The clinicians' dilemma1
G D Fraser Steele MD FRCPsych
Honorary Consultant Psychiatrist, Runwell Hospital Wickford, Essex SSHJ 7QE
Journal of the Royal Society of Medicine Volume 75 July 1982
Environmental control and behavioural anarchy
This century has witnessed the unprecedented development of science and technology, both in their scope and rate of progress. It is regrettable that man has not matched this unsurpassed control of his environment by a comparable advance in his ability to control his behaviour. This disquieting discrepancy between his scientific knowledge and technical skill, and his behavioural indiscipline has created problems critical for the endurance of civilization as we understand it and, perhaps, for the survival of mankind. There is violence throughout the world on a gigantic scale. Stockpiles of weapons, potentially lethal to civilization, grow daily. In early 1981, an international meeting of physicians was convened to discuss nuclear war - the world's most dangerous health hazard. They concluded that whatever organized medical response they mounted could make no significant impact on the catastrophic effects of a nuclear attack.
Everywhere there is massive environmental pollution. Clearly, man's new found authority over critical elements in his environment is not accompanied by comparable knowledge of human nature and human conduct. He knows little about their causes or the means of their control. Biologists have constantly to remind their fellow men that in many respects they are, to themselves, unknown, and that the most urgent task facing mankind today is to provide such scientific understanding of behaviour as will lead to its control (Tinbergen 1971).
Scepticism and rethinking
Man has been dimly aware for centuries of his deep and disturbing ignorance about such matters. Yet somehow he has managed for most of the time to adopt an attitude of complacent acceptance. Fortunately, the relentless barrage of searching questions which is characteristic of contemporary life has floodlit his resistance to change. This rebirth of scepticism, reminiscent of ancient Greece, is causing the abandonment of established institutions and conventional attitudes which cannot withstand rigorous scrutiny. Everywhere there is radical rethinking.
Outside the institution of medicine, for example, we are witnessing the probable demise of Darwinism which has dominated evolutionary thought for a century. Fossil investigations and cladistics are inclined to refute Darwin's contention of small, slow evolutionary changes. In another area concerned with. the genesis of ideas, traditional views are being challenged. Structuralists, for example, deny that ideas are a precise reflection of the senses - a view which is the essence of empiricism in science. If they are right, what of the validity and authenticity of scientific orthodoxy? It has become clear that nineteenth century anthropologists were misled by the prevailing notion which idealized man as a unique genius. Similarly, contemporary sociologists conclude from their studies of human society that free will is in much shorter supply than their predecessors believed. Reluctantly, the view spread that many of man's behavioural patterns were determined not by reason and will but by causes which appeared to be outside the limits of his conscious control. The psychoanalytic contribution reinforced this position, and ethologists' intensive studies over the last twenty-five years have led to the conclusion that much of man's behaviour is involuntary and not dissimilar to that of other animals.
Man, however, is always enigmatic. He retains a robust faith in his ability to exercise rational control of himself and the events which surround him. He has a strong desire for more freedom, more personal responsibility, and more control over his destiny. Even more enigmatic, having proclaimed his faith in democracy, he promotes the growth of technocrats and bureaucrats in such numbers that they erode his aspirations and leave them unfulfilled; or he embraces egalitarianism as the ultimate freedom.
Contemporary medicine and psychiatry
Doubts and limitations: Amongst these perplexities, what is the position of the institution of medicine and within it where does psychiatry stand? What has it contributed to the solution of the human predicament? What clarification flows from it in respect of the cause and control of behaviour? What has the psychiatric clinician to offer from his intimate vantage point? As science has advanced, medicine appears sometimes to doubt its role and purpose. Urgent clinical, ethical and social issues await resolution in more precise and effective terms. Seven 'test-tube' babies have been born in Britain and a further 60 women are pregnant by the use of this technique. There is the undoubted prospect of experimentation with human embryos. The moral and ethical implications will inevitably lead to controversy. Unnecessary confusion has arisen from the blurring of the boundaries between health and illness. Doctors are accused of a disproportionate interest in the diagnosis and treatment of the sick at the expense of the healthy; it is suggested that the main medical thrust should be towards the maintenance of health. There is contention between clinical need and economic realism.
Psychiatry lacks an ordered body of related, relevant and communicable facts. Unproved hypotheses obscure the main issues and provide ambiguous guidance. The gap between theory and practice often seems unbridgeable. Apparently incompatible ideologies coexist uncomfortably. What of diagnosis, cause, treatment and prognosis? Is their orientation in the medical model misplaced? What are the diagnostic possibilities and therapeutic goals? How much, in all honesty, does the psychiatrist know about the forces which determine man's nature? The history of psychiatry is punctuated by frequent changes of emphasis and direction. Each innovation is hailed with enthusiasm, applied with vigour, discarded and replaced - a course of events unlikely to enhance this specialty's recognition. At this moment, because of some adverse reports and publicity, we may be about to discard benzodiazepines which have afforded patients substantial symptomatic relief since the barbiturates fell into disrepute a decade ago. Has psychiatry's inconsistent and uneven growth resulted in part from non-scientific considerations? For example, has its progress as a science been retarded by its continuous entanglement with social considerations and humane reforms? Do scientific knowledge, clinical experience and patients' needs determine psychiatric policies, or are they dictated by political inspiration and administrative expediency?
Personal responsibility: There are so many questions to be answered, not irrelevant questions, not purely academic questions, but questions to which the answers are vital if the immeasurable importance of psychiatry is to be unreservedly acknowledged. There are the problems of free will and responsibility. Has man the potential to control his behaviour or has he deluded himself? Is he, after all, a complex automaton? In this ambiguous and controversial area it is necessary for the psychiatrist to clarify these vital issues and seek solutions. There is the question of the operative factors in psychotherapy. Do logic and reason determine the nature of the interplay between patient and doctor? Are words or attitudes the basic coinage of the therapeutic interaction? When treatment succeeds, is this due to a pill, a psychodynamic theory or a doctor's personality?
Hospital versus community: Clinicians have been criticized for being hospital centred, obsessed with diagnoses and drugs - even authoritarian. They are encouraged to get out into the community where a utopian wind will blow away unresolved clinical problems. Some of the more progressive of the community advocates, including a few psychiatrists, have decided that orthodox psychiatry is getting nowhere. The community jet set have enthusiasm in abundance, and commendable singlemindedness. But have their views substance?
Multiprofessional teams. There is ambiguity surrounding the question, 'Who takes clinical decisions, a multidisciplinary team or a consultant?' Evasiveness and rationalization figure prominently in such discussions. Clearly, there should be consultations with non-medical colleagues who may have specialized knowledge of particular aspects of each case. Multiprofessional contributions are rightly desirable, but who takes the ultimate decision? The dilemma: Nearly forty years of clinical practice is a salutory experience. Salutory because there has been time to grasp the paucity of hard facts, the perplexity and dubiety, the ambiguity and conjecture, the irresolution and enigma - therein lies the clinicians' dilemma. I shall deal briefly with some elements of cause, diagnosis, treatment and the organization of the resources.