Ethical Dilemmas in Psychiatry

Philip G. Ney MD, MA, FRCPC MRANZCP Rpsych

Published in: New Zealand Medical Journal, November 9, 1983

The medical profession, psychiatry in particular, does not have an entirely honorable record. It has been susceptible to popular and political demands to provide swift death rather than support difficult living. Psychiatrists, including nine professors of famous universities, led in the establishment of hospitals of final solution and helped develop the technology of euthanasia which Hitler used for genocide. "In 1941 the psychiatric institution, Hadamar, celebrated the cremation of the ten thousandth mental patient in a special celebration. Psychiatrists, nurses, attendants and secretaries all participated. Everybody received a bottle of beer for the occasion"^1. Approximately 300,000 German psychiatric and psychopaedic patients were exterminated. After analyzing the soci-political conditions in Germany during the period 1933-1945, von Spaete and Thom² indicate that those dark chapters of the contemporary history of psychiatry have been overcome only where the preconditions have been radically dealt with. In Russia and elsewhere psychiatry is still used for politically repressive purposes^3. No psychiatrist is free from the same pressures to normalize mavericks, or to make medico-social judgements on groups of people. The events at Oakley Hospital prompt us to ask if civilized, scientifically trained psychiatrists in Germany could so drastically deviate from ancient ethics, could the same happen to us?

Technology has given medicine a measure of those ultimate powers: the control over life and death and the modification of thought and behaviour. With the common exercise of those powers, psychiatrists may begin to believe that they have the wisdom to determine who should live and who should die. With a respirator, doctors can easily sustain a life that would end. And with the suction curette quickly terminate a life just begun. But are we able to judge who qualifies for life and who deserves to die? Patients who commit themselves to the care of a physician because he is clinically competent do not necessarily believe the physician is wise. If the physician goes beyond his mandate to always treat, the patient will question his competence.

If the size of the medical damage suits overseas⁴, the demand for informed consent, the pressure for patients' rights and the questioning of medical funding are any measure, then it would appear modern physicians are losing patients' confidence. When they swore never to poison their patients, our predecessors gradually gained an aura of trustworthiness, which allowed them to poke into those areas of the body and mind considered most private. We may be losing credibility because patients are no longer sure of their physician's commitment to preserve everyone's life if at all possible.

Recognizing they are gradually losing the confidence of patients, some physicians hope to substitute diminishing trust with greater popularity. "If they will not let me do this because they trust me, they may let me because they like me." Unfortunately, to depend on popularity in order to practise, is likely to make physicians very vulnerable to shifts in popular morality or political expediency. Since people particularly protect the privacy of their mind, people distrust psychiatry more than other branches of medicine. To avoid using legal constraints to treatment and to gain patients' co-operation, modern psychiatry tries hard to be understood and liked. This makes psychiatry very vulnerable to forces that shift medical ethics. The historical medical mores that have guided the professional personal conduct of physicians for so many centuries, are rapidly changing because: (1) there is an increasingly utilitarian attitude to life; (2) chronically ill people live longer but doctors want more time for rest and recreation; (3) dying is made to look easier; and (4) the increasing desire to be a popular physician.

Materialism is encouraging physicians to adopt a utilitarian attitude to life. Behind the question, "In that disabled state, what can he contribute?" are more basic ones, e.g., "Can he ever become a good worker or consumer?" or more particularly, "What can he ever do for me?" It is too easy to assume that if he can contribute little to our enjoyment of life, then life is not enjoyable to him; if he is of little value to society, then his life must be of little value to him. In a society with utilitarian values, the children, old people, handicapped and the mentally ill people will lose in value first, for they appear to demand more than they give. Patients know that as their value declines, so will their standard of medical care. They are more inclined to trust a physician who does not try to calculate a patient's value. Psychiatrists know that as the value of the mentally ill declines so will their work and their skills as valued by society, decline also. Labour saving devices have made it possible for almost every western person to have a right to rest and recreation. Modern technological medicine with its wonderful capacity to treat illness in the absence of the physician, has made it possible for doctors to enjoy as much recreation as anyone else. A good doctor may only diagnose and prescribe correctly before going off to play golf. He may forget that until recently physicians have had to struggle alongside the patients. Because they could seldom give patients a life-saving biochemical, our forefathers gave patients whey they could; hope, support, wisdom and comfort.

Psychiatry, with less predictable technology, still practices in the more ancient mode. A psychotherapist knows that his patient's well-being depends less on the pharmacopoeia than on the amount of time they spend together. It is not surprising that psychiatrists envy their colleagues who with predictably effective machines, biochemicals or techniques, are more able to assert their right to leisure.

All physicians are prone to resent expending energy on, or forfeiting recreation time for patients who refuse to improve. When technological medicine no longer effects a cure we may want our chronic patients to see another physician or go away or die. The presence of the chronic, dying or valueless patients, reminds us of our ignorance and impotence. Chronic patients force us to examine the limitations of our skills which we may not wish to recognize.

