The following guest editorial by Saltonstall Professor of Population Ethics, Arthur J. Dyck, is reprinted from the New England Journal of Medicine. In it reference is made to an article,  Ethics of a Cottage Industry in an Age of Community and Research Medicine,   by Paul Ramsey, professor of Christian Ethics at Princeton. Professor Ramsey\u27s article appeared in the same issue, April 1, 1971, of the New England Journal of Medicine, pages 700-706.
Reprinted with permission from the New England Journal of Medicine

Dyck, Arthur J.

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The Linacre QuarterlyVolume 38 | Number 4 Article 511-1-1971Guest Editorial ... Ethical Issues in Community andResearch MedicineArthur J. DyckFollow this and additional works at: http://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationDyck, Arthur J. (1971) "Guest Editorial ... Ethical Issues in Community and Research Medicine," The Linacre Quarterly: Vol. 38: No. 4,Article 5.Available at: http://epublications.marquette.edu/lnq/vol38/iss4/5Guest Editorial ... Ethical Issues in Community and Research Medicine The following guest editorial by Saltonstall Professor of Population Ethics, Arthur J. Dyck, is reprinted from the New England Journal of Medicine. In it reference is made to an article, "Ethics of a Cottage Industry in an Age of Community and Research Medicine, " by Paul Ramsey, professor of Christian Ethics at Princeton. Pro-fessor Ramsey's article appeared in the same issue, April 1, 1971, of the New England Journal of Medicine, pages 700-706. R eprinted with permission from the New England Journal of Medicine. Arthur J. Dyck is Salton stall Profes-sor of PopUlation Ethics at Harvard School of Public Health and a faculty member of the Harvard Divinity School. 220 by Arthur J. Oyck Ramsey's essay in this issue of the Journal identifies two broad areas in which serious ethical issues arise for the practice of medicine - namely, community medicine and medical re-search. His excellent discussion of these issues suggests that when medi-cine attempts to make judgments about social well-being and when its practitioners become increasingly dedi-cated to the advancement of science, important questions must be raised regarding the role , warrant and principles of medical practice. What tasks and what judgments accrue to physicians as physicians? What are they trained to do and what ought they to be trained to do? By what primary principles and modes of ethi-cal reasoning is and ought their prac-tice to be governed? Let us briefly examine a specific instance in which current medical practice is involved sometimes implicitly , sometimes ex-plicitly, in conflicting ways of answering these questions. In a recent series of articles in the Journal, Milunsky et aLl review the curren t state of prenatal genetic diag-nosis and argue for the widespread use of amniocentesis. As they use the term, amniocentesis refers to the aspir-ation of fluid from the amniotic sac for the purpose of making cytogenetic Linacre Quarterly studies. The immediate rationale for this use of amniocentesis is to advance the practice of genetic counseling by basing predictions of an increasing number of diseases upon actual diag-noses in utero instead of ca lculated probauility risKs. The advantages that they cite for this more accurate coun-sel is that it reassures couples regarding the nonnality of the fetus , it permits the decision to intervene thro ugh abor-tion where abnonnalities are detected, and it provides a way of preventing the births of infants with irreparable gen-etic defects and fatal genetic diseases. Milunsky and his co-workers recognize tha t this last use of amniocentesis changes the traditional role of the physician so far as he can now predict diseases accurately before birth and provide the means of preventing the birth of a child with mental defects or fatal diseases. Hence , we enter a new era of social and preventive medicine. Throughout the discussion of the diagnostic use of amniocentesis as ad-vocated by Milunsky et a!., there is no explicit recognition of the fetus as a patient. Apparently, genetic coun-eling does not include the task of preparing a family to accept and care for a defect ive child. "Therapy" at the present t ime is aimed at the family and not the fetus . I n an earlier essay, John W. Littlefield spoke specifically to this issue: Prena tal genetic diagnosis will con-st itute a major medical advance only if therapy can be given once a diagnosis is made. Eventually and occasionally, this may be prenatal tberapy for the fetus . .. But society and the professions mllst appreciate and accept that the proper th erapy now is for the family. and at times that means abortion. 