Joumnal of medical ethics, I982, 8, 122-127

Symposium

In defence of clinical bioethics

John D Arras Montefiore Hospital and Medical Center, New YorkThomas H Murray The Hastings Center, Hastings-on-Hudson, New York

In the course of his attack on the discipline of bioethicsProfessor Swales attempts to establish two con-clusions. First, he argues that medical ethics cannot bedissociated from clinical decisions and should not,therefore, be taught as a separate subject in the medicalcurriculum. Medical ethics is 'too important', he says,to have its own separate place in the curriculum. Giventhis ringing affirmation of the importance of ethics forclinical practice, one would reasonably expect Swales'ssecond conclusion to be that we must now proceed todevelop a clinically-based medical ethic - ie anapproach that would combine the conceptual sophisti-cation of contemporary ethical theory with an appreci-ation of the empirical details of clinical practice. Itcomes as something of a surprise, then, when Swales'sattack on the alleged separatism of bioethics turns intoan attack on the very possibility of applying ethics tomedicine. Since ethics in the world according toSwales is generally regarded as nothing more thansectarian, non-scientific speculation, he concludes thatbioethics cannot be fruitfully applied to the moraldilemmas that beset contemporary medical practice.Lest today's physician be left without a moral compassof any sort, however, Swales hastens to add that ahard-headed, pragmatic utilitarianism - seasoned byyears of medical experience - can serve as a guide tothe perplexed physician. This endorsement of aninstrumentalist ethical theory meshes nicely withSwales's conviction that all ethical questions in medicineare ultimately reducible to questions of technicalexpertise.

Although Professor Swales's unfavourable portraitof medical ethics bears scant resemblance to the disci-pline of bioethics as we know it, his dichotomous dis-tinction between the 'two cultures' of medicine andethics is sufficiently widespread in the medical com-munity to merit a reply. Swales's indictment of con-temporary ethics founders on a misunderstanding ofthe nature of ethics, of the interrelation of ethical andscientific considerations in clinical judgment, and ofthe role of the medical ethicist in the clinical setting.

The nature of ethicsFirst we should simply say that the opposition por-trayed between medicine and medical ethics as parallelto that between science and religious ethics amounts toa caricature ofboth the latter enterprises. Science is notmerely an inductive ingathering of empirical facts, butan immensely more complex and more interestingaffair, bristling with idiosyncratic hypotheses andother 'subjective' elements. Many eminentphilosopher-historians of science have argued that allof our theories necessarily presuppose a certain pre-scientific parti pris - a certain way of viewing the world- and have consequently ruled out the very possibilityof any clear 'direct observation' of nature un-mediatedby the tinted 'lenses' of our competing theories (i).Science is not nearly as concrete and anti-metaphysicalas Swales's outdated portrait of it suggests. Good sci-ence requires the same sorts of judgments and rationalarguments as good work in ethics.

Likewise, Swales does little justice to theologicalethics by portraying it as amounting to nothing morethan a dogmatic appeal to indefensible sectarianbeliefs. At the least, this caricature ignores the extentto which secular and theological ethics have convergedin defence of similar (but not identical) values, such asfidelity between physician-researchers and patients,the fostering of patients' welfare, and the rights ofpatients to self-determination and autonomousdecision-making. Swales consequently obscures theenormous contributions of theological, ethicists (suchas Paul Ramsey, Joseph Fletcher, James Gustafson andRichard McCormick) to contemporary secular debatesover such issues as genetic engineering, humanexperimentation, and the cessation of so-called 'extra-ordinary' medical treatments. If medical ethicsamounted to nothing more than the recitation of inde-fensible maxims, and if ethical expertise were equival-ent to the skills of the advertising man who cons us intobaying one kind of soap rather than its indistinguish-able competitor, then Swales would be correct, and theethicist would have no more business in the clinic thanthe carnival barker. But religious medical ethics and, afortiori, contemporary secular ethics amount to muchmore than Swales would have us believe.

In fairness to Professor Swales and those who share

Key wordsMedical ethics; bioethics; medical education; patients'autonomy; ethicists.