Modern methods of dying appear to be much more pleasant. We have begun to understand the process and we are encouraged to work through saying that final goodbye. We have drugs that relieve most pain and drugs to tranquillize much fear. Modern facilities provide a warm and comforting atmosphere. Unfortunately dying is still the most terrifying experience for the majority of people. Although it is helpful to gradually let go of all that is near and dear, it is not abnormal to not accept death, as Kubler-Ross seems to imply⁵. We may tend to justify a practice that may be more for the comfort of the physician, by stating it is in the best interests of the patient. We may become adepts a rationalizing our attitude toward death for other people. We have the verbal facility to sound very convincing to relatives who also might want to justify sending granny on her way. But the arguments that support euthanasia, the right of women to abortion, the importance of not encumbering parents with retarded children and the social benefits of amniocentesis, are tainted with the obvious selfishness of those who are most likely to gain. In spite of the careful rhetoric⁶, it is hard to believe the unborn infant gains much by being aborted. Physicians are terminating the unborn with techniques, that are unnecessarily hazardous to women, because they do not want to upset the staff⁷. Others justify abortion with pseudo-psychiatric rubrics well aware that psychiatric illness is a contra-indication for abortion⁸. Patients can perceive professional duplicity. Their increasing distrust is making it harder to practise.

The sworn tenets of the Corpus Hippocraticum⁹ were basically pragmatic. Influenced by their cultural belief that those patients who did not improve had offended the gods, early Greek physicians often felt it was their duty to terminate a painful life with poison. Hippocrates and his colleagues changed all that when they swore, "I will neither prescribe a deadly drug to anyone if asked for it, nor will I make a suggestion to this effect". Why? So that patients would become more trusting and therefore, co-operative, so they wouldn't question their physician's' intentions when they arrived to examine and treat. Hippocrates and his colleagues promised, "I will not give a woman an abortive remedy". Why? They knew that women with ambivalent feelings about pregnancy could easily be persuaded by spouse, parent or state that it was in everyone's best interest to abort. They understood that patients trust doctors more if they were beyond that persuasion. Hippocrates' group insisted that sex with any patient, free or slave, was taboo. Why? Because they knew that in their helplessness and dependency patients all too easily would acquiesce to their physician's selfish requests. They knew that patients could more comfortably allow themselves to be dependent, if they knew their doctor was bound by an oath never to take advantage of his patients.

The intent of the ancient oath of Hippocrates was to gain patient confidence and co-operation. I believe that without that oath or something very similar, we could not practise modern medicine. Physician popularity is no substitute for mutual trust. The patient-doctor confidence that has been developed with such difficulty over the centuries, can so easily be undone. Psychiatry has always been less well trusted and therefore, more than any other branch of medicine it needs to be guided by immutable oaths. The Oakley affair may undermine public and private confidence in psychiatry. It is time we kept a running measure on patient-doctor confidence and credibility. It is time we examined all the implications of changing medical ethics. If for no other reason than because they are so pragmatic, it is time we reaffirmed our ancient tenets. Such a reaffirmation that highlights the pragmatic aspects of an ethic would read as follows:

Since I am not sufficiently wise to know who qualifies for life and who deserves to die, I will seek to preserve the lives and improve the living of all my patients. Since I cannot practise good medicine without my patients' trust, I promise not to poison or hasten the death of anyone. Since I suspect my own motives in asking of what value is a life, I must treat everyone to the limit of my resources. Since I never know when people really want to die, and never truly understand under what duress they appear to accept their fate, I will always attempt to give reasons for my patients to hope.

Although some people cannot tolerate living as they are, I must assume no one really wants to die. I believe that all my patients prefer me to improve their living rather than hasten their dying. Since technology, politics and society tend to change morality, I will hold to an ethic that is independent of time and culture. Since there is no good evidence that any person is essentially better than any other, I will assume all people are equal regardless of size, sex, shape, colour, age, creed, intelligence, social status, or place of residence. Thus I must love my neighbour as myself and give him the quality of medical care I desire for myself.

References

1. Wertham F. A sign of Cain: an exploration of human violence. New York: Macmillan, 1966.

2. von Spaete HF, Thom A. Psychiatry under fascism, results of a statistical analysis. Zeitschrift fuer die gesamte Hygeine and ihre Grenzegebiet, 1980, 26: 553-60.

3. Bloch S, Chodoff P. ed. Psychiatric ethics. Oxford: Oxford University Press, 1981.

4. Murray WGD. Increasing litigation: the size of settlement in professional negligence. Lancet 1982; 1: 1063-64.

5. Kubler-Ross E. Questions and answers on death and dying. New York: Macmillan, 1974.

6. Hardin G. Abortion for the children's sake. In: Reiterman G. ed. Abortion and the unwanted child. New York: Springer, 1971.

7. Smith OH, Twigg HH, Croft IL, Prostaglandins in gel for mid trimester abortion: a method to minimize nursing involvement. Br. Med J. 1981; 1: 282.

8. Bakikian HM. Abortion. In: Kaplan HI, Freedman AM, eds. The comprehensive handbook of psychiatry. 2^nd ed. Baltimore: Williams and Wilkins, 1975; 1496-500.

9. Edelstein L. The genuine works of Hippocrates. Bull Hist Med 1939; 7: 236-48.