SYSTEMS ETHICS AND THE HISTORY OF MEDICAL ETHICS Colleen D. Clements, Ph.D.

This paper reviews the current conclusions in medical ethics which have followed the 1969-1970 Medical Ethics Discontinuity, a break that challenged the Hippocratic way of thinking about ethics. The resulting dislocations in quality of care and the medical value system are discussed, and an alternative medical ethics is offered: Systems Ethics. A methodology for a Systems Ethics analysis of cases is presented and illustrated by the case of a physician-assisted suicide. The advantages, both theoretical and clinical, of a Systems Ethics approach to medicine, which is an expansion of the Hippocratic tradition in medical ethics, are developed. Using Systems Ethics, it is possible to avoid the dangers of legalism, bureaucratic ethics, utilitarian cost cutting, and "political correctness" in medical ethics.

There are basic questions in ethics which remain unanswered despite the confidence of modern medical ethics that it has provided definitive answers. Those questions are straightforward: Can we know the "good" and How do we know the "good" for the h u m a n organism or for a larger moral reference group? The history of medical ethics parallels the history of philosophical ethics, and at its best is an honest attempt to determine what the right thing to do is in the practice of medicine. The Hippocratic tradition in medical ethics from as far back as 460 B.C. has worked at Colleen D. Clements, Ph.D., is Clinical Associate Professor of Psychiatry, University of Rochester, School of Medicine, Department of Psychiatry, 300 Crittenden Boulevard, Rochester, New York 14642. PSYCHIATRIC QUARTERLY, VoL 63, No. 4, Winter 1992 0033-2720/92/1200-0367506~50/0 © 1992 Human Sciences Press, Inc.

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answering those questions. But what I will call the Medical Ethics Discontinuity of 1969-70 (to use a paleontological metaphor) has made a radical break with both the medical ethics tradition and with philosophic ethics(I,2). That was best illustrated by an editorial in our local Rochester, New York, paper following the Quill case (a physician who assisted a patient in killing herself), and by a column written by a medical ethicist from the Rochester Medical School(3,4). The editorial was patronizing about the archaic nature of the Hippocratic Oath and suggested a substitute oath that would be more suitable for the Quill case, one written by Dr. Louis Lasagna, that supported cost-effective decisions about continuing medical care, and redefined the physician's role, so that physicians could terminate lives. The column was also patronizing about Hippocratic Ethics, suggesting that ethicists from the 70's on had arrived at the correct truth about the '~good," and that the oathtaking be retained in medical school as an irrelevant and only ceremonial link to the past. Since the Oath was of no real importance, it did not matter whether young physicians took it, at all. This article will attempt to answer physicians' questions about how we have come to this point in medical ethics. It will supply a map of medical ethics for physicians (See Figure 1) that can help give them some bearings after the unfortunate Discontinuity. It will suggest a better way and a hope that there can be survival for rational, naturalistic medical ethics after this Discontinuity(5,6). If psychiatrists ask themselves when they first became aware of the term ~'medical ethics," they will give differing answers, depending on age, cultural differences, their operating definition of what a physician should be, and gender differences. Medical ethics is not the clean set of principles and guidelines it wishes to present itself as being. It has a long history and many varying meanings, particularly since the Discontinuity. The Timeline map is a shorthand, expressing the results of this search for a uniform meaning. Confidentiality is a good key to begin tracing the history of medical ethics, but it is not the full story of the importance of Hippocratic Ethics. Trust in the physician is a better way to understand Hippocratic Ethics. That ethical system developed from the shaman tradition of pre-history. The shaman was both holy man and botanist, and while he or she was respected and feared, it was not possible to trust the shaman completely. The shaman could as easily murder as cure, or could supply the potion for a man to

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FIGURE 1 A Time Line of the Multiple M e a n i n g s of Medical Ethics 460-377 B,C.

196g-70

1100 A,D.

pa~lcularly

1970s 1980~90S

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HIPPOCRATIC E T H I C S s I SHAMAN TRADITION ROMAN CATHOUC ETHICS

CIVIL RIGHTS/LEGALISM

ii,

AUTONOMY ETHICS / M O R A L RIGHTS - UTtLITARfAN/C O M MONWEALTH ETHICS COST CONTAINMENT/BUREAUCRATIC POLICING AGENTOF STATE HIPPOCRATIC- PROFESSIONAL CODES OF ETHICS

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o

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murder his enemy. The important trust that a physician would put the patient's good foremost, and that the physician was an objective expert in determining what the patient's good was, is the fundamental ethical contribution of Hippocratic Ethics. That is expressed most clearly in its prohibition against the physician giving poisons to patients or to individuals to use on others. Physicians should also not abort pregnancies, a dangerous procedure at that time. Physicians should strive for a good outcome for their patients, but if a good outcome is not possible, they should at least try to do no further harm (this is not Do No Harm, which would be an impossible goal). Physicians should not sexually exploit patients, family members or servants. Physicians should not be gossips, spreading information about patients in the market place. It is assumed they will be competent and accountable, that they are a professional brotherhood, and that they have the objective expertise to know what a good outcome actually is. Starting between 460 B.C. and 377 B.C., physicians were, therefore, defined as a brotherhood of true experts, who were advocates for the patient's good. Physicians could be trusted.

