Controversies

Moral Absurdities in Critical-care Medicine: Commentary on a Parable

WARREN THOMAS REICH, STD

The foregoing tale of EmergiMedVan serves as a parable for the burgeoning moral world of critical-care medicine, and while the narrative embodies the agenda for moral choices facing critical-care medicine, a post- script that suggests these themes more explicitly is in order.

As this paper’s title suggests, the parable of EmergiMedVan portrays “moral absurdities” in crit- ical-care medicine. Many aspects of critical-care med- icine are rightly called absurd because they are incon- gruous, or “ridiculously incongruous,” as the dictio- nary defines the term; and others are absurd because they are irrational.

The absurdity in contemporary, critical-care medi- cine is implied in the over-arching theme of the par- able, for it appears incongruous that a rational society should simply discover that a highly valued and per- sonal area of life (health-life-death) is increasingly con- trolled by institutions that are rapidly proliferating and expanding their power over us.l Furthermore, it is ironic this discovery should be made at a time when we are becoming more deeply aware of the disappear- ance of those traditions that have given us a shared assurance of knowing right and wrong.

These two disjointed themes of power and the loss

From the Division of Health and Humanities, Department of Community and Family Medicine, and Kennedy Institute of

Ethics, Georgetown University, Washington, DC.

Supported by the National Humanities Center, Research Tri-

angle Park, North Carolina, and the Hillsdale Fund.

Manuscript received February 10, 1984; revision received April

13, 1984; revision accepted April 16, 1984.

To be published in modified form in Kopelman L, Moskop JC. Ethics and Critical Care Medicine. Copyright by D. Reidel Pub-

lishing Company, Dordrecht, Holland (February 1985).

Address reprint requests to Dr. Reich: Division of Health and Humanities, Department of Community and Family Medicine, Georgetown University School of Medicine, Washington, DC 20007.

Key Words: Emergency medicine, medical ethics, autonomy, hospitals, health-care corporations, health-care regulation,

health-care distribution.

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of a common moral tradition are found in another nar- rative, George Orwell’s Z984,2 whose title also reflects the publication date of this essay. Thus, the parallels between the subject matter of the parable and that of Orwell’s work are more profound than a mere coin- cidence of dates. Both these themes are found in the larger world of American health care but are exacer- bated in high-cost, critical-care medicine. We face two themes, then, that are very similar to those bother- some to Orwell.

POWER

The first of these common themes is that of in- creasing power and shifting autonomies. Among those autonomies the first is the autonomy of the medical profession, which has acquired a privileged status in American society3-a monopoly achieved through a variety of economic and political strategies.4 Paul Starr’ has described the “sovereignty” of the medical profession in terms of its scientifically-based authority over patients and its monopoly over the structure and finances of the health-care system, especially through its control over the relation of patients to hospitals, pharmaceutical companies, and use of third-party pay- ment. Insurers became an important power base in medicine, but generally allowed doctors to retain the autonomy of independent entrepreneurs, passing on the costs of professional autonomy to the consumer.

However, the scope of the autonomy of many prac- ticing physicians was eroded by the increasing au- tonomy of the various hierarchies of medical special- ties, which began to control both supply and demand in critical-care medicine. As they acquired the role of transmitters of scientific advances in medical treat- ment, they were able to shape the demands of the ill; and through certification, restricted hospital privi- leges, and in-hospital rules they also came to control the supply.

In addition, the autonomy and authority of the hos- pital have grown as it became the dominant health- care institution. With liberal government support, there has been a tremendous growth in proprietary health-care institutions: hospitals, nursing homes, di-

REICH H MORAL ABSURDITIES

alysis clinics, home-care health businesses, and emer- gicenters. The institutional autonomy of hospitals has generally protected the professional autonomy of phy- sicians; hospitals themselves, however, (and health maintenance organizations) are becoming more heter- onomous, gradually sacrificing their authority to ex- panding health-care corporations5 In these multihos- pita1 systems, individual physicians will be deprived of much of the influence they have wielded over hos- pital policy.5 Indeed, there are indications that physi- cians practicing under corporate management will ex- perience a more profound loss of autonomy: for ex- ample, “the corporation is likely to require some standard of performance, whether measured in reve- nues generated or patients treated per hour.“5

