Knowing when to stop: the limits of medicine.
Subject: Medical ethics (Beliefs, opinions and attitudes)
Author: Jecker, Nancy S.
Pub Date: 05/01/1991
Publication: Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 1991 Hastings Center ISSN: 0093-0334
Issue: Date: May-June, 1991 Source Volume: v21 Source Issue: n3
Persons: Named Person: Hippocrates (Greek physician); Bacon, Francis (English philosopher, 1561-1626)
Accession Number: 11070338
Full Text: Enshrined in modern medicine is a distinct set of values. When medicine assumes these values uncritically, a host of ethical problems results. A glimpse at the ancient roots of modern medicine reveals that an older scientific tradition entertained a very different set of values--values that provide wise counsel and shed light on the specificf ethical concern of providing medically futile care to patients.

Hippocratic Medicine

Hippocratic physicians in the fifth through third centuries B.C. were among the first to question the ethical limits of medicine. Historians regard one of their achievements to be an understanding of when and when not to intervene. In a work attributed to the Greek physician Hippocrates, it is written that the purpose of medicine is "to do away with the sufferings of the sick, to lessen the violence of their diseases," but also "to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless." According to this tradition, knowing the limits of medicine is related to the physician's appreciation of the art of medicine and the power of nature (physis). The predominant meaning of nature in the Hippocratic corpus is "the essential substances which make up human beings." The physician searched for the human being's natural state of health that had been altered by changes wrought by disease. The Hippocratic writings caution that should a physician demand "from an art power over what does not belong to the art, or from nature a power over what does not belong to nature, his ignorance is...allied to madness." [1] For the Greeks, medicine is techne, which implies doing. In doing, one is " the potentialities of the object...[and] by those of the techne itself." [2] According to this tradition, only the physician who understands natural limits and uses this understanding to set wise boundaries avoids the error of excessive confidence. The Greeks called this error hubris, and the tone of their approach counseled against it. In the words of one historian, "Those who disregarded the natural scope of therapies stained the authority of medicine." [3]

The basis for moderation and atttention to limits in Hippocratic medicine reflects the medical theories upon which Hippocratic medicine was built. Ancient medicine conceived its task to be one of working with human nature to assist in restoring disruptions in its natural order. Thus the author of the Precepts enjoined physicians to "display the discoveries of the art, preserving nature, not trying to alter it." [4] This viewpoint developed out of the Greek understanding of human health and disease. Health was viewed as a natural balance of four bodily humors (yellow bile, blood, black bile, and phlegm); disease was defined as an imbalance among these four. For example, a fever meant that too much yellow bile, and so too much heat and dryness, was present in the body. To restore health, a physician might instruct that water be used as a cooling agent: the patient might consume fluids or be immersed in cool water baths. Hippocratic physicians emphasized the importance of environment and climate in maintaining a natural balance within the body. Since human beings are under the influence of their essence or nature, in situations where disease is incurable the physician must accept that medical means should not be used.

The spirit of this approach is described by Plato, who extolled the kind of medicine taught by the followers of Asclepius. In the Republic, Plato emphasizes that

Asclepius...taught medicine for those who were healthy in their nature...but were suffering from a specific disease; he rid them of it...then ordered them to live as usual....For those, however, whose bodies were always in a state of inner sickness he did not attempt to prescribe a regimen, make their life a prolonged misery...Medicine was not intended for them and they should not be treated, even if they were richer than Midas. [5]

Elaborating this point in the Phaedrus, Plato states that medicine is practiced well when it is practiced philosophically. He cites Hippocrates as exemplar of the philosophical physician, because Hippocrates views the body in relation to the whole of which it is a part. [6]

Baconian Science

In modern times, physicians who struggle to assist critically ill patients have sometimes spurned the counsels and approaches of ancient medicine. Aggressive efforts in the face of extremely poor odds reflect an ethics of medicine born during a later scientific era, an era that has roots in the scientific revolution of the seventeenth century. Whereas the ancient Greek physician lent assistance and support to human nature, the new science was applied in order to exercise dominion and control over nature broadly construed. Bacon, for example, defined the goal of modern science to be the conquering of nature, and distinguished this goal from other, lower ambitions:

The first [kind of ambition] is of those who desire to extend their own power in their native country, a vulgar and degenerate kind. The second is of those who labor to extend the power and dominion of their country among men. This certainly has more dignity, though not less covetousness. But if a man endeavor to establish and extend the power and dominion of the human race itself over the universe, his without doubt both a more wholesome and a more noble thing than the other two. [7]

