complete psychological pro- the medical facts, they will never be able to 'throw light file of each patient, upon which they could base their on what we [doctors] should do'. This, he says, is judgment of 'best interests', we would still think that because ethics is essentially metaphysical or religious, the patient retains the right to decide for herself what while medicine proceeds according to a scientific should be done by others (including doctors) to her method. Here Swales seems to be arguing that ethics is body. We would say that she exercises this right so easily distinguished from medicine that it is actually because of her moral status as an autonomous, self- irrelevant to it! determining person. Thus, even if the welfare of a As we have already seen, this attempted assimilation patient would seem to require a blood transfusion, the of ethics to religion is based on a seemingly complete patient retains the moral and legal right to refuse such a ignorance of the discipline of secular ethics and on an procedure. Thus, Swales's bald assertion that 'the wel- unjustified devaluation of religious ethics. Neverthe- fare of the patient is paramount' would have to be Symposium: in defence ofclinical bioethics 125 J Med Ethics: first published as 10.1136/jme.8.3.122 on 1 September 1982. Downloaded from complemented by an equally sensitive concern for choices. Whereas the moraliser wastes no time in rush- patients' rights. ing to a moral judgment, the analyser self-consciously In fact, anyone familiar with the development of refrains from making any moral judgments, resting contemporary biomedical ethics would realise that this content to clarify the moral issues and expose fallacious cluster ofrights emanating from the notion ofpatients' reasoning. Repelled by the notion that his job is to tell self-determination has provided the basis for an ex- other people how to behave morally, the analyser pressly covenantal or contractual patient-centred med- would most likely disown the title of 'moral expert'. ical ethics that has produced rather impressive results While we know of no one doing medical ethics seri- in the last decade. Contrary to Swales's claim that ously who subscribes to the moraliser prototype, many contemporary bioethics has not had any noticeable do believe in some version of the analyser. We hold effect on medical practice - a claim based on an embar- neither view to be adequate. Each contains elements of rassingly faulty analogy between ethics and the a more complete medical ethic, but neither can stand philosophy of science - the impact of bioethics on alone. The ethicist as moraliser is a parody of serious issues of private and public health policy has been work in medical ethics; the ethicist as analyser places significant and far-reaching at least in the USA. unnecessary limits on the kinds ofwork that need to be Although bench scientists may not have changed their done. Let us illustrate with a case. behaviour to suit the theories of Hempel, Kuhn and Recently one of us encountered a comatose middle- Popper, doctors have dramatically altered their aged woman in an intensive care unit whose best hope, behaviour in recent years. While some ofthese changes however slender, was to emerge severely brain- can and should be attributed to larger cultural forces at damaged, having lost both legs, an arm, and the work on the medical community, it is hard to believe, remaining hand. Although some discussion had taken for example, that the advent of a reinvigorated disci- place regarding the continuation of the massive efforts pline of medical ethics had nothing to do with physi- required merely to stabilise her debilitated condition, no cians' changed attitudes toward truthtelling to patients one was willing to take responsibility for talking with with cancer (5). Other examples of the impact of the family about the possibility of discontinuing the bioethics - eg in the fields ofhuman experimentation, aggressive treatments she was currently receiving. death and dying, genetic screening and behaviour con- The problem facing the house staff and the nurses copyright. trol - could be multiplied indefinitely. was what to do about the patient's surgeon. During the All this has been mere brush-clearing, to establish course of the unsuccessful operation the surgeon had thepossibility of a fruitful collaboration between ethic-s- apparently made a forgiveable error, setting off a cas- and medicine despite their familial resemblances to the cade of unfortunate medical complications, and had humanities and the sciences, respectively. Proof that subsequently withdrawn both from the woman's fam- practitioners of the two arts can benefit from each ily and from the other medical staff involved in the other's skills, and especially that the patient can also, case. As a result, the agonising task of communicating must come from the actuality of practice. with the family fell to the nurses and house staff. A responsible ethicist could make confident moral http://jme.bmj.com/ judgments about certain features ofthis case, but about The role of the bioethicist other things he might only be able to engage in a If we accept that the application ofethical reasoning to dialogue with the family and staff, helping them all to moral problems in medicine can be done in a sophisti- muddle through. A clinical ethicist should have no cated, non-dogmatic fashion, we must still ask what trouble concluding, for example, that the family must role or roles the medical ethicist can play in interaction be brought into a dialogue regarding this patient's
