What Is the Question?

WHAT IS THE QUESTION? GEORGE A. WOLFJR., M.D. Our tradition as a society has been to live by rules and regulations. Our religious heritage has recognized levels of sinning, rewards in the hereafter, and punishment for infraction of the rules—whether apprehended or not—on this earth. Some aspects of our legal system punish the offender but do not reward the one who complies (who ever heard of a citation for not speeding?). In this setting, societies have developed that admittedly pursue the principle that the endjustifies the means: war, assassination, torture, imprisonment, brainwashing, and even Watergate, are testimony to that principle. Some political activists have also espoused this principle, although with the loftiest of "ends" in mind. In other words, rules are broken consciously because of certain ends to be achieved, and the ends become part of the value system or rewards. This is a strain, indeed, on any code of ethics or system of laws! In medicine, also, we have had our rules and regulations in our code of ethics. We are not rewarded by law for good behavior in our practices, but we are regularly punished for malpractice. Possibly we are too glib in our efforts to do good in claiming ourselves that the end justifies the means. Just because we can perform a procedure well clearly does not mean that the "ends" accomplished for the patientjustify the procedure. One definition of "ethics" found in the Oxford Universal Dictionary (1955) says: "The rules of conduct recognized in certain limited Departments of Human Life." Such a code of prescribed behavior has many limitations in medicine. Moreover, ethics and law are not necessarily synonymous, because the implication is that ethics is a list of professional rules to be followed without the necessary force of law. Time alters ethics: for example, according to Hippocrates, it was not ethical for doctors to perform abortions. For centuries, our laws made it very hazardous for a physician to be involved in abortions, and now the times and ethics have changed and are still changing [I]. Circumstances, as well as times, alter ethics. Mercy killing or *Professor of medicine, University of Vermont College of Medicine, Burlington, Vermont 05401. 482 I George A . Wolf, Jr. · What Is the Questioni euthanasia is not only unethical, but illegal. But war is acceptable, even if the Congress does not think so. Think about the Tonkin Resolution and the flap over Cambodia! In addition, people alter ethics, and I need say no more than that "what is good for General Motors. . . ." I submit that we have matured in medicine, at least, and in society I hope, to the point where ethics is still not a code or rule book to be followed. The rules often do not fit because of time and circumstances and people. More important, if we look at tax laws, motor vehicle laws, welfare legislation, and environmental legislation, laws basically designed to help and protect people, we are struck by the concerted efforts to get around them. Finding legal loopholes in income tax laws is a specialty, and a gadget can be purchased that warns the driver when he is under radar surveillance in a speedtrap! In a young civilization, rules, regulations, and codes of ethics make the job of living a little easier and keep most everyone out of trouble. However, when I counted 150 discarded beer cans per mile on a road in the coastal mountains of California between the signs forbidding littering, I wondered if the end has become to break the law, and the means the beer cans. In essence, individuals and society have become so complicated that rules and regulations have limited usefulness. Just how complex is indicated by some of the recent hassles about environment. James Reston in his column in the New York Times of August 26, 1973, quotes John H. Knowles, M.D., as saying, "What is the moral and ethical framework in which we are all living; of our work as a nation, as individuals, as institutions, in our relations with one another and with the world? We go on doing ourjobs . . . but what is the meaning and purpose of all this energy?" Reston himselfcontinues, "I...