Bacon held that scientific aspirations to dominate nature could best be accomplished by aggressively applying an empirical method: "You have but to follow and as it were hound nature in her wanderings, and you will be able, when you like, to lead and drive her afterwards to the same place again." In contrast to Hippocratic medicine, Baconian science was a tool for plundering, rather than a means of revering, nature. In Bacon's words, the applications of science do not "merely exert a gentle guidance over nature's course; they have the power to conquer and subdue her." Defending the interrogation of nature by the scientific method, Bacon compared it to the interrogation of witches. He argued that witch trials were above reproach because they ferreted out truth, and "Neither ought a man to make a scruple of entering and penetrating into those holes and corners [of nature], when the inquisition of truth is his whole object." [8]

For Bacon and his followers, the ambition to dominate and conquer is unrelenting, tempered only by the recognition that nature's secrets must first be acquired: "Man, being the servant of Nature, can do and understand so much, and so much only, as he has observed in fact or in thought of the course of nature: beyond this he neither knows anything nor can do anything....[Therefore,] Nature to be commanded must be obeyed." [9] The scientist "obeys" nature by means of hounding, subduing, leading, and driving it in order to force disclosure of nature's laws. Later seventeenth-century scientists continued to speak enthusiastically about mastering and managing the earth, and philosophers, such as Descartes, expressed the hope that the new science would render human beings the "masters" and "possessors" of nature. [10] Historians of science often refer to Bacon as the "father of modern science," and judge his efforts to command nature as central to subsequent scientific inquiry.

Nineteenth-Century Medicine

Despite the revolution in scientific thought during the seventeenth century, humoral thinking, with its emphasis on working to assist nature, continued to exert a powerful influence on medicine well into the nineteenth century. Medical practice was unscientific by the standards of the day, and involved "unverified doctrines and resulting controversies." [11] Colonial physicians in America inherited from their European forefathers no "substantial body of usable scientific knowledge on which to base their practice." [12] Midway into the nineteenth century, however, medicine began to identify itself more effectively with the scientific method and with a more aggressive scientific approach. American physicians troubled by a lack of professional prestige and authority and by competition from various medical sects in 1847 founded a new organization, the American Medical Association (AMA), which defined explicit standards for medical practice. These standards enunciated a scientific approach to medicine that allegedly set AMA members apart from other practitioners. It was hoped that the association with modern science would convey the authority needed to bolster the new profession's public stature.

The goal of bending nature to one's will, which is integral to modern science, became a goal of scientific medicine as well. Shifts in the conception of health and disease during the nineteenth century contributed to this phenomenon. Building on advances in bacteriology by Koch and Pasteur in the 1860s and 1870s, scientific medicine came to view disease as an explicit ontological entity. According to the germ theory of disease, specific microorganisms were responsible for specific diseases. In contrast to the Hippocratic conception of disease as an imbalance within the body, nineteenth-century physicians came to understand diseases as a specific organism invading the body from outside. Whereas Hippocratic physicians sought only to assist in restoring a natural balance, nineteenth-century physicians believed that the "conquest of disease" required isolating and destroying a foreign organism.

It stands to reason that physicians working in the tradition of modern science could picture medicine as expansive and limitless. Rather than placing the practice of medicine within a broader context, they aimed to wage and win a war against discrete pathological entities. In 1865 the physiologist Claude Bernard vividly portrays the modern physician as so completely taken by the scientific idea he intends to implement that he is oblivious to any boundary line:

A physiologist is...a man of science, absorbed by the scientific idea which he pursues; he no longer hears the cry of animals, he no longer sees the blood that flows, he sees only his idea and perceives only organisms concealing problems which he intends to solve. [13]

When the prestige and authority of modern science became associated with medicine, so did a philosophy of scientific progress. The eighteenth-century mathematician and philosopher, Condorcet, aptly expresses this philosophy:

The improvement of medical practice...will mean the ned of infectious and hereditary diseases and illness brought on by climate, food, or working conditions. It is reasonable to hope that all other disease may likewise disappear as their distant causes are discovered. Would it be absurd to suppose that this perfection of the human species might be capable of indefinite progress; that the day will come when death will be due only to extraordinary accidents? [14]

The boundless energy of the medical man Bernard describes is linked to the inveterate faith in science that Condorcet expresses. So long as this faith is kept alive in the minds of medical practitioners, their labors are leading to something. Like the grand purpose religion imparted to the religious life, the modern idea of scientific progress "represented the secularization of an attitude, initially religious, which looks to a fine fulfillment in some future, far-off event." [15] Bacon viewed science as a power whose exercise would be man's salvation. It therefore became the moral responsibility of the physician to assume and exercise that power. [16]