with other actors in the medical drama. Consider two future course oftreatment (or non-treatment). Appro- on October 2, 2021 by guest. Protected contrasting prototypes: the 'moraliser' and the 'anal- priate family members should be forthrightly (but sen- yser'. Swales seems to view the medical ethicist as sitively) appraised of the patient's dire condition, necessarily a moraliser - a person whose self-conceived dismal prognosis, future quality of life, and the role is to pass moral judgment on the actions of those remaining medical options. Assuming that they wish around him, or her, usually (we might add) without to decide and that they will base their decision on the giving any thought either to the rational foundations, if patient's best interest, the family should be allowed any, ofhis pronouncements, or to the ambiguities that to determine whether 'aggressive' treatments should plague most situations calling for a moral choice. be employed further to prolong the patient's life. The Swales justifiably rejects this conception of 'moral 'moraliser' model permits the bioethicist to pass moral expertise'; and if this were all that medical ethicists judgments when there is a clear understanding that did, we would not defend them either. some important standard of ethical conduct has been At the opposite extreme from the moraliser is the violated. In this case, the surgeon's behaviour placed 'analyser' - a person whose expertise consists in iden- an unfair burden on the other medical staff, and added tifying the values implicated by various choices, chart- to the terrible burden borne by the patient's family. ing the implications of these choices for other values What happened in this case, was that the patient's that people might hold, and assessing the logical coher- family indicated, when finally approached, that they ence of the arguments offered on behalf of ethical would be willing to care for her no matter what her con- i26 John D Arras and Thomas H Murray J Med Ethics: first published as 10.1136/jme.8.3.122 on 1 September 1982. Downloaded from dition, so long as she could rejoin them at home. A grapple with the 'tragic choice' of who ought to get the tragic choice, but one which must be sensitively last bed in the ICU, ethicists should also ask them- attuned to the values ofthe woman and her family, and selves why this bed happens to be the last one. Is it based on the best medical knowledge available. because the hospital administration has allocated insuf- A case ofanother woman with similarly bleak pros- ficient resources to its ICU? Or is it the last bed because pects was further complicated by the intransigent the medical director of the ICU exercises insufficient stance taken by one of the first-year surgical residents control over who gets in and who goes out? Perhaps the involved in the woman', care. This young physician ethicist will discover that the problem of chronic over- was scandalised by the prospect ofallowing his patient crowding - and thus the dilemma posed by triage - to die. 'I think we must keep her alive', he asserted, could be alleviated by a more enlightened policy of 'that's what the medical profession is all about. That's giving only 'supportive' care to those patients who are what I've been trained to do'. The resident went on to truly beyond the pale of aggressive measures. argue that a decision to withdraw 'aggressive' therapy One of us has spent a good deal of time with a from the patient would be tantamount to killing her. particular hospital intensive care unit. Its director had Here; we would argue, is an ideal occasion for the requested our help in dealing with some thorny ethical ethicist-as-analyser to make an appearance. Either dur- dilemmas which, he said, were a source of continuing ing the case consultation itself or (more likely) in divisiveness among nurses and physicians. We found subsequent teaching rounds, the ethicist can aid clini- that, although the staff was indeed confronted by per- cal decision-making through a sophisticated, yet clear, plexing ethical problems, the source of dissension had analysis of the conceptual and moral differences be- more to do with the manner in which physicians tween 'killing' and 'letting die' in various circum- (including inexperienced house staff) related to the stances. We think it highly desirable that this sort of nurses, who often knew much more about appropriate reflective analysis replace the mere repetition of treatments than the neophyte doctors. In this case, an slogans - 'Saving life is our job' - especially when the 'ethical engineer' would have accepted the diagnosis as unreflective parroting of such maxims can lead to presented by the director and thus would have over- increased pain and suffering for patients and their looked the real source of dispute. Although we agreed
