Living Ethics:

Homeostasis as Ethical Principle

Adopting a life-systems perspective and an ethics based on the Good of systems homeostasis opens up new levels of analysis and argument as we deal with the complex questions facing the medical community today. An ethics based on our science of life systems is satisfactory philosophically in that it corresponds to our under- standing of biological "truth", and clinically in that it is understandable and communicable in physiological terms.

Clinicians still sometimes consider that philosophers devise theory in isolation. The world of "should be" often seems in conflict with clinician's imperative to prescribe for the patient in full recognition of the world as it is. For example, Wallace has commented that there has been a "philosophobia" in medicine and a matching "blindness" of philosophy toward medicine. [1]

Further, public debate on issues in bioethics is often polarized between "absolutist" and "situationalist" positions. However, if moral argument is couched in absolutist terms, it is not adequate to deal with the multi-level variabilities found in clinical situations and in biological systems generally. Yet argument that does not offer a high degree of "moral certainty" offers little guidance in the day-to-day exigencies of clinical practice, particularly in a litigious practice environment. Reconciling the separate languages and perspectives of philosophy and of pathophysiology remains a key problem for clinicians concerned about ethics, and we still seek a unifying theory of medical ethics that is satisfactory both clinically and philosophically.

In previous work, [2,3] I have pointed to Schweitzer's formulation of reverence (respect) for life as a clinically applicable principle which can harmonize divergent philosophical points of view, and which speaks to the complexities of modern clinical situations. Yet in today's discourse, whether in the public square or the public hospital, understanding of Schweitzer's ideas may be impaired by the religious connotations of "reverence", and by confusion with "right to life" absolutism. Many of these problems can be overcome by understanding ethics in the language of life-systems theory.

In practice, we seek to define actions according to ethical "principles". There is a broad consensus among ethicists that among the most important principles of medical ethics are autonomy, no-harm, benefit, and justice. All of these represent goods to be served in our conscious actions. But what more basic principle guides us when these four deravitive principles are in conflict?

For example, what guides us as we seek to balance risk of great harm with a desire to achieve benefit; or how do we reconcile justice in society when the autonomous needs of individual patients conflict? If we are to find clinically satisfactory answers to such basic questions, ethical theory must extend beyond the confines of a narrowly defined "pure" philosophy to include the biological, and even psychological, dimensions of ethical theory.

Early in this century, G. E. Moore [4] pointed to the pitfall, or "naturalistic fallacy", of defining some characteristic as good merely because it is "natural". Accordingly, there is a prevalent view in ethics today, expressed by Thomas Nagel, [5] that ethics is a "theoretical inquiry that can be approached by rational methods, and that has internal standards of justification and criticism". He calls for an "ethics without biology".

This traditional approach of "pure" philosophy seeks resolution of questions by "pure reason". In terms of Freud's model of the psyche, ethics is an "ego" activity, for the processes of reason are processes of consciousness. Reason seeks to insulate its processing of the observed (objective) phenomena of the material world from the subjective unconscious instinctual world, and particularly from the "spiritual" content of the unconscious psyche.

However, the ego (individually and collectively) is often capricious. In defining its own good, it usually seeks to serve its own purposes. If ethics is to operate entirely at the ego level, the ego is placed in an inherent conflict of interest, writing the rules by which it audits its own ethical accounts. Without some standard of moral reference external to consciousness, we are left with ethical ambivalences with respect both to theory and to individual actions.

If we are to overcome this difficulty, we must take a new look at "ethics with biology". Physician Bernard Towers writes that the proper mode is not first to establish ethical theory which is then to be applied to the theory and practice of science and medicine; rather:

Just as Aristotle's physics necessarily antedated and was logically prior to his meta-physics, so must modern science (and in particular the science of biological evolution) lay the groundwork for, and establish the mode of, modern ethics. [6]

As previously argued, [7] the proper "philosophic milieu" for clinical practice is the modern life systems world-view. [8] The dominant characteristic of life systems is flux equilibrium, which, at the level of the individual organism was named by Cannon as "homeostasis". [9] For the organism, or for a whole system of organisms, survival requires the capacity to maintain a dynamic stability, on which depends the ability to heal wounds and to adapt to environmental stresses.

Thus, nature has "defined" the Good as that well-tuned condition of least strain, in which the system as a whole (or the reference subsystem that is the object of ethical concern) survives and seeks to actualize its potential for development as a whole. The Good is homeostasis, a term which we may apply both to the flux equilibrium and to the processes by which it is achieved. Such a model requires that one look beyond the reference sub-system to consider effects at levels "above" and "below" it. It is in this homeostatic "summum bonum" that we may find the external standard by which to judge our actions in complex life situations.