In addition to this array of institutions that function as entrepreneurs competing for power, medicine has been strongly influenced by “rationalizers”-institu- tions that regulate the structures, quality, and cost of health care. These include the federal government, federally-sponsored organizations, states, businesses, business-sponsored organizations, employers, etc. Authority and autonomy are shifting rapidly among these regulatory agents. The role of the federal gov- ernment in financing (e.g., through Medicaid and Medicare) and regulating (e.g., through Professional Standard Review Organizations) health care is well known. Less well known are the regulatory mecha- nisms now increasing in the private sector, especially the role of the health-care corporations. In that con- text, it is likely that clinical performance of physicians will be assessed by statisticians who utilize quality- control programs in corporation headquarters.5 Thus, increasingly, medical decisions will become, or at least become strongly influenced by, business decisions. The rise of a corporate marketing ethos in medical care is now leading to designs for corporate techniques for modifying the behavior of physicians, “getting them to accept management’s outlook and integrate it into their everyday work.“’ This development will produce a subtle but profound loss of autonomy for the medical profession-not only over the social and economic dimensions of medicine, but also over the technical, medical content of their practice and the very ideals of professionalism.5

Furthermore, these institutions not only regulate American health care but also use their power to re- orient the system. It has been claimed that the Rocke- feller Foundation, for example, had an enormous in- fluence over the medical profession in America through funding activities undertaken with the partial but pronounced intention of molding a medical profes- sion that would promote corporate influence over American institutions.6 Similarly, the ascendancy of a business ethos in American medical care can be ex- pected to subordinate health care and its distribution

to considerations of marketing and profit without the cushion of the professional ideals of medicine.5

In the midst of these shifting economic, social, and political powers are individual persons, eager to ex- ercise their own autonomy. People want control over their own health affairs and to assist their relatives and friends in the personal control of their lives. Yet the individual patient may be quite helpless, because of his exclusion caused by poverty, or simply his pow- erlessness caused by having too little control over the system. Similarly, individual professionals-like the parable’s hospital administrator and chief of neonatal intensive care-seek an autonomous acting-space where they can function as true professionals with moral integrity. Yet, those very professional endeavors are rendered dubiously effective by the shifting auton- omies of institutional health-care powers.

This, then, is the first theme modern medicine shares with Orwell’s world, for it is a world of con- trolling powers and voracious autonomies that creates a sense of moral confusion, even helplessness.

LOSS OF A COMMON MORAL VISION

The second theme, common to critical-care medi- cine and Orwell’s 1984, is the disappearance of our shared belief in a firm basis for knowing rights and wrongs.7 The era of moral incertitude is, of course, not of recent origins. In the 16th century Montaigne wrote:

What am I to make of a virtue that I saw in credit yes- terday, that will be discredited tomorrow, and that be- comes a crime on the other side of the river? What of a truth that is bounded by these mountains and is false- hood to the world that lives beyond?’

As the parable of EmergiMedVan illustrates, our so- ciety is characterized by pervasive moral ambiva- lence, partly due to our uncertainty about what sort of society we want to be.9 The incongruities and con- flicts among our principles bear out this analysis. The egalitarian principle, which has strong legal standing in the emergency departments of our hospitals,10 is deeply at odds with the autonomy-based theory of rights that would protect individual holdings from so- cietal redistribution, 1 1 and with assumptions about the autonomy of the political community whereby it can determine as it will what services it will render to whom it wi11.r2

If I am correct in observing that we are now exper- iencing the juxtaposition of these two themes- powers that render us in some important respects powerless and the lack of a clear sense of right and wrong for coping with them-then we do indeed face some of the agitating questions posed by 0rwell.13 Transposed to the scene with which we are concerned, those questions are: In the economic, political, and

AMERICAN JOURNAL OF EMERGENCY MEDICINE n Volume 2, Number 6

institutional world of critical-care medicine, do we commit ourselves to action without a clear moral vi- sion? Do we commit ourselves to a set of moral beliefs without the power to act? Does the sheer complexity of a new medical era characterized by the power bases of critical-care medicine lead one to succumb to moral exhaustion? EmergiMedVan becomes the symbol of the manipulation of existing health-care structures for the perpetuation of power-a manipulation that is ef- fective because it exploits the very absence of societal moral vision.

The over-arching concern of the parable, then, is the moral shape of our institutions and the moral vi- sion that molds them. If we view ourselves as individ- uals who seek a coherent and rational explanation of things, we are struck with a sense of absurdity: and we are justified in referring to the absurdities of critical- care medicine, for the moral dimensions of the medical institutions that are being shaped by and for critical care are irrational and incongruous-in some respects ridiculously incongruous.