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These were exactly the targets for the Post-Modern movement in medical ethics during the 1969-70 Discontinuity. Both the claim of medical science to expertise, and the philosophic conclusion t h a t the good for the h u m a n organism could be known, were attacked under the label ~Paternatism."(7). Pragmatic or Naturalistic Ethics was replaced by a legal or bureaucratic process. This attack and replacement of the Hippocratic tradition was not due to some new and definitive proof in ethics that this tradition was wrong, but was due to social and political trends. The Timeline shows that from 1100 A.D., particularly 1477 A.D., medical ethics also developed a religious meaning and tradition, Roman Catholic Medical Ethics. There was still the ethical position that a good outcome can be objectively known by observing natural law, that physicians were a brotherhood, and that physicians had a fiduciary obligation to achieve a good outcome for their patients. Physicians were not to violate the natural law by unnaturally impeding a natural process, and they could not commit a major evil to achieve good consequences. They could, however, accept some consequences that were not intended in the process of trying to achieve a good outcome for the patient, the concept of Double Effect(8). This medical ethics tradition also allowed the physician and patient to refrain from using extreme or extraordinary means to continue life, but it is still carried the prohibition against the physician intentionally killing the patient. Physicians were defined as a religious brotherhood, and questions of reproductive ethics, euthanasia, and the encompassing question of the ethics of intervention were seen within the religious tradition. The underlying epistemotogical base of the Hippocratic tradition and the Roman Catholic tradition were compatible. Both were based on a philosophic argument that expertise in knowing the good was possible, and that the empirical world of natural events could be investigated to identify the good objectively. The right thing to do was not determined by a political process, by the passing of legislation, by negotiations in committee, or by regulatory guidelines. It could be known from an empirical study of the natural word, not in an absolute sense, but in the philosophic and scientific sense of probability. There could be tolerance, but tolerance did not mean nihilism, the view that human beings could never know anything to be true or right. That philosophic base for ethics, which, with some modifications but no change in the workability of objective knowledge and value

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theory, had developed through the history of ancient Greece, the Dark Ages of medieval Europe, the Renaissance, the Reformation, the Industrial Revolution, the scientific and biological explosion of knowledge, even the age of communication and information, has been abandoned by current medical ethics; the marker for this is the 1969-70 Medical Ethics Discontinuity. Two names stand out as markers for this event. Joseph Fletcher and Paul Ramsey, both theologians, published books within a short time of each other(9,10). Two more different ethical approaches to medicine would be hard to find, but both presaged the Discontinuity. Two books alone could not create such a break, but a list of other social trends or factors could. The Nuremburg Trials and information about what physicians did legally in Germany created a new sense of distrust of physicians. Henry Beecher's article on experiments done in the United States that he considered highly unethical (not all were) added to the distrust of physicians. This coincided with the use of nuclear weapons at the end of World War II and the sudden public fear of scientific experts. Those two fears, of medical experts and of scientific experts, were heightened during the 1960's cultural revolution, in which there was a loss of trust in all experts and establishments. To this mix was added the Civil Rights movement in the 60's and 70's, with its faith in the law to correct social problems, and its emphasis on civil rights as the overriding value. Changes in tort law (deep pockets, extended liability, consumer protection) added to this legalizing of social problems. Economic agendas also became part of the social trend, drawing on the Limits to Growth movement, the belief in a natural scarcity of resources that was translated or conflated with shortages created by political prioritizing or arbitrary choice (11,12). This aspect of the social trend was compounded by the growth, during World War II and after, of third-party medical insurers and the loss of direct personal control of health choices by both patients and physicians. Other trends have been suggested but do not appear to be as important. Technology is frequently blamed for the changes in medical ethics and medical practice. The development of antibiotics during World War II, transplants, advances in microbiology, bold surgical procedures, and high-tech equipment are often given as reasons for the changes made in medical ethics. But history contains other equally startling advances which did not affect the Hippocratic tradition in such a major and negative way. Vaccina-

