Whatever the reference system, to act ethically is to support consciously the flux equilibrium (homeostasis) that life systems normally seek autonomically and unconsciously. The life-systems model of ethics is especially helpful in recognizing and solving complex problems at inter-disciplinary interfaces.

Presented March 30, 1990, Clemson University: Hunter Honors Colloquium, "Ethical Issues at the Interface Between Bioengineering and Medicine". Published in J Investigative Surg 1992 (Sept); 5:185-190

Surgery is a very narrowly focused discipline. For some microsurgical operations, the tolerance for focus is only a few tens of microns. But even for those routine procedures done with the naked eye, cholecystectomy for example, millimeters are important. When I cannulate the cystic duct for an intraoperative cholangiogram, a few millimeters can make the difference in whether I see bile or a great deal of blood.

At that point of the operation, my consciousness is focused very narrowly indeed. However, after the dye is injected, I have a few moments to step back from the table while I wait for the film to be developed, and before I learn whether I will have to retrieve an errant gallstone from the common bile duct.

As I step back, the view becomes much more broad. It encompasses the surgical technicians and tables of specialized tools. I also see the anesthesia person sitting before a very complicated console of medical electronics, among a host of hoses and cables connecting the instruments to transducers, to the patient, to each other, to the wall, to the ceiling, and thus to a whole complex of hidden technology beyond the room.

Even if I do not see a bioengineer in the room, the influence of bioengineering is pervasive there. Certainly, since you have honored me with this invitation, I have been very much more aware that what you do is important for what I do. More significantly, it is important to that patient lying open before me.

Though I am honored to be asked to participate in this meeting, I am also humbled, because you have asked me to represent my profession as your profession struggles with the question of professional duty. By the nature of things, yours is a new profession. Mine is quite old. Yours had to wait for the history of science to develop to a certain point. In a very real sense, the healing profession began before science.

If we were to have historical patrons for this meeting, I would nominate Hippocrates to represent physicians, for he is the father of scientific medicine, and the founder of its ethical sensitivity. I don't think we would find a bioengineer from that era, but Hippocrates' contemporary, Aristotle, could well represent you.

Today, Aristotle's work is remembered more by moral philosophers than by scientists, but he did have a keen interest in the physics, mathematics, and biology of his day. This meeting owes much to each of these giants of the fourth century of ancient Greece, each concerned with science, each concerned with ethics.

In these reflections, we mentally zoomed down to the narrow view of the cystic duct, then suddenly pulled back to an instantaneous panoramic view of science and ethics. I hope that does not make you dizzy! As my thesis will suggest, we need to refine our skills to look at our work both ways. We need a particularist reductive view of scientific detail, but we also need an encompassing globalistic view of ethical responsibility.

Just what is the scope of a professional ethic? In seeking to outline principles governing professional conduct, whether for physicians or bioengineers, there are a number of areas of concern. Within a profession, we must look at collegial relationships, at business ethics, at the way we handle information, and at the way we deal with people individually and as society.

In our research, we are concerned with rigor of experimental design. There is no science without experiments which are well designed and honestly reported. There can be no science without ethics; neither can there be ethics without science. That is, we may not know what we ought to do without first knowing what we can do, and what the effects of the action are likely to be.

We must also deal with the inter-professional aspects of our respective work. I must rely on you for specific knowledge about the materials and devices that you supply. You must rely on us (that is, on physicians generally), for information about how well devices work in practice, and for decisions about when to use them, and when not to.

Professional ethics must also come to terms with challenges in manufacturing and marketing. A few years ago, physicians never considered that health care had anything to do with marketing. Now we have to face the issue of full disclosure, not only about risks of operations, but also when physicians sell pharmaceuticals or refer to laboratories in which they have an economic interest; and there is the whole new issue of medical advertising.

We produce services rather than products, and in that sense we are not as directly involved with manufacturing as some of you may be. However, we are much concerned with quality control, and in this era of HIV infection, we are more concerned than ever with issues of worker safety. In terms of general categories, the ethical concerns of bioengineering correspond with the concerns of medicine.

In a recent paper, Churchill [1] argued for a "distinctive medical ethic". He holds that in defining its ethic, the medical profession must rely primarily on a "moral sensibility" based on the profession's special traditions, rather than on one or some of the competing theories and principles of ethics.

The doctor-patient relationship does indeed call for a special moral sensibility. However, I suggest that what seems distinctive about medical ethics is its descriptive context, rather than its moral basis. If "all men are created equal" in their moral and spiritual worth, all of us share the same moral imperative, and the guiding principle of medical ethics is not distinct from that of ethics generally. Similarly, a professional ethic for bioengineering must build also on a general, and preferably universal, moral understanding.

In describing professional ethics we must begin with a careful distinction between ethics and etiquette. Well-defined codes of custom and procedure can provide the grease that reduces friction in our social and professional systems, but mere rules of etiquette may be, and usually are, morally neutral.