2 Clea rly , neither reassurance for the family nor abo rtion provides therapy for the fetus . The hope is held ou t for eventua l and occasional therapy for November, 1971 the fetus, with no explicit reference to the kinds of postnatal therapy pres-ent ly available. For now, the treat-ment of the diseases of this "sometime patient" is, in this view, achieved by its elimination as a patien t and as a hving entity. Suppose a physician argues that deciding whether to treat the fetus as a patient is a judgment that a physician as physician is not in a position to make. In effect, this is the view taken by Milunsky et a!. when they suggest that physicians and society are, and should remain, impartial or neutral regarding decisions by fami lies about whether to use amniocentesis and whether to abort the fetus where deformities are detected. This point of view is strange considering both the traditional ro le of physicians and cu r-rent medical practice. As the physicians' role was tradi-tionally depicted in the Hippocratic Oath and many subsequent codes, he was expected to be the physician advocate of both the pregnant woman and developing life within the womb. If, as Milunsky et al. suggest, both physician and society should be impar-tial regarding the use of amnioce ntesis to prevent diseases by elimin at ing the di seased, what advocate is left for defenseless life? Are physicians about to abandon also their time-honored role as advocates on behalf of the hopelessly ill , the unconsc ious and the experimental subject who is unin-formed? And even if one wishes to leave the exact status of the fet us as a human life an open question , sho uld it not be part of the specia l responsi-bility of the physician, as it certainly has been traditionally , to err on the side of saving and fostering human life rather than to develop or encourage programs that se lectively prevent such life? 221 To drop the fetus as a patient at this time in history is also incongruous with the aims and increasing accom-plishments of contemporary fetology. Furthermore, why should physicians claim increasing responsibility for de-fining and specifying the end of human life, and decreasing responsi-bility for defining and specifying the beginning of human life? Why, for example, should the absence of signs of brain activity spell death wh ile signs of brain activity in the eight-week-old fetus are largely unheralded as signs of human life? If physicians nevertheless insist that specifying when human life begins is not a medical decision, by what warrant do they decide that the fetus is not a patient and that his life is dispensable? As Ramsey has indicated, the medical warrant for recommending abortion occurs only when a fetus threatens the life or the health of a pregnant woman. To decide that a given set of diseases is to be eliminated by elimination of the diseased is one of the principles on wh ich programs of eugenics and eu thanasia rest. Decisions of this kind are surely not morally neu tral. What special competence does a physician have to decidc that a society ought to prefer death to giving custodial or remedial care for those who require it? Milunsky et al. cite the costs of care for the mentally retarded in Massachusetts. What a meager sum this is as compared to the amount of money being spent for destroying lives in Vietnam! If saving money is im-portan t, why not save much more money and save lives as well by thinking of other costs that could be cut? One of the problems here is that, as the physicians strive to contribute to social well-being, they find that only certain kinds of actions are pre-dictably within their power as physi-222 cians. Hence, they look to the surest way in which they can affect social policy. Their warrant for doing so is very unclear, and, whereas we can vote out those who might suggest legisla-tion that permits or encourages selec-tive killing, including capital punish-ment and the like, our recourse in forming the conscience of physicians is less certain. Heretofore, in the area of abortion , we have generally pu t con-straints upon physicians and others on behalf of the fetus. The assumption that the use and application of amn iocentesis is a neutral sphere for physicians and society presupposes tha t, for physicians and society, abortion is not a moral issue , and that existing or fu ture laws do or will assure that abortions are decided solely by families and physicians. To go that way is not morally neutral , and it is not life affirming. Like so many technical innovations, amniocentesis is a powerful tool in search of a noble purpose. On the whole, medicine has exhibited a re-markable degree of compassion for the ill whatever their condition, agressive zest in affirming, extending and en-hancing life, and loyalty to the welfare of individual patients whatevcr their presumable social utility. The use of amniocentesis is surely to be judged by these principles, for if it is not , it threatens to erode them. REFERENCES I. Milunsky A. Littlefield JW, Kanfer IN, et al: Prenatal genetic diagnosis. N Engl J Med 283 :1370-1381, 1441-1447, 1498-1504,1970 2. Littlefield JW: Prenatal diagnosis and therapeutic abortion. N Engl J Med 280:722-723, 1969 Linacre Quarterly 

Guest Editorial ... Ethical Issues in Community and Research Medicine

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Guest Editorial ... Ethical Issues in Community and Research Medicine

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