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tion, the introduction of sulfa drugs, the use of forceps, the cell theory itself, certainly rival any of the more recent advances in biotechnology. Nor is the claim that medicine has suddenly become really effective a sufficient explanation for the attack on the Hippocratic tradition. That ~effectiveness" has to be seen in the context of evolutionary biology and the lesson of new diseases such as AIDS. Medical care is always one step behind new and improved pathogens(6). Whatever the ranking of importance, these social trends, in combination with the publication of Fletcher's and Ramsey's books, produced the Discontinuity. That Discontinuity marks the de-professionalization and the secularization of medical ethics as its first major effect. The second effect is that medical ethics is seen as relative, pluralistic, subjective, and without content, in other words, nihilistic(13,14,15). Individual choice, democratic group consensus and the political and legal process replace any knowledge about the good for the h u m a n organism. Everything becomes, in a sense, political, and there are a limited number of politically correct conclusions, There are thus a limited number of politically correct ethical perspectives in medicine, and those are diagrammed on the Timeline as they developed in medical ethics. Informed Consent and Patient Autonomy became the symbols for the initial development of medical ethics after the Discontinuity. For psychiatrists, involuntary commitment issues were the expression of this ethical view(16). At first, there were general ethical concepts of autonomy and moral rights that characterized this post-Discontinuity medical ethics, which was still a philosophic ethics. The ~'person" was seen as being of highest significance, deserving respect as a free moral agent. The most important value was free choice or autonomy, the act of freely choosing, no matter what the content of the choice. The only restriction on free choice was that such choices not seriously violate the free choices of others (a much more complicated idea than it appears to be). In addition to Kant, this developing medical ethics had roots in Mill, claiming that the person was the best judge of what was in his or her best interest. It also drew on the tradition of moral rights, stemming from natural law. Moral (or human) rights are described as inherent in being human. They are eternal and immutable, not given by society and not able to be taken away by society. There

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were a number of metaphors for this new medical ethics: The Physician as Body Mechanic, as Contractor, as Facilitator, as Value-Neutral. The ethical issues that were highlighted were informed consent, refusal of treatment, coercion or "paternalism" and respect for the incompetent (involuntary commitment). The Principle of Autonomy was constructed by presidentially appointed commissions, and it almost always overrode the revamped Hippocratic tradition, now expressed as the Principle of Beneficence(17). Although rooted in two contradictory epistemologies, these "universal principles" were combined by medical ethics commissions into a consensus that, although a contradiction, became the medical ethics of the 70's(18). At the same time, as an undercurrent in the 70's but as a flood in the 80's and 90's, a utilitarian version of medical ethics was also present, sometimes expressed as commonwealth, sometimes as efficiency and cost-containment(19,20). There is belief in an objective good, based on h u m a n happiness defined in a statistical sense: a utilitarian calculus which looks at the unit consequences to all individuals and chooses the action which maximizes the most group happiness. Happiness finally becomes understood as social utility and efficiency. The ethical distribution of resources then sacrifices patients' individual needs for the most effective operation of a health care system. The physician is a resource-saver or calculator. Although philosophic analysis still played a major role immediately after the Discontinuity, this rational methodology was supplanted in the 80's. Autonomy ethics became transformed into a civil rights legalism, which is regulatory and political as well as legalistic. Now the patient's civil (political) rights replace moral rights and determine what is the right decision in medicine. Lawmakers and judicial decision makers construct medical ethics. Since civil rights in medicine are based on the right of privacy for one's own body, they tend to be negative rights about intrusions into one's body or, in other words, rights to refuse treatment. Civil rights can be modified or overturned by judicial interpretation and legislative mechanisms. They are not eternal and immutable, and because given by society, can be taken away by social change. The physician then becomes a practical lawyer, and a major goal is legal immunity. The list of ethical issues in medicine during this further revision of the meaning of medical ethics is long: forms for

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informed consent, medical chart documentation, DNR regulations, refusal of treatment, right to die, physician-assisted suicide, sexual or dual relationships, confidentiality laws, coercion or discrimination, privacy, abortion, civil commitment, and laws such as Rivers vs. Katz (Right to Refuse Medication) or NYS Public Health Law Article 27-F (Do Not Resuscitate). Medical ethics had become medical law. By the 80's, the Utilitarian development in medical ethics not only had gained prominence, but had also changed into cost-containment ethics and bureaucratic ethics. In addition, the commonwealth component, the police power of the state, had entered medical ethics. Cost-Containment/Bureaucratic Ethics maintained social utility and efficiency as the ethical standard for determining care, along with the negotiating process and consensus. An assumption was made that there is a natural limit to medical resources, rather than a political limit caused by social first-order economic decisions(12). Even non-economic decisions in the practice of medicine are made through statistically developed protocols or computer-generated diagnosis and treatment, rather than individualized empirical and clinical practice. The physician is defined as a civil servant (The Physician as Postman) who should follow protocols determined by utility and efficiency, and as an economic gatekeeper who should save society's scarce resources. Medical ethics then concentrates on triage issues, rationing of care, restriction and rejection of costly technology, cost-saving withdrawal of treatment, cost-effectiveness, deinstitutionalization and length-ofstay issues, and compliance with regulatory and third-party-payer guidelines and requirements. In the policing agency component, the new medical ethics defines the physician's goal as cooperating with the state in controlling the health of citizens by setting standards for health-promoting behaviors and working with the state to structure citizens into complying with those standards. In addition, physicians are required to report to the state deviant behaviors which threaten the public health (or in some cases, the individual's health). The physician is then a police agent or behavior modifier. Examples of identified ethical issues are: duty-to-warn issues, determining dangerousness, confidentiality versus reporting, HIV disease policies, smoking policies, drug screening, and mandated reporting of colleagues. Through the past three decades, the embattled Hippocratic Ethics has also undergone modification as the medical value sys-