Ethical Problems in Medicine

The traditions of Hippocratic medicine and Baconian science shed light on contemporary ethical problems in medicine. The Baconian tradition helps us to diagnose the origins of ethical problems involving inappropriate aggressive medical treatment. These problems are the outgrowth of a scientific tradition whose mission is to control and dominate, whose proving ground is nature, and whose means is an unfailing faith in the scientific method. The kinds of ethical problems that most directly reflect this legacy are situations where medical treatments are applied despite a low likelihood of success or poor quality of expected outcome. Also related are problems of social justice and the distribution of scarce medical resources; when physicians employ all available means to treat patients, they create a situation where genuinely beneficial care must be denied to some in order to pay for excessive and inappropriate care for others. In focusing narrowly on the goal of curing disease, modern physicians can readily lose sight of these broader ethical concerns. Like the medical man Bernard depicts, modern medical practitioners can come to will but one thing: to use medical means to solve the medical problem immediately at hand. Like the ruddy optimist Condorcet, they may hold fast to the promise of successful outcome. Their hope may even increase as the actual likelihood of success diminishes.

The tradition of Hippocratic medicine shows the possibility of sheding our Baconian heritage and reaching back to older, Hippocratic roots. Reclaiming our earlier tradition would require self-consciously reincorporating ethical limits within the practice of medicine. By contrast, current medical ethics approaches may unwillingly address the problems caused by excessive and inappropriate medical treatment by "applying" ethical theories and principles from the outside without first questioning the values inherent in medicine. [17] So long as the myth of a value-free science distorts medical and ethical thinking, no final resolution of ethical problems in medicine can be achieved. For the ethics of our science will persist in creating the same kinds of ethical problems anew.

Medical Futility

As especially vivid illustration of how the tradition of Baconian science infects medical decisionmaking is the extension of cardiopulmonary resuscitation (CPR) to medically futile cases. Originally developed to treat victimes of sudden cardiac or respiratory arrest, today CPR is promptly begun on any patient whose heart or lungs stop functioning, regardless of the likelihood of successful outcome or the patient's underlying quality of life. Unless a patient formally expresses a preference not to be resuscitated, a presumption in favor of treatment determines the course of care. One outcome of this presumption has been the prevalence of so-called Hollywood codes, in which physicians and nurses halfheartedly go through the motions of resuscitating a patient. Something somewhere will have to give. While no one would wish to return to the days of dots on wrist bands or pencilled-in orders indicating the doctor's decision not to resuscitate a patient, the choices are hardly so bleak or dark. For it is quite possible to develop a community-wide standard that distinguishes medically futile cases, rather than delegating this decision to individual physicians at the bedside.

The presumption in favor of aggressive treatment can also be seen in the continuation of life support. The law has been a main culprit in requiring continuation of treatment under futile circumstances. Its effects have been especially tragic for the most vulnerable patient groups, such as defective newborns and patients who were previously competent but failed to express their wishes through legally valid advance directives.

The recent Supreme Court ruling in Cruzan v. Missouri leaves vulnerable patients and families captive to medical treatments in hopeless cases, in that it allow states to enact laws forbidding the withdrawal of life-sustaining treatment unless a patient has previously provided "clear and convincing" evidence stating that life-sustaining measures should be withheld. New York State's highest court recently issues a similar ruling. As the Cruzan decision shows, patients are not the only ones held hostage by such laws. Families and health professionals also find their efforts to have a voice in treatment decisions for incompetent patients thwarted.

Changing the present presumption in favor of aggressive treatment in medically futile situations does not require wresting treatment decisions from patients. For it is far from clear that patients who have not stated their preferences in legally binding ways would themselves prefer that a presumption in favor of treatment be applied to them. As the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research demonstrated in its report, Defining Death, it is quite possible both to recognize the value components inherent in medical choices and to agree upon community-wide standards for addressing them. [18] Just as physicians are not required to offer, and patients have no right to demand, that artificial means be used to keep a heart pumping or lungs breathing after total brain death has occurred, so too physicians should not be required to perform, nor should patients or families be entitled to insist on, medically futile treatment. Just as brain-dead patients are not referred to a physician's colleagues when a physician is unwilling to treat them, so too therapies that do not work should not be sought from the caregiver's colleagues when the caregiver refuses to administer them. While there will always be uncertain cases of death, and borderline cases of futile treatment, there are many, many cases where a patient is clearly dead and where treatment is obviously futile. Identifying the basis for determinations of medical futility requires uncovering its historical, medical, and moral meaning. [19]