There are some who would draw conclusions about the inevitable moral skepticism or pessimism that can arise from a perception of absurdity in our social in- stitutions. Pessimistic conclusions of this sort have been drawn from Orwell’s writings.13 I would not draw those conclusions, because I think we should re-ex- amine the purposes and functions of our institutions, including those that are only now taking shape, to pro- vide them with a rational and moral direction. In pro- ceeding to examine critically the individual quandaries and principles related to critical-care medicine, how- ever, we should continue to be aware of the incongru- ities in the individual concepts and principles with which we are dealing.

Corporate Values and Responsibilities

At the theoretical level, important effects have been made to examine collective moral responsibility in contexts that bind together physicians and other professionals with collectivities such as the hospital, the health-care team, the medical school, and orga- nized professional societies.*4 Yet, while it is impor- tant to reflect on the nature and application of con- cepts of collective responsibility in already-existing in- stitutions, it seems less than reasonable simply to witness uncritically the formation of new health-care institutions such as hospital corporations, without at- tending to the question: Which collective locus of health-care responsibility would best preserve the de- sirable values associated with health care? The ques- tion becomes increasingly urgent as one notes that health-care institutions arise or take new corporate shape on the impetus of such diverse forces as critical- care technology in search of use, investment potential

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in search of profit, and the desire to serve the most important health needs of the public.

One starting-point is the problem of how to recon- cile the ethics of corporations and other large institu- tions with the ethics of medicine. For example, the administration and trustees of hospitals whose con- struction or renovation is financed by revenue bonds may put pressure on medical staffs to increase the use of those facilities, thus escalating health-care costs so as to meet bond repayments by manipulating profes- sional judgments about the best interests of the pa- tients.15 But a far more pervasive and threatening moral conflict exists between the commitments of an investor-owned hospital corporation to the profits ex- pected by its shareholders and those aspects of a professional medical ethic that represent commitments to serving the sick and injured without discrimina- tion-a commitment that also coincides with society’s need for a full range of medical services within reach of the whole population.‘+‘6*‘7

Some hospitals have demonstrated the ability of an individual institution to make major allocational de- cisions by restricting programs in critical-care medi- cine partly on the basis of discriminations among the benefits that a hospital should be giving to the public.‘* But those cost-containment decisions, no matter how praiseworthy, are not sufficiently far-reaching. For what is at stake is the moral shape of our health-care institutions. A response to that challenge would seem to require articulation of a theory of corporate health- care responsibility, and ultimately a widespread public reflection on what sort of society we want to have.

Professional Integrity

There is a kind of absurdity in the actions of a di- rector of an intensive-care nursery and of a hospital administrator who feel compelled to abandon their professional roles so as to preserve their own personal integrity, but at the expense of the integrity of the institutions in which they are immersed. Thus, the problem of integrity to which this parable draws at- tention is not simply that of the difficulty of being true both to one’s own moral self (together with its pre- suppositions in certain models of professional ethics) and to the expectations of a health-care institution,19 or even of reconciling conflicting responsibilities at personal and institutional levels.*O Certainly, those moral problems are important for any discussion of the ethics of institutionalized critical-care medicine. But the problem of integrity I would highlight is found where the institutional structures of medicine render irrelevant the moral character of the individual profes- sional and the endeavor to ground one’s character in an autonomous commitment to professional values.

REICH W MORAL ABSURDITIES

Autonomy of the Patient

The informed consent policy on EmergiMedVan is suggestive of a genuine and pervasive problem. It is no longer adequate to discuss the self-determination of patients merely in terms of reduced autonomy in hospitals, for what is at issue is personal autonomy within the broad societal structures of medicine and within the narrower institution of hospitalization (not within the hospital as institution, but within the insti- tution of hospitalization).

At the societal level, we would do well to consider the relevance of what Ivan Illich has called the “in- stitutionalization of values.“*l He argues that health care is one of those areas of life in which modern so- ciety teaches us that the things we value are produced only by the “experts”; thus, medical and social insti- tutions define our needs and persuade us to purchase their services.** The result is that we lose our au- tonomy over health-care, which should fundamentally be a matter of self-care.

Furthermore, at the institutional level it is doubtful to what extent we can apply the traditional model of autonomy to treatment decisions made by patients who are institutionalized in critical-care institutions.23 This doubt is based, for example, on the institutional factors that lead patients to be ambivalent about their treatment because they are ambivalent about what others expect of them. 24 Thus, it seems incongruous to discuss patient autonomy as though it were busi- ness-as-usual, whereas in fact-as the imagery of EmergiMedVan portrays-patient autonomy is being manipulated within the enveloping purposes of cor- porated economics and the politics of technology.