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tern has become attenuated. That value system, which was previously implicit in medicine, has been converted into formalized codes of ethics which change over time and are arrived at through committee consensus. Such codes of ethics reflect the social values or conventions of their time and currently reflect the conventions following the Discontinuity rather than the professional values developed through multiple cultures and over time. One only needs to look at the American Psychiatric Association's annotations of its code of ethics from the 70's to the end of the 80's to see the changes t h a t reflect the radical Discontinuity(21,22). The second major change has been the reinterpretation of standards of conduct (code of ethics) into standards of practice (legal standards for determining malpractice claims) which convert medical codes of ethics into a legalism rather t h a n an ethics(23). The physician now becomes a mirror of social values or conventions, with no medical ethical base from which to disagree with whichever way the political or social wind may blow. Individual physicians may dissent, based on personal conscience or belief systems, but the transcultural and historical professional base of medical ethics will have been undermined. History amply demonstrates the danger when only "political correctness" remains as a standard for medical ethics.

THE H I D D E N FLAW IN M E D I C A L ETHICS Applying ethics to medicine assumes that the state of knowledge and development in ethics is sufficient for its application. That is probably mistaken(24,25). Medical ethics has serious problems with validity. Contrary to bureaucratic consensus, philosophically there are multiple contending theories of value and ethics. None of the traditional theories has been rationally demonstrated to be true or accurate(14,26,27,28). There are cultural biases, gender biases(29), political ideologies, and prejudices t h a t distort ethical theories. What the new medical ethics has done is actually to reject rational investigation of values and replace it with post-modern process, an academic name for politics and its strategies for consensus. That such a new medical ethics can work at all may reflect the psychological and practical needs of physicians. The need for certainty and the difficulty of making life-and-death decisions in the context of uncertainty are strong factors in accepting prema-

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ture closure or consensus, in gaining comfort from the use of protocols, and in seeking security from malpractice concerns through the use of bureaucratic ethics. The cost to the physician, patient, and profession is, however, high. Given the lack of validity and the contradictions embedded in the medical ethics developed after the Discontinuity, how have all these lines on the Timeline managed to coalesce into a medical ethics powerful enough to break with the Hippocratic tradition? There are two significant conflicts to resolve: (a) the conflict between Civil Rights Legalism and Cost-Containment Ethics, and (b) the conflict between a combination of those two and the weakened Hippocratic Code of Ethics. This is done quite adroitly, if not quite validly. Civil Rights legalism concentrates on only the negative right to refuse treatment and does not seriously claim an ethical right to have treatment (consider the NYS Do Not Resuscitate Statute, the NYS Durable Power of Attorney, the NYS Court of Appeals Eichner-Storrar Decision, the NYS Court of Appeals R i v e r s vs. K a t z Decision, the US Supreme Court Cruzan Decision, federal and state nursing home regulations on treatment refusal rights, all of which involve withdrawing, withholding, refusing treatment). Non-treatment of chronic and terminal cases generally is cost-saving. The almost absent ethical right to have treatment would be expensive. As a result, the only theoretical right to treatment involves giving everyone equal access to few or no treatments, or ruling that if treatment is not given, involuntary commitment cannot be upheld. The negative right to refuse medical care according to the civil rights legalism then is incorporated with the underlying economic goal of cost-containment utilitarianism and only needs an integration with the modified Code of Ethics to produce the basically economic-political consensus of Post-Modern Medical Ethics. This is easily accomplished. The Codes require respect for patient autonomy over the best interest of the patient, relieving physicians of their role as advocates for the patient's good and allowing easy and unexamined refusal of treatment. Good outcomes are redefined as cost-effective outcomes and the misunderstood Do No Harm standard militates against technology and active intervention. Acceptance of the economic gatekeeper role legitimizes rationing of resources. The standard of confidentiality of medical records is given an exception for third-party payers, utilization reviewers,