Symposium: in defence ofclinical bioethics 123

his views, we must concede that some of the literatureon medical ethics does seem to portray the enterprise as

a facile invocation of remote and abstract ethical prin-ciples to specific issues: G E Moore on informed con-

sent, Leviticus on prenatal surgery, or, as ProfessorSwales appears to prefer, Bentham on terminatingtreatment. His remarks on the meaninglessness ofethical expertise - or at best its irrelevance to clinicalpractice - would be well taken if medical ethicists didnothing more than recite from grand theories. Butsound ethical inquiries in medicine are not like this atall.

Consider, for example, the nature of the principlesthat bioethicists habitually apply to the doctor-patientrelationship. In response to an antiquated and nar-

rowly professional Hippocratic ethic, contemporarybioethicists have enshrined the 'principle ofautonomy'as the centrepiece of their emerging theory of howpatients and physicians should relate to one another.A firm principle has gradually emerged from theconvergence of various ethical traditions to the effectthat medical decisions concerning the lives ofpatients properly belong to those patients, and not tophysicians, no matter how knowledgeable or well-intentioned the latter might be. This principle of self-determination draws support from a wide variety ofdisparate ethical and religious traditions: from Kantiannotions ofautonomy and dignity, from the Utilitarians'conviction that the greatest good is best served byallowing each person to decide what is in his or her bestinterests, from the Lockean theory of natural rights,and from the Judeo-Christian teaching on the unique-ness and preciousness ofeach individual human being.Diverse as their ultimate first principles might be, eachof these 'grand theories' lends support to the moremodest middle-level proposition that, in the absence ofcompelling countervailing reasons, individual self-determination should prevail, even in the face of con-

trary medical advice.Although the principle of autonomy occupies by far

the most important place in the constellation of bio-ethical principles, several other middle-level principleshave been articulated to guide the moral deliberationsof health professionals and health planners. Theseinclude the principles of non-maleficence, benefi-cence, justice, veracity, and confidentiality (2). Thus,one perfectly respectable view of this emerging fieldholds that 'doing medical ethics' should (and oftendoes) consist in the identification, articulation, andapplication of such convenient middle-level principlesto concrete situations.

This conception of the relationship between ethicaltheory and practical application has undoubtedlyachieved the status of a reigning paradigm in the bio-ethics community, but it is by no means the onlyavailable self-understanding of what bioethics is or

should be about. An intriguing alternative is currentlybeing explored by Albert R Jonsen and StephenToulmin (3). These philosophers take the usual pre-sumed order (from principles to cases) to be mistalen,

or at least greatly oversimplified. Our clearest andsurest ethical judgments, they claim, are often aboutcases. In fact, novel cases often cause us to modify ourprinciples; this is how much argument actuallyproceeds, even in theoretical ethics. If we understandJonsen and Toulmin correctly, they conceive of ethicsin practice as a dialectical process of 'casuistry',wherein principles are fashioned and modified largelyin response to their ability to articulate our intuitiveresponses to particular cases. Once again, the workingprinciples are at the middle level; much of the work ofpractical ethics consists in identifying which principleor principles are most important or fruitful in theparticular case. Whether we prefer principle-ethics orcase-ethics (approaches that might well merge inpractice), both require careful attention to concretedetails, and both involve more than the vacuous incan-tations of abstract principles that Swales mistakenlyidentifies as ethics.

The intersection of clinical judgment and moraljudgmentAssuming that ethics is not the spooky metaphysicalbusiness that Swales makes it out to be, exactly how arewe to conceive of the relationship between clinicaljudgment and moral philosophy?

Swales appears to be of two minds concerning thepossibility of a fruitful collaboration between moralsand medicine. In the first part of his essay, he main-tains that ethical decisions in medicine cannot be dis-sociated from clinical decisions, adding (rather disin-genuously, in our opinion) that medical ethics is 'tooimportant' to be taught separately. But in the remain-der of his essay, Swales adamantly declares thatmedicine is science, medical ethics non-science, andnever the twain shall meet. One is left wondering howtwo inseparable subjects can have nothing to do withone another. Perhaps our perplexity will abate uponcloser examination of Swales's (apparently) contradic-tory assertions.