A systems model of ethics changes somewhat the traditional model of good polarized against evil, and of specific actions as "always" ethical or "always" evil. Here, the ethical action is that which tends to restore the self-regulating balance of (and thus benefit) the relevant sub-system(s). When the same action persists beyond sufficiency and thus tends to destablize (to harm), it becomes unethical (evil). When a proposed action confers no benefit, the ethical act is to refrain from acting.

Schweitzer's formulation of reverence for life [10] is a life-systems ethic, based on awareness of, respect for, and support of all life's "will-to-live". Writing six years before Cannon "named" homeostasis, Schweitzer used a nineteenth century term that may now sound archaic. Yet it is clear that he was entirely conscious of the interactive, inter-dependent nature of life, and of its inner dynamic for survival.

If life is viewed as an integrated, interactive whole, all forms of life have value. Each form of life "values" itself, in that its own processes seek its survival and development, and it must do so at some expense to other life. While there is a hierarchy of relationships to be served and conserved (individual, family, society, species), general life-systems theory does not offer a scale of values for choosing one form of life over another, or one individual over another.

If we are to direct our choices properly and provide structure for the solving of poorly structured problems, we must impose another level of ethical consideration -- a "metaethical" level -- which seeks to discern the various values operative in the life system.

Some of these operative values are inferred from the autonomic operation of life-systems across many species: certain needs which must be met, freedom for development, and diversity through individuality for maximization of adaptive options. Respect for life implies respect for these values, and for the limits imposed on individual life by the life process itself.

Other operative values are unique to the human level of conscious action. While one must consider the multi-level ("global") implications of one's efforts, insuring that an action is ethical requires focus on the immediate ("local") object of concern. It is only there that an action can be judged to be both effective and sufficient to its Good: homeostasis. The "local" subsystem (e.g., patient) interests may not be subjugated to those of the "global" system (e.g., societal) interests, for to do so would make the system tend toward becoming self-consuming and destabilized. Such action would thus be anti-ethical.

Life-systems ethics, as does quantum physics, carries its own "uncertainty principle": As a part of the complex and variable life system, we may not be certain of the outcome of a chosen action, or of the particular "rule" to apply. We must, however, act to maximize the probability of an ethical outcome, and to conserve individual responsibility and thought.

Clinical ethics must arise from a clinical attitude that respects not only a patient's "signs of life", but all levels of the patient's biopsychosocial milieu [11] and the larger society. To understand ethics, we must move beyond a concept of life as product (that is, as individual persons or discrete organisms) to a concept of life as process.

"Life", as process, has needs which must be met. Life conserves individuality and celebrates diversity. It is inter-active and inter-dependent. It acts on many levels simultaneously. Yet, life has its limits. Individuals do not live forever, and medical skill is not infinite.

Life systems are too complex to be completely controlled by medical skill. In the final analysis, it is homeostasis which does the regulating. The physician can only tilt the balance toward homeostasis and let the life process itself do the fine-tuning. Yet this is not an argument for non-intervention, only a call for recognition of human limits. Indeed, the model emphasizes the imperative for ethical intervention, to avoid the harms at each level (patient, family, physician, society) when disease, pain and suffering are not appropriately addressed.

The question raised by some of "When does life begin?" is not especially pertinent to medical ethics, for life is a continuum. It began a very long time ago. Life is the given by which, and in which, we all function. Thus, while we direct our skills toward sustaining life, it is inappropriate to consider our skills as "life-giving". It is also inappropriate, even arrogant, to say that we have taken life when we merely withdraw or withold treatments which will not help life's balance.

Medicine began, and in some situations continues, its technologic era under a clinical and legal presumption that we should seek to preserve individual metabolic activity at all costs and in spite of all odds. All too frequently, the physician's legal duty seems to be defined by doing the usual and customary treatments for the diagnosis at hand. However, the life-process considerations mentioned above impose a different perspective.

An exhaustive inquiry into clinical applications of systems ethical theory is well beyond the scope of this essay. It is appropriate, however, to consider a brief example.

For the patient in coma with multiple systems failure, clinical efforts must focus on assisting the restoration of homeostasis so long as there is a prospect of doing so, for we seek to conserve and support, and if possible restore, the individuality of the patient. We seek to recognize and preserve autonomy, to respect the patient as a whole organism, and to assist restoration of whole function. Such an attitude and objective express the concern of the social system for its individual members, as well as the individual physician's commitment to each patient.