families. to analyse the ethical dilemmas themselves, we alsocopyright. Thus, we prefer to think of the medical ethicist as a insisted upon discussing the organisational and per- person skilled in moral reasoning and schooled in the sonal problems that served to exacerbate the staffs medical and psychological realities of the clinic, whose difficulties in resolving the ethical disputes. primary function is to engage all concerned in serious and clear reflection upon the moral dimensions oftheir Conclusion work. Sometimes this task will require the ethicist As long as medical decisions are about human beings emphatically to remind a physician that adult patients and the kinds of lives they will lead - or leave - those of sound mind have a right to determine what shall be
decisions will be inextricable mixtures of medical, sci- http://jme.bmj.com/ done to their bodies; at other times it will require the entific and moral considerations. In most cases, no application of analytical skills to conceptual and nor- great ethical dilemmas emerge, and both doctor and mative problems. But beyond these two functions of patient can get on with their affairs without the aid ofa the 'moralist' and the 'analyser', we see a third role for bioethicist. But when those dilemmas do arise, or when the ethicist in the hospital: as a diagnostician of the common medical practices rest on dubious moral 'deep structure' of ethical dilemmas. Just as a good grounds, it is handy to have a bioethicist around. Not physician might attempt to relate reported symptoms make the but to the an biochemical a ethi- to decisions, certainly, improve to underlying cause, perceptive dialogue, to help doctors to appreciate the moral com- on October 2, 2021 by guest. Protected cist should be alert to the possible institutional causes of plexities of their vocation, and, in the tradition of one the ethical dilemmas that present themselves in the ofthe first 'ethicists', to be the horsefly biting the rump medical context. Rather than resting content with a of the (or steed when needed. model of the ethicist as a 'moral engineer' (6) - ie, as Athenian Hippocratic) someone who applies the tools of ethical analysis to problems precisely as they are presented by the medi- References and notes cal staff - we believe that the ethicist should view the (i) Kuhn T S. The structure of scientific revolutiwns, 2nd staff's presentation of a dilemma as one bit ofinforma- edition. University of Chicago Press, i97o; Hanson N R. tion fitting into a larger picture. Often enough, the Patterns of discovery. London: Cambridge University particular form in which a problem is presented will Press, 1958; Feyerabend P K. Against method. London: either badly misconstrue the actual problem or tend to Verso, I978; and Koestler A. The sleepwalkers. New York: Grosset and Dunlap, I963. obscure the underlying organisational reasons for the (2) See generally Beauchamp T, Childress J. Principles of dilemma's appearance. Take, for example, the prob- biomedical ethics. New York: Oxford University Press, lem of triage within a medical ICU. The dilemma of 1979. 'whom to save when not all can be saved' is certainly (3) Jonsen A R. Can an ethicist be a consultant? In: one of the most difficult and persistent ethical prob- Abernethy V, ed. Frontiers in medical ethics: applications lems faced by hospital-based ethicists; yet, as they in a medical setting. Cambridge: Ballinger, I980; Symposium: in defence ofclinical bioethics 127 J Med Ethics: first published as 10.1136/jme.8.3.122 on 1 September 1982. Downloaded from
Toulnin S. The tyranny of principles. Hastings Center parties. However, I would emphatically give primacy report December I98I. in such debate to patients rather than 'experts' or pres- (4) We are, however, a bit puzzled by Swales's contention sure groups with a particular viewpoint and it is depress- that the case of Leonard Arthur exhibits this 'shift from ing that both replies give so much space to the role of the ethical to the clinical domain'. If the practice of various experts and so little to the role of the patient 'allowing the deaths' of anomalous newborns is not a moral issue, what is? If the crucial question raised by which I emphasised in my original piece. I would have this case called forclinical, rather than moral, expertise, hoped that from their experience Arras and Murray why did the members of LIFE press the issue in court? could have produced evidence for the value of the For a sensitive discussion of the Arthur case, see 