First, what does Swales mean when he claims thatmedical ethics cannot be dissociated from clinical deci-sions? The least he could be claiming is that medicalethics necessarily or essentially concerns itself withmedical decisions, just as business ethics is aboutbusiness, or engineering ethics about engineering.This claim is true, but only because it is a tautology; assuch, it does not tell us whether it is either possible ordesirable to teach medical ethics as a separate subject.A more interesting interpretation of the essential

connection between medical ethics arnd clinical deci-sions would assert that theory construction in medicalethics must draw on a knowledge of medical facts andmedical practice. Few, if any, practising bioethicistswould take issue with this claim. Indeed, they wouldassert that good work in bioethics must be firmlyanchored in the medical facts. Still, this belief in noway implies that the theories and methods of medicalethics cannot be presented apart from the clinical set-ting. It may or may not be pedagogically desirable to

1124 John D Arras and Thomas H Murray

teach medical ethics as a separate subject but it iscertainly possible to do so.

So we are left with a much stronger and much morecontroversial interpretation that alone seems to capturewhat Swales has in mind: medical ethical judgmentscannot be separated from clinical or technical judg-ments because they cannot be distinguished concep-tually as two distinct sorts of judgments. In otherwords, medical ethical decisions are clinical deci-sions. Contrary to the previous interpretations, thisone is neither tautologous nor platitudinous; it is,however, plainly false.

Swales attempts to support this contention by notingthat ethical and clinical decisions frequently mas-querade as each other. It is true that a good deal ofmasquerading goes on in the hospital setting; doctorsoften cloak their moral advice to patients in the lan-guage of medicine, and bioethicists are often calledupon to discuss problems that turn out, on closeexamination, to be largely medical (4). But Swalescannot support his sweeping implication that all medi-cal ethical issues are really clinical by alluding to theseoccasional transformations. Although moral concernspervade clinical decisions, they can nevertheless bedistinguished from the merely technical. The occa-sional case in which a question ofmedical managementposes as an ethical issue does not demonstrate that allmedical ethical issues are really at bottom clinical. Noamount of medical knowledge can tell us whether theJehovah's Witness is morally entitled to refuse a bloodtransfusion, whether a woman with breast cancershould be able to choose between a radical mastectomyand lumpectomy, or whether severely defective neon-ates should have to make way for healthier babies in anovercrowded intensive care unit (ICU). Doctors mustprovide much-needed medical knowledge bearing onsuch questions, but medical data alone will neverdetermine the 'solutions' to these moral dilemmas.Problems such as these highlight the fact that, whileethical issues might well be firmly embedded in theclinical setting, these clinical decisions are themselvesembedded in the larger human context where suchmoral concerns as truthtelling, personal autonomy andjustice hold sway. These larger ethical concerns formthe warp and woofofcontemporary biomedical ethics.

After having argued that ethical and clinicaldecision-making cannot be dissociated, Swales per-forms an about-face, declaring that no matter howearnestly bioethicists try to acquaint themselves withthe medical facts, they will never be able to 'throw lighton what we [doctors] should do'. This, he says, isbecause ethics is essentially metaphysical or religious,while medicine proceeds according to a scientificmethod. Here Swales seems to be arguing that ethics isso easily distinguished from medicine that it is actuallyirrelevant to it!As we have already seen, this attempted assimilation

of ethics to religion is based on a seemingly completeignorance of the discipline of secular ethics and on anunjustified devaluation of religious ethics. Neverthe-

less, Swales makes other points here that merit aresponse. While he insists that non-scientific outsiderscan contribute nothing to clinical decision-making,Swales does grant a certain validity to a utilitarian ethicespoused by many in the medical community. Thisethic is concerned exclusively with 'doing good' - iewith maximising the welfare of the patient. And sincean accurate appraisal of the patient's welfare must restupon a knowledge of the medical alternatives, Swalesconcludes (rather hastily) that only physicians are in aposition to make this sort of ethical judgment.