The broader response that is needed is for both patients and physicians to acknowledge and abide by limits. As the Hippocratic tradition teaches, medicine is properly bound by the potentialities of the object and the powers of art. To fully appreciate and integrate this teaching would require refashioning values integral to modern medicine. It also would require viewing medical values in the broader perspective of human concerns. In contrast to Bernard's physiologist, a humanist physician who took this approach would heed the counsel given by the protagonist in Mary Shelley's Frankenstein, when he looked back upon his own errors with deeper understanding:

A human being in perfection ought always to preserve a calm....I do not think that the pursuit of knowledge is an exception to this rule. If the study to which you apply yourself has a tendency to weaken your affection and to destroy your taste for those simple pleasures in which no alloy can possibly mix, then that study is certainly unlawful, that is to say, not befitting the human mind. [20]

The danger of staying the present course is not only that it can do unwitting harm to the practitioner of medicine, but that the subjects of this science are human beings. The values of modern Baconian science are more troubling where the battleground for dominating nature is an animate being, and the nature to be conquered is our own.

Nancy S. Jecker is assistant professor, Department of Medical History and Ethics, and adjunct assistant professor, Department of Philosophy, University of Washington, Seattle, Wash.


[1] Hippocrates, "Art," in Ethics in Medicine: Historical Perspectives and Contemporary Concerns, ed. S. J. Reiser, A. J. Dyck, and William J. Curran (Cambridge, Mass.: MIT Press, 1977), p. 6.

[2] L. Edelstein, "The Hippocratic Physician," in Ancient Medicine: Selected Papers of Ludwig Edelstein, ed. O. Temkin and C. L. Temkin (Baltimore: Johns Hopkins University Press, 1967), p. 106.

[3] S. J. Reiser, "Critical Care in an Historical Context," in Ethics and Critical Care Medicine, ed. C. Moskop and Loretta Kopelman (Dordrecht: Kluwer, 1985), p. 216.

[4] Hippocrates, "Precepts," in Ethics in Medicine, p. 6.

[5] Plato, Republic, trans. G. M. A. Grube (Indianapolis: Hackett, 1974), pp. 76-77.

[6] Plato, Phaedrus, in Plato: The Collected Dialogues, ed. E. Hamilton and H. Cairns (Princeton, N.J.: Princeton University Press, 1961), p. 516.

[7] F. H. Anderson, ed., Francis Bacon: The New Organon and Related Writings (Indianapolis: Bobbs Merrill, 1960), p. 29.

[8] J. Spedding, R. L. Ellis, and D. D. Health, eds. The Works of Francis Bacon, vol. 4 (Stuttgart: F. F. Verlag, 1963), p. 296; vol. 5, p. 506. According to Merchant, the 1612 trials of Lancashire witches deeply influenced Bacon. Much of his imagery, which regards nature as a female to be controlled and tortured, probably derived from the courtroom (C. Merchant, The Death of Nature [San Francisco: Harper and Row, 1980]).

[9] Francis Bacon, Novum Organum, in Philosophical Works by Francis Bacon, ed. J. M. Robertson (New York: E. P. Dutton, 1905), p. 259.

[10] Merchant, Death of Nature, chap. 7.

[11] R. H. Shyrock, Medicine and Society in America: 1660-1860 (Ithaca, N.Y.: Cornell University Press, 1960), p. 52.

[12] W. G. Rothstein, American Physicians in the Nineteenth Century: From Sect to Science (Baltimore: Johns Hopkins University Press, 1972), p. 27.

[13] Claude Bernard, The Study of Experimental Medicine, (New York: Dover, 1865), p. 103.

[14] J. M. Condorcet, A Sketch for the Historical Picture of the Progress of the Human Mind, (London: Weidenfeld and Nicholson, 1955), p. 235.

[15] H. Butterfield, "Ideas of Progress and Ideas of Evolution," in The Origins of Modern Science, ed. H. Butterfield (New York: The Free Press, 1957), pp. 222-346, at 225.

[16] Evelyn Fox Keller, "Baconian Science: The Arts of Mastery and Obedience," in Reflections on Gender and Science, ed. Evelyn Fox Keller (New Haven: Yale University Press, 1985), pp. 33-42.

[17] Nancy S. Jecker, "Appeals to Nature in Theories of Age Group Justice," Perspectives in Biology and Medicine 33 (1990): 517-27.

[18] President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research, Defining Death (Washington, D.C.: U.S. Government Printing Office, 1981).

[19] Lawrence J. Schneiderman, Nancy S. Jecker, and Albert R. Jonsen, "Medical Futility: Its Meaning and Ethical Implications," Annals of Internal Medicine 112 (1990): 949-54.

[20] Mary Shelley, Frankenstein, (New York: New American Library, 1965), p. 54.
Gale Copyright: Copyright 1991 Gale, Cengage Learning. All rights reserved.

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