'bioethicist'. Unfortunately they have not. Indeed we Glover J. Letting people die. London Review ofBooks are merely assured that 'it is hard to believe' that 4-17 March I982; Vol 4 No 4: 3. changes in doctors' approaches have not been influ- (5) Veatch R M, Tai E. Talking about death: patterns oflay enced by bioethicists. The examples they quote do not and professional change. The annals of the American support this view. The justifiable concern with human Academy of Political and Social Science January I980; experimentation in the United Kingdom, for instance, 29-45; and Novack D H et al. Changes in physicians' does not follow from ethicists' investigation. It largely attitudes toward telling the cancer patient.Journal ofthe American Medical Association March 2, 1979; 241: stems originally from Dr Pappworth's book (2) which 897-9oo. meticulously chronicled published studies in the medi- (6) Caplan A L. Ethical engineers need not apply: the state cal literature and explained for a lay public what was of applied ethics today. Science, technology and human involved. Ethical judgment was clearly necessary but values Autumn I980; 6: 24-32. equally clearly no expert moral analysis was required to demonstrate the unacceptable nature of what was being done. The relevant previously unrecognised fact was that it was happening. It is as illogical to claim that public concern with the dilemmas of medicine follows Response from the evolution of bioethics as it is to maintain that J D Swales School ofMedicine, University ofLeicester the equally widespread concern with the modern
epidemic of cardiovascular disease stems from thecopyright. I am flattered that my short piece drew forth such development of professional cardiologists. Post hoc, lengthy rejoinders. I am also delighted because in spite non propter hoc. of the assertions made in these replies I believe that a Most disturbing of all in Arras and Murray's article .debate between individuals of the widest range of is the description of an expansion of the role of the backgrounds is a desirable and necessary precondition ethicist into a social worker/psychotherapeutician who to finding a working provisional solution to the ethical knows 'about the patient's own hopes, fears, plans and dilemmas of medicine. My objection was not to such a problems in order accurately to predict what course debate. My objection was to the development of the will in fact maximise her welfare'. I am even more 'ethical expert' and the discipline of 'medical ethics' as surprised to read that this is 'a more difficult under- http://jme.bmj.com/ a discrete subject in the teaching of medical students taking than Swales would have us believe', since my analogous say to endocrinology or gastroenterology. original article expresses no views about this difficult The implication of Arras and Murray that ethical area. Further, in the last paragraphs, a role in analysing value judgments and the inductive observations and organisational and personal problems of staff and testable hypotheses ofmedical science are qualitatively patients is described which suggests quite different similar hardly stands up to critical examination (i). Do activities from those which the term 'ethical philoso- they seriously believe that the ethics of, for instance, phy' would normally subsume. Such activities should the termination of pregnancy are testable in the same be judged in their own right but have no bearing on my on October 2, 2021 by guest. Protected way as, say, those of clinical treatment? If ethical original contention. hypotheses were testable I would agree that analogous Since the burden of my article has clearly escaped roles for the ethicist and endocrinologist could indeed Drs Arras and Murray perhaps I could emphasise again be identified. Until I am convinced of this the argu- the importance of an open debate. What I remain ments for 'professional ethicists' remain specious. sceptical about is the role of the ethicist as an expert I might be persuaded by the more empirical whose authority can resolve the dilemmas of medicine approach of demonstrating benefit. I certainly am not for ourselves and our students. Judging by the analysis persuaded by statements referring to 'Swales's convic- presented by Drs Arras and Murray it cannot do this, it tion that all ethical questions in medicine are ultimately can however generate a considerable smoke-screen. reducible to questions of technical expertise' or the statement that 'he [Swales] insists that non-scientific outsiders can contribute nothing to clinical decision- References making . . .'. I recognise that it is easier to attack a (i) Popper K R. The logic of scientific discovery. London: stereotype of an intensively conservative medical posi- Hutchinson, 1977. tion, but nowhere in my article or elsewhere have I (2) Pappworth M H. Human guinea-pigs: experimentation on objected to a wider debate with non-medical interested Man. London: Routledge & Kegan Paul, 1967.