This contention is vulnerable even if we assume thevalidity of an exclusively pragmatic or patient-benefiting ethic in the Hippocratic tradition. Such anethic, if it is to be anything more than a mere diagnosticand treatment manual, must be geared to the totalwelfare of the patient - not simply to her medicalcondition narrowly construed, but also to her emo-tional, psychological, and socioeconomic conditions aswell. Thus, in deciding, for example, whether or not totell a cancer patient the truth, the doctor must knowabout the patient's own hopes, fears, plans and prob-lems in order accurately to predict what course will, infact, maximise her welfare. This sympathetic identifi-cation and weighing of needs, preferences, and (some-times) idiosyncratic values is no doubt a much moredifficult undertaking than Swales would have usbelieve; but even more importantly, such a task isplainly not a matter of medical or technical expertise.Doctors have no special training to do it; and they areoften pretty bad at it - (not, we hasten to add, becausethey are unusually insensitive to psychosocial con-siderations, but rather because of their own pre-disposition to treat patients in certain ways and becauseof the increasingly anonymous character of doctor-patient interactions in large hospitals and nursinghomes today). A knowledge of the technical options isobviously necessaty to make informed decisions, but itis not sufftcient to calculate the patient's best interests.To do that, one would have to factor in all sorts ofhazy,non-scientific variables such as the patient's attitudetoward cosmetic appearance, aversion to risk, etc.

Apart from these problems which are internal toSwales's pragmatic medical ethic, there are goodreasons for rejecting any medical ethic that is blind tosuch themes as patients' rights, self-determination,truthtelling, and confidentiality. Even if most doctorswere to develop the necessary counselling skills towork up an accurate and complete psychological pro-file of each patient, upon which they could base theirjudgment of 'best interests', we would still think thatthe patient retains the right to decide for herself whatshould be done by others (including doctors) to herbody. We would say that she exercises this rightbecause of her moral status as an autonomous, self-determining person. Thus, even if the welfare of apatient would seem to require a blood transfusion, thepatient retains the moral and legal right to refuse such aprocedure. Thus, Swales's bald assertion that 'the wel-fare of the patient is paramount' would have to be

Symposium: in defence ofclinical bioethics 125

complemented by an equally sensitive concern forpatients' rights.

In fact, anyone familiar with the development ofcontemporary biomedical ethics would realise that thiscluster of rights emanating from the notion ofpatients'self-determination has provided the basis for an ex-pressly covenantal or contractual patient-centred med-ical ethics that has produced rather impressive resultsin the last decade. Contrary to Swales's claim thatcontemporary bioethics has not had any noticeableeffect on medical practice - a claim based on an embar-rassingly faulty analogy between ethics and thephilosophy of science - the impact of bioethics onissues of private and public health policy has beensignificant and far-reaching at least in the USA.Although bench scientists may not have changed theirbehaviour to suit the theories of Hempel, Kuhn andPopper, doctors have dramatically altered theirbehaviour in recent years. While some ofthese changescan and should be attributed to larger cultural forces atwork on the medical community, it is hard to believe,for example, that the advent of a reinvigorated disci-pline of medical ethics had nothing to do with physi-cians' changed attitudes toward truthtelling to patientswith cancer (5). Other examples of the impact ofbioethics - eg in the fields of human experimentation,death and dying, genetic screening and behaviour con-trol - could be multiplied indefinitely.

All this has been mere brush-clearing, to establishthe possibility of a fruitful collaboration between ethic-s-and medicine despite their familial resemblances to thehumanities and the sciences, respectively. Proof thatpractitioners of the two arts can benefit from eachother's skills, and especially that the patient can also,must come from the actuality of practice.

The role of the bioethicistIf we accept that the application of ethical reasoning tomoral problems in medicine can be done in a sophisti-cated, non-dogmatic fashion, we must still ask whatrole or roles the medical ethicist can play in interactionwith other actors in the medical drama. Consider twocontrasting prototypes: the 'moraliser' and the 'anal-yser'. Swales seems to view the medical ethicist asnecessarily a moraliser - a person whose self-conceivedrole is to pass moral judgment on the actions of thosearound him, or her, usually (we might add) withoutgiving any thought either to the rational foundations, ifany, of his pronouncements, or to the ambiguities thatplague most situations calling for a moral choice.Swales justifiably rejects this conception of 'moralexpertise'; and if this were all that medical ethicistsdid, we would not defend them either.At the opposite extreme from the moraliser is the

'analyser' - a person whose expertise consists in iden-tifying the values implicated by various choices, chart-ing the implications of these choices for other valuesthat people might hold, and assessing the logical coher-ence of the arguments offered on behalf of ethical

choices. Whereas the moraliser wastes no time in rush-ing to a moral judgment, the analyser self-consciouslyrefrains from making any moral judgments, restingcontent to clarify the moral issues and expose fallaciousreasoning. Repelled by the notion that his job is to tellother people how to behave morally, the analyserwould most likely disown the title of 'moral expert'.