We must also distinguish ethical principle from the context, or "field", of ethical action. In physics, we are taught that particle interactions take place in a complex field of forces governed by an uncertainty principle. In addition to uncertainty about measuring a particle's momentum and position, there is a prospective uncertainty as to the outcome of a given particle interaction.

Similarly, all human interactions take place in a complex field of socioeconomic, legal, scientific, and technologic forces, and these actions have their own level of uncertainty as to outcome. We usually are not able to define precisely the ethical rule or theory which best fits the "context" of the action. In a complex situation, often we are not sure whether we should solve the problem using rules of duty, rules of value, or rules of utility. Neither the "forces" nor the contextual situation itself yields an ethical principle.

How then do we solve problems? More to the point of today's meeting, how do we describe the ethical responsibilities of bioengineers, and the relationships between our two professions? Are we looking for absolute rules and for moral certainties, even though the world of life-systems is a world of probabilities and uncertainties?

Are we looking for a morally pure philosophy that is sterilized of life's untidiness, even when our world of problems is teeming with life? I suggest that, when we try to solve life's problems, we look at an ethics of life process.

Only from a life-systems ethic are we likely to learn which principle to apply to a given problem. Only in the language of life process are we likely to find the common language that our professions need as we discuss life problems at the interface of our disciplines. Before turning to some specific questions that arise at that interface, let us sketch the outlines of a life-systems model of ethics.

The common thread running through all sciences today, from the new science of chaos in physical systems to a growing understanding of ecologic and evolutionary complexity in life systems, is the idea of sensitivity to conditions throughout the system. All life subsystems are interactive and interdependant. Whatever the level of study, systems exhibit self-regulating behaviour, independant of our conscious input.

I have suggested elsewhere [2] that the proper world view for physicians is based on that understanding. A modern world view must relate us not only to our patient's own biopsychosocial sphere as defined by Engle, [3] but also to our professional system, to the world at large, and to our own sense of self.

In medicine, the objective of patient care is to restore autonomic homeostasis for the whole organism. Our medicines and machines do not "give life". Life is the given in which we all operate, and which our therapies must respect and seek to support. To practice ethical medicine is not merely to measure up to some stated standard about isolated issues. To practice ethically is to support the patient's own homeostatic autonomy, respecting the whole life system of which we and the patient are a part.

The same concept may be applied to other systems. Whatever the reference system, to act ethically is to support consciously the flux equilibrium (homeostasis) that life systems normally seek autonomically and unconsciously. Homeostasis -- the survival balance -- is the summum bonum (highest good) of natural systems. This understanding provides us with the "grand unifying theory" of ethics that must govern actions if we are ultimately to thrive or survive.

Our traditional rules of ethics -- the great "Thou shalt nots" -- support that homeostatic principle and serve us well in simple well-structured situations. However, life systems relationships often are so complex as to seem quite unstructured. Often we are not sure which "Thou shalt not" to apply.

In such situations, we must apply a new level of ethical consideration. This is a meta-ethical level, which structures our approach toward maintaining or re-establishing homeostasis in the reference system in which we serve.

Some of these considerations derive from our understanding of autonomic process in life systems generally. For example, life process has needs which must be met. Life process exhibits an imperative toward the development of individuality and diversity, which serve the survival of the life system generally.

Other meta-ethical considerations derive from the human level of conscious action. We must act with "global" awareness of situations, concerned (as a minimum) with effects at the levels "above" and "below" the reference level. We must also act at the most proximate ("local") level possible. There we can best determine what action is needed, and how much is sufficient.

We can serve the integrity of the whole system only by seeking to preserve the integrity of its parts. If a larger system (e.g. society) consistently operates to suppress or exploit its constituent subsystems (e.g. the individual person), the system becomes self-consuming and self-destructive. In the life-systems view, the utilitarian formula of "the greatest happiness for the greatest number" [4] is really served only by focusing on the interests of each part of the system in harmony with the whole.

In large systems, the effects of individual actions may be so damped out that they are not immediately evident. Yet actions do "make waves" that have their own wavelength and periodicity, and resonate beneficially or destructively. When Kant exhorted us to act as if our actions were to constitute a "universal law of nature", [5] he was touching on just such a systems view.

This model opens up multiple levels of analysis, whether we look at ethics generally or at bioengineering specifically. One important question is, "Whom does the bioengineer serve?" Is primary professional allegiance to the corporation? To the physician who will use the materials and devices in practice? Or to the patient, as the "end user"?

The considerations discussed above would focus first on the smallest subsystem. The bioengineer, the corporation, and the physician all constitute an interdependant system which must serve the patient. To fail to serve the patient not only harms the patient, but also harms each level of that particular reference system.

Do we then dismiss a bioengineer's responsibility to the corporation? Certainly not! If everyone in the corporation is aware of the whole-system relationships, there would seem to be no conflict with serving the patient's interests first. One of the most urgent concerns of ethics is to bring all within the system into such an awareness.

In this model, maximizing benefit to the patient maximizes benefit to the corporation and increases its efficiency, for example by reducing the strains of litigation and the costs of risk management. Profit is seen, not as the "summum bonum" of a corporation, but as one index of its efficiency. If the system relationships are properly understood, ethics is not in conflict with a desire for reasonable profit.