Distribution of Critical-care Medicine

Acting as gate-keepers for hospitals and medical care, the medical profession has long functioned as benevolent redistributors of health-care resources through price discrimination and adjustment of insur- ance and hospital fees. But as critical-care and high- technology, noncritical-care medicine increase ex- penses, it is dubious whether the informal “robin- hooding” of the parable is a just and rational way of proceeding. Indeed, the very function of beneficence in critical-care medicine becomes problematic when we consider the range of views on the ethics of be- neficence: first, that beneficence is entirely optional, in the sense that one does no wrong in omitting be- neficent acts; second, that there are serious moral du- ties of beneficence;25 and third, that beneficence (e.g., Good Samaritanism) can be IIW&I more seriously in- cumbent on political communities than on individual persons.26 An interesting question is whether a com- mitment to beneficence on the part of the various agents of critical-care medicine (the state, the medical

profession, health-care institutions) might not lead us to justifiable moral expectations of health-care inter- ventions that would prevent the very illnesses (in- cluding the parable’s end-stage renal disease) that bring both citizens and aliens to our critical-care fa- cilities .

Our society is clearly torn between expansive prin- ciples of egalitarian justice and restricting factors such as autonomy-based rights and the sheer necessity of cutting costs. This conflict becomes most provocative when it pits citizen against stranger and life-saving ac- tions against other health care.

A strong, legal principle of egalitarianism in emer- gency medicine was articulated in Wilmington General Hospital v. Manlove,*’ in which the court held that a private hospital is liable for refusing service to a pa- tient in case of an unmistakable emergency, if the pa- tient has relied on the hospital’s custom of rendering aid in such a case-a custom that is presumed from the fact that the hospital operates an emergency room. 28 In another important decision, Guerrero v. Copper Queen Hospital,29 a court found that a pri- vately-owned hospital is obligated to provide emer- gency care to all persons who present themselves at the facility for treatment, even in this case, in which the patients were aliens who entered the country spe- cifically to receive the emergency treatment. (This de- cision of the Court of Appeals of Arizona, Division 2, was vacated by the Supreme Court of Arizona on July 18, 1975, on other grounds.)30 Similarly, the U.S. Su- preme Court’s 1983 Plyler v. Doe decision protects the rights of illegal alien children to a free public educa- tion, because of equal protection that must be given to all U.S. residents.” A similar principle, articulated on philosophical grounds, is that both documented and undocumented aliens have human rights which result from one’s humanity and do not depend on citizen- ship.32

It is clear that reasonable limits must be placed on the welfare services, such as education or health ser- vices, which a nation might grant to aliens, just as the obligation of hospitals to treat all emergency patients regardless of cost must also have a reasonable limit. In resolving these conflicts, it will be necessary to tend to issues of local loyalties and bigotries;33 theories of national autonomy l2 that could be used to justify a nation’s distributing its resources solely on the basis of its autonomy and aside from any considerations of distributive justice; and principles of international dis- tributive justice. 12.34

A major pressure against equality of access to high- cost criticai care is the move toward health cost con- tainment.35 Thus, physicians and hospitals have found themselves faced with a U.S. federal policy that makes it a federal offense to withhold food or medical care from infants on the basis of their handicaps.36 Official

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notices in hospital nurseries reminded the staff of the federal offense in omitting “medically indicated treat- ment”; yet this sweeping egalitarian regulation was paired with the same federal government’s cut of funds to support the life and treatment of infants who can be saved. Thus, physicians and nurses are put on notice that they are being watched for conformity to an im- possible standard. The absurdities of profoundly con- flicting policies now threaten to become deeply em- bedded in those legal and medical institutions upon which we commonly rely for life-support.

SUMMARY

A dominant characteristic of critical-care medicine today is the emergence of powerful institutions func- tioning within a framework of a noncoherent set of values and philosophical persepctives. Anyone who would assign a significant role to the philosophy of medicine for today’s era must not simply account for the quandaries of critical-care medicine, but also at- tend to the antecedent values, conflicts, and absurdi- ties that form the ethical issues, as well as the models of ethical response (market ethos, professional ethos, etc.) that indicate which moral principles might be rel- evant. These considerations form the new agenda for the philosophy of critical-care medicine. This broad philosophical task is an urgent one, for critical-care medicine is rapidly molding the moral dimensions of all of medicine.

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