While we know of no one doing medical ethics seri-ously who subscribes to the moraliser prototype, manydo believe in some version of the analyser. We holdneither view to be adequate. Each contains elements ofa more complete medical ethic, but neither can standalone. The ethicist as moraliser is a parody of seriouswork in medical ethics; the ethicist as analyser placesunnecessary limits on the kinds ofwork that need to bedone. Let us illustrate with a case.

Recently one of us encountered a comatose middle-aged woman in an intensive care unit whose best hope,however slender, was to emerge severely brain-damaged, having lost both legs, an arm, and theremaining hand. Although some discussion had takenplace regarding the continuation of the massive effortsrequired merely to stabilise her debilitated condition, noone was willing to take responsibility for talking withthe family about the possibility of discontinuing theaggressive treatments she was currently receiving.The problem facing the house staff and the nurses

was what to do about the patient's surgeon. During thecourse of the unsuccessful operation the surgeon hadapparently made a forgiveable error, setting off a cas-cade of unfortunate medical complications, and hadsubsequently withdrawn both from the woman's fam-ily and from the other medical staff involved in thecase. As a result, the agonising task of communicatingwith the family fell to the nurses and house staff.A responsible ethicist could make confident moral

judgments about certain features ofthis case, but aboutother things he might only be able to engage in adialogue with the family and staff, helping them all tomuddle through. A clinical ethicist should have notrouble concluding, for example, that the family mustbe brought into a dialogue regarding this patient'sfuture course of treatment (or non-treatment). Appro-priate family members should be forthrightly (but sen-sitively) appraised of the patient's dire condition,dismal prognosis, future quality of life, and theremaining medical options. Assuming that they wishto decide and that they will base their decision on thepatient's best interest, the family should be allowedto determine whether 'aggressive' treatments shouldbe employed further to prolong the patient's life. The'moraliser' model permits the bioethicist to pass moraljudgments when there is a clear understanding thatsome important standard of ethical conduct has beenviolated. In this case, the surgeon's behaviour placedan unfair burden on the other medical staff, and addedto the terrible burden borne by the patient's family.What happened in this case, was that the patient'sfamily indicated, when finally approached, that theywould be willing to care for her no matter what her con-

i26 John D Arras and Thomas H Murray

dition, so long as she could rejoin them at home. Atragic choice, but one which must be sensitivelyattuned to the values ofthe woman and her family, andbased on the best medical knowledge available.A case of another woman with similarly bleak pros-

pects was further complicated by the intransigentstance taken by one of the first-year surgical residentsinvolved in the woman', care. This young physicianwas scandalised by the prospect of allowing his patientto die. 'I think we must keep her alive', he asserted,'that's what the medical profession is all about. That'swhat I've been trained to do'. The resident went on toargue that a decision to withdraw 'aggressive' therapyfrom the patient would be tantamount to killing her.Here; we would argue, is an ideal occasion for theethicist-as-analyser to make an appearance. Either dur-ing the case consultation itself or (more likely) insubsequent teaching rounds, the ethicist can aid clini-cal decision-making through a sophisticated, yet clear,analysis of the conceptual and moral differences be-tween 'killing' and 'letting die' in various circum-stances. We think it highly desirable that this sort ofreflective analysis replace the mere repetition ofslogans - 'Saving life is our job' - especially when theunreflective parroting of such maxims can lead toincreased pain and suffering for patients and theirfamilies.