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and other regulatory data-collectors. One of the last hold-outs, the prohibition against killing patients (which in many cases is not a cost-effective prohibition), is currently under attack as unethical. Medical ethicists are arguing that patients have a right to be assisted in suicide by physicians, and that physicians should have legal immunity for terminating the lives of patients, not only passively, by allowing them to die, but actively, by directly killing them. The Wanglie and Baby L cases clearly illustrate that when patients or their surrogates want continued medical care, medical ethics applies a utilitarian standard of scarce resources and an appeal to medical authority and control of access to care, whatever the legal decision(30,31). However, as in the Cruzan or Busalacchi cases, when patients or their surrogates refuse medical care, medical ethics applies a civil rights legalism standard of autonomy of choice and enjoins physicians from working against the patient's wishes, because that would be unethical(32). The Quill case points to the social and political agenda of the new medical ethics for the future: the civil right of physician-assisted suicide, because it is more cost-effective t h a n medical care for pain control and comfort until death(33). The rewritten Hippocratic Oath suggested by a physician at the beginning of this article now can be seen as fitting into a social pattern or trend which is quite ominous, and as expressing a politically correct view of medical ethics which needs to be criticized and challenged: ~'I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being, whose illness may affect the person's family and economic s t a b i l i t y . . . " If it is given me to save a life, all thanks. B u t it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty..."(3) (underlining for emphasis mine)

SYSTEMS ETHICS I want to suggest an alternative to the nihilism and political correctness of medical ethics since the Discontinuity: Systems Ethics. Something new and very fruitful occurred in the world of ideas during this century, spreading through the physical and biological

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sciences but still not fully appreciated in the humanities. It is known by different names in different specialties: General Systems Theory(34), Hierarchy Theory(35), Chaos Theory(36), Ecosystem Ecology(37,38,39,40), Family System Theory(41), Holistic Theory(42). It is the modern method used by biologists (population dynamics, ecosystem research), physicists, biomathematicians (chaos dynamics and "attractors"), medical science researchers (homeostasis, bioamine systems, chaos systems in cardiac arryhthmias), ethologists, and psychiatrists. It could be a powerful tool in the humanities(43), and particularly in ethics, helping us understand accurately and fully the interrelated ethical issues in Human Immunodeficiency Virus (HIV) disease, as well as the abstract, highly theoretical puzzle of the mind/body problem which is crucial to the theory and practice of psychiatry(6,44). In this paper it will not be possible to trace the origins of systems theory. The following is a list of basic concepts from which a Systems Ethics approach to medical ethics will be developed, with a case illustration: 1. Systems Theory is an integrative, inclusive way of viewing experience (multi-level, multi-focal)(44). 2. Systems Theory is part of the inductive method of scientific thinking(13,24). 3. Systems Theory describes levels or focuses of the organization of the building blocks of the natural world(34-40). 4. Simple and complex levels or focuses are fundamentally connected with bi-directional effects(45,46). 5. One level or focus is not "better" or "higher" than another, simply more or less organized. 6. Because of basic integration, interventions should try to maintain a workable balance of all levels.

THE QUILL CASE The method for Systems Ethics medical ethics can be outlined briefly and applied to the Quill case. Briefly, Timothy Quill, M.D., a physician trained in Behavioral Medicine, wrote an article for The New England Journal of Medicine in which he described his assistance in his patient's suicide(33). ~'Diane" was a long-term

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patient of his with a previous history of alcoholism and depression, as well as a successful recovery from vaginal cancer. She developed a skin rash and fatigue, which tests indicated was acute myelomonocytic leukemia. Dr. Quill presented the treatment choices (as he says, he ~'probed the costs of these cures" and listed in detail the possible side effects) which would give her a 25% chance of a long-term cure. The patient rejected any treatment and only wished to go home and be with her family, a husband and collegeage son. Discussion with her and her husband centered on her cognitive understanding of the choice and her belief, partially confirmed by the physician, that she would die while suffering ~unspeakably." A second hematology consult was obtained, and the patient talked with a psychologist she had seen in the past. Home hospice care was arranged. At that point, the patient also indicated that she wanted to commit suicide in the least painful way possible. Dr. Quill thought this request made "perfect sense." He referred her to the Hemlock Society which has an active chapter in the Rochester area, composed of physicians, psychiatrists, nurses, religious leaders, and others. The patient then phoned for barbiturates for sleep. Dr. Quill invited her to the office to discuss this and made sure she knew the dosage for sleep and the dosage for suicide. He evaluated her as not impaired in her judgment. After writing the prescription, he requested t h a t she inform him before committing suicide. Several months later, she called to tell him she intended to do it shortly. They met at his office, said tearful goodbyes, and talked about a reunion in the future on Lake Geneva, %vith dragons swimming in the sunset." Two days later, her husband phoned to say she was dead. Dr. Quill went to the house, talked with the family, and called the medical examiner to report a hospice patient death from acute leukemia. He did not mention the suicide. It was later learned t h a t the patient's body was donated for nursing student education, and the body was finally located and autopsied. A careful autopsy confirmed death by overdose of barbiturates. The district attorney's office presented the case to the grand jury with no recommendation to the jury. There was also no indictment returned for falsifying a report to the medical examiner. For purposes of analysis, there are actually two Quill cases: (a) the "private" Quill case which was a medical interaction between a patient and physician in the privacy of a medical relationship, and