Yet, when we have no further prospect of restoring the homeostasis of the patient as a system, attention must turn to a recognition of life's limits and of medicine's limits, and to concerns about the homeostasis of the larger biopsychosocial system of which the patient, family and clinicians are a part. From such a perspective, one respects life more, not less, by "letting the patient go" with dignity.

Would we not in such a case serve that larger system better by accelerating the process of death, especially when a patient's organs are suitable for transplantation? No, for being beyond benefit of specific medical therapies is not tantamount to being beyond harm. "Active" euthanasia [12] obviously harms the unconscious homeostatic "autonomy" of the patient as an organism. Giving societal interests precedence over individual ones also harms society's equilibrium, as noted above. Further, physicians who act contrary to individual life-interests foster distrust of physicians generally, and thus tend to destabilize the medical-social subsystem.

Is the life system better served by arbitrary standards for terminating treatment, such as age? [13] At the human societal level, diversity derived from individuality serves species adaptation, and the social balance derives benefit from respecting all individuals, irrespective of arbitrary categories, even if their contribution is only potential or is unrecognized by the majority. However, in the face of scarce resources, societal balance could be served by limiting treatments to those which have been clearly shown to provide benefit to similar patients.

A life-systems ethic based on the good of homeostasis gives rise to a key question: Homeostatic processes can find several states of equilibrium, especially in the face of disease; which state are we obligated to serve? At the human level, the "highest good" is that state of equilibrium which the self-regulating organism will autonomically attain in its own biopsychosocial milieu, given the freedom and opportunity to do so. Acting ethically consists in supporting that process insofar as knowledge, skill, and resources permit, and insofar as harm to other individuals (and other levels of the system) can be avoided.

Adopting a life-systems perspective and an ethics based on the Good of systems homeostasis opens up new levels of analysis and argument as we deal with the complex questions facing the medical community today. An ethics based on our science of life systems is satisfactory philosophically in that it corresponds to our understanding of biological "truth", and clinically in that it is understandable and communicable in physiological terms.

Because of the complexity of the problems which confront us, we may not expect immediate, easy, or automatic answers to our clinical dilemmas. Applying theory to practice will remain a continuous, rigorous, and often tedious intellectual process of balancing knowledge and reason in an attitude of compassion.

In acknowledging reverence for life as the "natural ethic", we do not find a sentimental and detached contemplation of life. We find instead a basis for an intellectually rigorous theory of ethics, for reverence for life requires us to know what we are doing, and to do in accordance with what we know.

This systems ethic seeks a humane balance between clinical science and clinical art. It requires us always to seek to serve our patients with respect, and in so doing, can help us give medicine a human face that truly reflects its human heart. That is our ethical challenge, and our hope.

1. Wallace ER. What is "truth"? Some philosophical contributions to psychiatric issues. Am J Psychiatry, 1988. 145: 137-147.

2. Bessinger CD Jr. Medical ethics and reverence for life. J SC Med Assoc 1986; 82: 405-408.

3. Bessinger CD Jr. Reverence for life in clinical practice. J SC Med Assoc 1987; 83: 69-71.

4. Moore GE. Principia Ethica, 1903. See Stroh, GW. American Ethical Thought. Chicago: Nelson-Hall, 1979. p 175 ff.

5. Nagel T. Mortal Questions. Cambridge: Cambridge University Press, 1979. p 142.

6. Towers B. Toward an evolutionary ethic. Teilhard Review, October 1977. p. 80.

7. Bessinger CD Jr. Doctoring: The philosophic milieu. Southern Med J., 1988; 81: 1158-1162.

8. von Bertalanffy L. General System Theory: Foundations, Development, Applications. New York: Braziler, 1968.

9. Cannon W. Organization for physiological homeostasis. Physiological Reviews 1929; 9: 399-431.

10. Schweitzer A. Philosophy of Civilization (1923). Reprint, Tallahassee: University Presses of Florida, 1981.

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

12. Lundberg GD. 'It's over, Debbie' and the euthanasia debate. JAMA, 1988; 259: 2142-2143.

13. Callahan D. Terminating treatment: Age as a standard. Hastings Ctr Rpt 1987; 17: 21-25.

The author appreciates the critique of an earlier version of this work by Nora K. Bell, Ph.D and Douglas M. McDonald, Ph.D.

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Essays on Ethics and Healing