Thus, we prefer to think of the medical ethicist as aperson skilled in moral reasoning and schooled in themedical and psychological realities of the clinic, whoseprimary function is to engage all concerned in seriousand clear reflection upon the moral dimensions of theirwork. Sometimes this task will require the ethicistemphatically to remind a physician that adult patientsof sound mind have a right to determine what shall bedone to their bodies; at other times it will require theapplication of analytical skills to conceptual and nor-mative problems. But beyond these two functions ofthe 'moralist' and the 'analyser', we see a third role forthe ethicist in the hospital: as a diagnostician of the'deep structure' of ethical dilemmas. Just as a goodphysician might attempt to relate reported symptomsto an underlying biochemical cause, a perceptive ethi-cist should be alert to the possible institutional causes ofthe ethical dilemmas that present themselves in themedical context. Rather than resting content with amodel of the ethicist as a 'moral engineer' (6) - ie, assomeone who applies the tools of ethical analysis toproblems precisely as they are presented by the medi-cal staff - we believe that the ethicist should view thestaff's presentation of a dilemma as one bit of informa-tion fitting into a larger picture. Often enough, theparticular form in which a problem is presented willeither badly misconstrue the actual problem or tend toobscure the underlying organisational reasons for thedilemma's appearance. Take, for example, the prob-lem of triage within a medical ICU. The dilemma of'whom to save when not all can be saved' is certainlyone of the most difficult and persistent ethical prob-lems faced by hospital-based ethicists; yet, as they

grapple with the 'tragic choice' of who ought to get thelast bed in the ICU, ethicists should also ask them-selves why this bed happens to be the last one. Is itbecause the hospital administration has allocated insuf-ficient resources to its ICU? Or is it the last bed becausethe medical director of the ICU exercises insufficientcontrol over who gets in and who goes out? Perhaps theethicist will discover that the problem of chronic over-crowding - and thus the dilemma posed by triage -could be alleviated by a more enlightened policy ofgiving only 'supportive' care to those patients who aretruly beyond the pale of aggressive measures.One of us has spent a good deal of time with a

particular hospital intensive care unit. Its director hadrequested our help in dealing with some thorny ethicaldilemmas which, he said, were a source of continuingdivisiveness among nurses and physicians. We foundthat, although the staff was indeed confronted by per-plexing ethical problems, the source of dissension hadmore to do with the manner in which physicians(including inexperienced house staff) related to thenurses, who often knew much more about appropriatetreatments than the neophyte doctors. In this case, an'ethical engineer' would have accepted the diagnosis aspresented by the director and thus would have over-looked the real source of dispute. Although we agreedto analyse the ethical dilemmas themselves, we alsoinsisted upon discussing the organisational and per-sonal problems that served to exacerbate the staffsdifficulties in resolving the ethical disputes.

ConclusionAs long as medical decisions are about human beingsand the kinds of lives they will lead - or leave - thosedecisions will be inextricable mixtures of medical, sci-entific and moral considerations. In most cases, nogreat ethical dilemmas emerge, and both doctor andpatient can get on with their affairs without the aid of abioethicist. But when those dilemmas do arise, or whencommon medical practices rest on dubious moralgrounds, it is handy to have a bioethicist around. Notto make the decisions, certainly, but to improve thedialogue, to help doctors to appreciate the moral com-plexities of their vocation, and, in the tradition of oneofthe first 'ethicists', to be the horsefly biting the rumpof the Athenian (or Hippocratic) steed when needed.

References and notes(i) Kuhn T S. The structure of scientific revolutiwns, 2nd

edition. University of Chicago Press, i97o; Hanson N R.Patterns of discovery. London: Cambridge UniversityPress, 1958; Feyerabend P K. Against method. London:Verso, I978; and Koestler A. The sleepwalkers. NewYork: Grosset and Dunlap, I963.

(2) See generally Beauchamp T, Childress J. Principles ofbiomedical ethics. New York: Oxford University Press,1979.

(3) Jonsen A R. Can an ethicist be a consultant? In:Abernethy V, ed. Frontiers in medical ethics: applicationsin a medical setting. Cambridge: Ballinger, I980;

Symposium: in defence ofclinical bioethics 127

Toulnin S. The tyranny of principles. Hastings Centerreport December I98I.

(4) We are, however, a bit puzzled by Swales's contentionthat the case of Leonard Arthur exhibits this 'shift fromthe ethical to the clinical domain'. If the practice of'allowing the deaths' of anomalous newborns is not amoral issue, what is? If the crucial question raised bythis case called for clinical, rather than moral, expertise,why did the members of LIFE press the issue in court?For a sensitive discussion of the Arthur case, seeGlover J. Letting people die. London Review of Books4-17 March I982; Vol 4 No 4: 3.

(5) Veatch R M, Tai E. Talking about death: patterns of layand professional change. The annals of the AmericanAcademy of Political and Social Science January I980;29-45; and Novack D H et al. Changes in physicians'attitudes toward telling the cancer patient.Journal oftheAmerican Medical Association March 2, 1979; 241:897-9oo.