This model of ethics also has a number of implications for the relationships between bioengineers and physicians. In any self-regulating system, accurate information flow is essential at every level. In unconscious nature, this is especially evident in reproduction. Highly accurate replication of DNA's information code is essential for species stability. For individual stability (homeostasis), there must be accurate transmission, sensing and appropriate response to neural and chemical data in physiologic feedback loops.

So too must our conscious systems -- our ethical systems -- provide for accurate communications, especially in science. Ethics requires accurate information in marketing and in product evaluation. Adverse clinical information must be transmitted and responded to promptly, even when it runs counter to the profit principle.

One significant question in bioengineering is this: May the bioengineer consult directly with the patient? Direct communication between bioengineer and patient may be especially appropriate in research and teaching environments. However, analyzing the ethics of that interaction brings us to consider a different level.

The human psyche is very much a part of our life system. The classic "scientific" formulation that only reason and objectivism are valid must give way to an understanding that all of us, patient and professional, are psychological beings. The objective can not function without the subjective.

Psyche, as system, is vulnerable to a vast array of strains. (Here we distinguish "strain" which is undesirable, from "tension" which is desirable as the gradient causing circulation in a system.) Communications with patients must avoid conflict with the physician's perogatives in prescribing, and must support the subjective as well as the objective aspects of the healing relationship between physician and patient.

For example, what if the patient asks the bioengineer about the surgeon's qualifications? The complexities of the psyche are such that a given patient may have a better result with a surgeon she trusts (perhaps for linguistic, ethnic, or religious reasons), than with a surgeon that the bioengineer perceives to be more knowledgeable about implanting the particular device.

What if a patient asks the bioengineer about the merits of a device, a hip prosthesis for example? The question of what the device can do in general is vastly different from what should be done for the individual patient in the current circumstances. What other diagnoses have been made that influence the chances for success, or the long-term prognosis? What if the patient is a Jehovah's Witness, and refuses blood transfusions?

What if the patient asks whether a hip prosthesis should be replaced because of a new study which shows imminent failure after a certain number of years? Would the answer be different if that patient were now HIV-positive?

Information from the bioengineer might be very helpful to a patient, but decisions to use a device obviously entail many considerations beyond the engineering ones. The bioengineer who is incorporated into the physician-patient communication loop, becomes subject to the same set of ethical concerns that the life-system imposes on the physician.

I accepted this assignment because of my prejudice that this life-systems model of ethics can be especially helpful in recognizing and solving the complex inter-disciplinary problems that we face in society today. I believe that it has something especially interesting to offer as we discuss relationships between physicians and bioengineers.

Can the validity of this model be proved in one paper? Of course not. Large-scale theories, such as the theory of evolution or theories of the psyche, do not lend themselves to proofs by simple experiments or classic syllogisms. Their acceptance must rest on many observations and on thought experiments, testing for consistency and congruency over time. Only now in the history of science are we gathering sufficient objective data to permit such a synthesis for ethical theory.

However, the subjective data for such a theory are quite ancient. We recalled Hippocrates and Aristotle to suggest that the bond between ethics and natural science has existed since the beginnings of western science. Before that, Mosaic law had related ethical duty to the creator of the natural order. In the sixth ancient century, the relationship between ethics and natural order burst again into human consciousness over a wide geographic range.

If ancient datings are correct, in the decade beginning with the year 540 BCE, Lao Tzu, Confucius, Mahavira, Gautama Buddha and Heraclitus were alive at the same time. Each contributed in a major way to the religious and philosophic understanding that our ethical duty lies in harmonizing our actions with the "Way" or "Chi" or "Logos" of the natural universe.

Can we now make the same synthesis on the basis of objective scientific data? I make so bold as to say "Yes", we can. We must.

If indeed we do so, we open the way to prospective and concurrent ethical problem solving. Our recent trend has been first to create technology, and then to do ethical studies retrospectively, after problems are created. If we see our technology and all of our work as an integral part of the natural life-system, we may be able to maintain the ethical equilibrium as we go.

In the life-systems view, ethics is not an isolated discipline built on esoteric knowledge. All knowledge rests on ethics, and all knowledge that comes from our laboratories and our clinics has potential implications for our actions in the life-system. I applaud your recognition of that in this meeting, and I thank you for the opportunity to join you in this most important of quests.

1. Churchill LR. Reviving a distinctive medical ethic. Hastings Center Report, 1989 (May/June); 19: 28-34.

2. Bessinger CD Jr. Doctoring: the philosophic milieu. Southern Medical Journal, 1988 (Dec); 81: 1158-1162.

3. Engle GL. The need for a new medical model: a challenge for biomedicine. Science, 1977; 196: 129-136.

4. Bentham J. Deontology (1834).

5. Kant I. Fundamental Principles of the Metaphysic of Morals (1785). Sect 2.

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Essays on Ethics and Healing