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(b) the "public" Quill case which was a symbol and trial balloon for the cause of generalized physician-assisted suicide. The article in The New England Journal of Medicine was part of the second Quill case. How can Systems Ethics begin to look at this case? These are the suggested steps and their application: 1. After noting the facts of the case, determine whether the medical facts indicate a pseudo-ethical problem or an actual ethical problem. Are there options which can eliminate what seems to be an ethical problem? Are the standards used in identifying ethical problems reality-oriented, or do they neglect multiple effects, naturally occurring trade-offs, or the effects of allowing the status quo to continue?(47) 2. Make a list of all the levels relevant to this case-clinical, political, legal, economic-which must be identified to understand what information is needed, what hidden agendas may be operating, and what conflicts of needs and interests can be anticipated(5). 3. Make participants in a given case aware of the level at which they are operating and to which they owe their primary obligation. Conflicts of interest are even more of a problem when the participants are not aware of the conflicts. Clarifying the focus of obligation is critical(48). 4. Describe the internal functional requirements Cneeds" and "interests") of the level at which the ethical analysis becomes focused. Listing needs and interests will quickly reveal the unfinished state of ethics and the area where the most work needs to be done. This should not be armchair work, but should bring in all we know about the h u m a n organism, so that we can scientifically identify objective needs and interests. Such needs will usually be a web (homeostatic) rather than a ladder (rigid hierarchy)(49). 5. Consider consequences of the available options at all levels; do the full analysis for both non-interventions and intervention options. Make sure the consequences are not science fiction fantasies, but truly probable consequences, both external and internal (psychological, emotional, sense of self). 6. Determine the balance-set point that would meet the primary obligation to the focus-level while maintaining reasonable systems function. "Balance" is an ongoing integration of as many functions at all levels as it is realistic to achieve, and is not, therefore an either/or mechanism requiring the sacrifice of one pole(46).

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7. Monitor the changing situation, since situations are dynamic. Premature closure or consensus is as bad in ethics as in therapy. Inflexible legal codification is unacceptable. 8. Assume t h a t when the ethical conclusion to a case is reached, it will represent ethical behavior which is typical h u m a n behavior. Although the media (and some professionals) describe medical ethics as hard choices, tragic dilemmas, agonizing over cases, lamenting with the patient, or other extreme terms, ethical behavior is routine and normal behavior grounded in the early empathy of infants and children(50,51,52). Medical ethics too often drops to personal attacks, to labelling of saints and sinners, or to identifying reformers with halos versus old-guard '~dinosaurs." Systems Ethics can help us avoid the traps of punitive judgmentalism and unconscious sadistic self-righteousness.

APPLYING SYSTEMS ETHICS TO THE QUILL CASE

Step 1 Both the private Quill case and the public Quill case represent an ethical problem that is fundamental to medical ethics, an attempt to change the historical medical value system's prohibition against physicians killing patients intentionally. The trust in physicians which was assured by the previous value system will be greatly impacted by this case and others like it. The definition and selfimage of physicians will also be impacted. The goals of the medical care system will be altered. This case is certainly an actual ethical problem in medicine. The private Quill case is perhaps less critical as an ethical problem and it might have remained private. Physicians may step outside their public role as physicians to make decisions that they do not want generalized, that are personal, and that reflect a long-standing friendship with some patients that physicians feel can legitimately modify the professional prohibition against killing a patient. Family ties or a close personal relationship may allow for some exceptions to the general rule. Such an exception cannot be routine, however. The majority of physicians reporting such decisions describe just such a relationship, and consider the decision an exception to their general prac-

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tice which they do not continue to make with multiple cases(53). Also, it is very important to separate intentionally killing a patient from knowing the patient will die from large doses of painkiller, since pain control is then the primary ethical goal. Those are two very different situations, and activists have unfortunately attempted to conflate the two in arguing for the obligation of physicians to kill patients. The obligation to control pain and provide comfort care (sadly lacking in much current practice)(54) is not the same as the obligation to assist in a patient's suicide by killing the patient. Finally, we should not become lawyers or Irangate witnesses in our shading of the act of assisting in suicide. If the physician supports the patient's suicide choice and even encourages it, if the physician supplies the means and instructs in its use, if the physician is informed about when the suicide will occur and talks with the patient just before the act, the physician and patient are together planning and impIementing the suicide, whether the patient's hand takes the pills, a machine injects a drug, or the physician injects a drug into the patient. If, in addition, the physician refers the patient to the Hemlock Society, there is a clear message of supporting and aiding in the suicide. There are as many psychological ways to cause an act as there are physical ways. Step 2 This case presents a huge spread of relevant levels. Physicians may not want to consider the multiple levels of their cases, because of all the time- and efficiency-constraints of modern medicine, but in medical ethics, it is imperative to know the important levels in a problematic case. Starting from the least organized (although very complex), one must list the breakdown in the bone marrow monocyte system and the possibilities for reversal of that breakdown. How this physiological breakdown effects other systems (e.g., the CNS) should be considered. The patient's affective adaptation also needs to be listed, particularly since there is a history of alcoholism and depression, and since she is not in therapy with a psychiatrist but is being treated by a behavioral medicine physician. The patient's family system needs to be listed and given much more description than has been given in any of the discussion of this case. The family has basically not been considered except as very