(6) Caplan A L. Ethical engineers need not apply: the stateof applied ethics today. Science, technology and humanvalues Autumn I980; 6: 24-32.

ResponseJ D Swales School ofMedicine, University ofLeicesterI am flattered that my short piece drew forth suchlengthy rejoinders. I am also delighted because in spiteof the assertions made in these replies I believe that a.debate between individuals of the widest range ofbackgrounds is a desirable and necessary preconditionto finding a working provisional solution to the ethicaldilemmas of medicine. My objection was not to such adebate. My objection was to the development of the'ethical expert' and the discipline of 'medical ethics' asa discrete subject in the teaching of medical studentsanalogous say to endocrinology or gastroenterology.The implication of Arras and Murray that ethical

value judgments and the inductive observations andtestable hypotheses of medical science are qualitativelysimilar hardly stands up to critical examination (i). Dothey seriously believe that the ethics of, for instance,the termination of pregnancy are testable in the sameway as, say, those of clinical treatment? If ethicalhypotheses were testable I would agree that analogousroles for the ethicist and endocrinologist could indeedbe identified. Until I am convinced of this the argu-ments for 'professional ethicists' remain specious.

I might be persuaded by the more empiricalapproach of demonstrating benefit. I certainly am notpersuaded by statements referring to 'Swales's convic-tion that all ethical questions in medicine are ultimatelyreducible to questions of technical expertise' or thestatement that 'he [Swales] insists that non-scientificoutsiders can contribute nothing to clinical decision-making . . .'. I recognise that it is easier to attack astereotype of an intensively conservative medical posi-tion, but nowhere in my article or elsewhere have Iobjected to a wider debate with non-medical interested

parties. However, I would emphatically give primacyin such debate to patients rather than 'experts' or pres-sure groups with a particular viewpoint and it is depress-ing that both replies give so much space to the role ofvarious experts and so little to the role of the patientwhich I emphasised in my original piece. I would havehoped that from their experience Arras and Murraycould have produced evidence for the value of the'bioethicist'. Unfortunately they have not. Indeed weare merely assured that 'it is hard to believe' thatchanges in doctors' approaches have not been influ-enced by bioethicists. The examples they quote do notsupport this view. The justifiable concern with humanexperimentation in the United Kingdom, for instance,does not follow from ethicists' investigation. It largelystems originally from Dr Pappworth's book (2) whichmeticulously chronicled published studies in the medi-cal literature and explained for a lay public what wasinvolved. Ethical judgment was clearly necessary butequally clearly no expert moral analysis was required todemonstrate the unacceptable nature of what wasbeing done. The relevant previously unrecognised factwas that it was happening. It is as illogical to claim thatpublic concern with the dilemmas of medicine followsfrom the evolution of bioethics as it is to maintain thatthe equally widespread concern with the modernepidemic of cardiovascular disease stems from thedevelopment of professional cardiologists. Post hoc,non propter hoc.Most disturbing of all in Arras and Murray's article

is the description of an expansion of the role of theethicist into a social worker/psychotherapeutician whoknows 'about the patient's own hopes, fears, plans andproblems in order accurately to predict what coursewill in fact maximise her welfare'. I am even moresurprised to read that this is 'a more difficult under-taking than Swales would have us believe', since myoriginal article expresses no views about this difficultarea. Further, in the last paragraphs, a role in analysingorganisational and personal problems of staff andpatients is described which suggests quite differentactivities from those which the term 'ethical philoso-phy' would normally subsume. Such activities shouldbe judged in their own right but have no bearing on myoriginal contention.

Since the burden of my article has clearly escapedDrs Arras and Murray perhaps I could emphasise againthe importance of an open debate. What I remainsceptical about is the role of the ethicist as an expertwhose authority can resolve the dilemmas of medicinefor ourselves and our students. Judging by the analysispresented by Drs Arras and Murray it cannot do this, itcan however generate a considerable smoke-screen.

References(i) Popper K R. The logic of scientific discovery. London:

Hutchinson, 1977.(2) Pappworth M H. Human guinea-pigs: experimentation on

Man. London: Routledge & Kegan Paul, 1967.