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peripheral to the patient-physician relationship. The extended intimate relationships might include the physician, and this needs to be listed and discussed in terms of role relationship, real friendship, transference relationship-particularly because of the metaphor in the Quill article about dragons swimming in the sunset(33). This level also needs to describe the physician's countertransference feelings or real feelings about medical intervention, new treatment technologies, and identification with death. The social system level includes membership in activist groups such as the Hemlock Society or Concern for Dying and the involvements of those groups, the social commentators' perceptions of medical care and treatment of the terminally ill, and social movements concerning those questions. It will also include the political and economic goals of cost containment in medicine, and the relationship of economic cost-cutting and cost-effective medicine to limiting access to treatment or encouraging treatment refusal(I,5,6,12,55). The legal codes of society and their justifications will also have to be included and broadened into political philosophy. If the patient or physician has a religious belief system, t h a t too needs to be listed. As an illustration of the importance of listing all important levels, consider the possible hidden economic agenda in the public Quill case. All too often, medical ethics avoids this level, or assumes t h a t a utilitarian sacrifice of the individual for the group is the only right choice, or confuses giving everyone equal access to inadequate or non-existent medical care with a just resolution of society's obligation to meet its members' needs. Cost-effectiveness sacrifices the individual level for the efficiency and utility of the social level, forgetting that the individual level composes the social level in an integrated system and that unnecessary or unwise sacrifices of individuals can destroy the system or create an unacceptable level of functioning(6,25,44,48). Current economic/political first-order decisions about the amount of money to be allocated to health care should not be assumed as a given natural scarcity of resources(11,12). It is a chosen scarcity, kept quietly implicit because its explicit discussion would violate social values we wish to think we have. Instead, second-order decisions (triage, rationing of access, limiting of research and development, scaling down of facilities) are discussed in terms of how best to achieve them, assuming that they must be made. Second-order decision such as closing clinics, limiting beds,

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having waiting lists, and disallowing coverage are publicly debated; first-order decisions are not. One important second-order decision is the terminating of patients who are expensive and have no utility: those in vegetative states, those with progressive chronic diseases, those who require advanced medical treatment or ~experimental" treatment, and those who will be terminal but will be very expensive to maintain comfortably until death. Already, nursing homes, maternity wards, and business benefits offices are, or are encouraged to begin, seeking decisions on Do Not Resuscitate forms and Living Will documents. Although Dr. Quill's patient was not structured by an institution or business to terminate her life sooner rather than later, many other patients and workers will be. The economic element in this ethical situation should not be ignored or discounted.

Step 3 In this case, there are so many possibilities of conflicts of interest that it is very important for the physician to have identified what the focus-level of his obligation actually is. As an advocate of physician-assisted suicide, DNR orders, and withholding medical intervention, has his advocacy created a conflict of interest with the patient's needs? Systems Ethics will not support the relegating of that responsibility to the patient's choice alone; the physician is more t h a n a facilitator of patients' wishes. For all physicians, will the cost-efficiency imperative compromise their ability to fulfill the role of achieving a good outcome for their patients? Can one be a good economic gatekeeper without coming in conflict with clinical obligations to patients? From a psychiatric perspective, have physician needs come in conflict with the patient's best interest? The patient also needs to consider how narrowed a focus (present self-benefit) is appropriate in view of the extended system in which she operates. Will there be a suicide legacy left to the family, as happens often enough to cause realistic concern? Is the request to assist in suicide an ethical request to make of one's physician and is the enormity of this request fully appreciated? The family must decide where their focus will be as well. Are there family dynamics that are extruding the patient or sacrificing the patient? And can these be justified, even with patient collaboration? What balance will be set between the patient's needs and the needs of the family

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system? For medical ethics, is it appropriate to use the patient's case for a goal or purpose, and does t h a t conflict with patient or family needs, even with consent? There are so many potential conflicts of interest in this case, t h a t the participants were really being naive in public discussion and documentation of the case when focuses and goals were not clearly identified. In Systems Ethics, it is important to remember, the patient's autonomy of choice does not automatically make decisions ethical.

Step 4 What might be the needs of all the levels that have been identified? In order to develop this step fully, more than the public information and Dr. Quill's interpretation of the situation is needed. This step can only be done on a case-specific basis, with adequate information and some working generalizations. The patient shared common h u m a n needs for aesthetic and intimate pleasures, for a sense of meaning and worth, for possibilities of enjoying the present and anticipating the future, for a sense of connection with family and world, for strengths to cope and adapt, for acceptance without superficial conditions, for freedom from biological depression, for comfort care and pain control, and for a sense of what can be controlled and what can be accepted. The emotional desire to commit suicide after first refusing potentially life-saving treatment needed more exploration. A patient can be intelligent, articulate, and successful in business, and still have her choices driven by psychological mechanisms that are irrational, maladaptive, and unfortunate. For the family support system and the medical support system to acquiesce to these dark forces and allow or assist in suicide would be a tragedy. To look only at the superficial level of apparent cognitive understanding would be to fail to understand the needs of the h u m a n organism. The needs of the body system, as well as the personality, also should be included. Given the natural system, the choices made must be responsible to the body and the self: the patient has an ethical obligation to herself which should not be lightly set aside under the narrow concept of autonomy. The need for '~dignity" needs clarification. There is inner dignity (self-worth, self-love) and also the respect and recognition of that dignity given by our personal relationships and social systems. H u m a n dignity does not

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exclusively depend on outer appearances, or absence of weakness and defects, or super-health. Patients are beginning to feel, however, that they will lose worth and respect unless they meet standards of appearance t h a t reject tubes, diapers, bed pans, vomitus, delirium, etc. We do not know what this patient feared about losing dignity, but we do need to include some unexpected consequences of her physician-assisted suicide. Her physician used her case publicly, her identity was discovered (in a small city, this should have been expected), her cadaver was moved from a nursing department to the morgue for autopsy, and the community learned details about her private life. Her family also had needs which the management and subsequent public use of the case did not consider: privacy, respect for her memory, inclusion in treatment choices, the need not to feel rejected by her, the need to avoid a ~'suicide legacy." The medical profession has the need to maintain trust, to have pride in meeting its obligations, to insure the compassion of its members, to protect the mental health of its members. The danger of becoming unfeeling about death because of the distancing mechanism practiced in medicine is very real. The even greater danger of psychologically identifying with death (the aggressor) should not be overlooked. Such psychological mechanisms will become more common if physicians routinely assist w i t h suicide and redefine their role to include killing patients. Even those who would not use such defenses would suffer, because the awesomeness of taking a patient's life intentionally will have unanticipated effects on the physicians who do it. Steps 5, 6 and 7

A balance needs to be set among these needs. The possibility of an implicit economic agenda needs to be recognized and the consequences of creating a medical specialty of physicians who kill patients have to be weighed. The utilitarian (cost-effective) choice assumes what has to be demonstrated. Systems Ethics requires asking and answering: Is sacrifice of the individual level proved necessary and feasible, or are the predictable effects at all levels unacceptable? Are the effects on the medical profession consistent with its mission of achieving biological and psychological goals, are these consistent with social values, and how are conflicts

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between biological goals and changing social goals to be resolved by the profession? What balance is most workable between family system needs and the needs of the patient? When activist agendas (such as euthanasia) politicize questions in medical ethics, how can those be identified and reframed into ethical questions rather than political strategies? (Sometimes it is only necessary to be able to identify the economic/political level in order to understand its proper, rather than exaggerated, role in developing a balanced medical ethics analysis.) For those who question the clinical relevance of these steps, let me sketch the ongoing direction of unexamined choices for patients with a potentially terminal disease, so that the full systems view is laid out. • Underfunded medical care systems are implementing triage or other second-order decisions without further questioning the ethics of first-order economic decisions. • Euthanasia activist groups will condition patients to choose early death as a socially-approved expression of control or autonomy, disguising the high risk of abuse. • Economic pressures will structure patients into physicianassisted death, initially at the patient's request, finally for cost-effective indications. Given the clear and imminent dangers at all levels, Systems Ethics would set the balance point quite far against physicianassisted suicide, proposing other alternatives to resolve the problems of those patients who w i s h assistance in killing themselves (an honest attempt to give the individual meaning and worth, modern pain control, reframing hidden family messages about burden and burn-out, reframing or prohibiting hidden medical messages about cost-effectiveness, medical nihilism, and uncovering social messages about utility and sacrifice). Killing oneself or assisting in suicide should not be trivialized, because there is such a high probability of abuse. Step 8 These medical ethics decisions are routine throughout the system and individuals with very good intentions will hold opposing views. What Systems Ethics require is a full analysis at all levels,

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an understanding of primary focus and obligation, and an honest attempt to find the balance set-point. A full analysis of the Quill case and the questions of physician-assisted suicide leads to a conclusion that returns us to the basic question addressed by Hippocratic Ethics: trust in compassionate physicians. It would be a major redefinition of the physician, were the medical profession to support routine and legalized physician-assisted suicides. It would return the profession to the fears of the shaman role where the patient could not know if the healer would beneficially help or maliciously destroy. Physicians should not delude themselves into believing they can institutionalize and routinize killing and not become agents of economic and social agendas t h a t will not be based on the needs and best interests of their patients(56).

ACKNOWLEDGMENT The author wishes to t h a n k Norman J. Pointer, M.D. for his practical wisdom about ethical theories.

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