Saturday, December 3, 2011

Advocacy -Legal and Medical

I attended the Trial Lawyers Association of BC conference on rehabilitation medicine.  There was about a 50% split between lawyers and doctors.  I was reminded of university when arts faculty met science faculty and how people forget the wide gulf of difference between arts students and science students.  Having begun my career as an arts students, straight A's by the way, become a scientist, with strait A's, completed a medical degree, speciality and subspeciality, then completed a minister of theology degree I am fully aware of the difference between the religious view and the secular view.  Yet there was this amusing anthropological confusion as to the 'manners' and 'style' of language to be used in which house.
The genius of the Trial Lawyers Association of BC medical topic conferences is that they challenge doctors and lawyers to consider that we are Chinese and they are American, or vice versa.
This resulted in two justices, several lawyers and doctors speaking to the concept of 'advocacy'.  Lawyers, collectively, have a conflict of interest in this matter, as their very income depends upon their role as 'advocate' .  As Jesus was to be the advocate of the individual soul before God so a patient's lawyer advocates for his client before the god like judge.  Yet physicians are routinely called upon to be an advocate for their patient. In the nether region, we stand beside him facing death ,going far beyond the court room when it comes to 'advocacy'.  I know.  I have caught too much illness at the bedside and seen friends die as they have stood without guards before deadly diseases and faced epidemics at the side of their patients.  I have entered rooms that families have closed the door on. I have wounds from my work in patient advocacy and scars. In the old sense I would be seen as snatching my patients back from Satan or out of the mauls of death.
I like the pristine suited world of the courts. The women look fresh in comparison to my colleagues who have done much time at bedside.  Not like the 'new doctor' who avoids touching patients and chooses instead to 'administrate medicine'.   There's an effete dandyism and ego beyond anything I've ever encountered in the humbling reality of medicine.  The board rooms of hospitals probably make the courts look pure and innocent but the medical office itself is more like a jail house experience in comparison.  Chambers and wigs and so much of the political are absent on the ground floor in the trenches where the rubber meets the road. .  Certainly the politics of university also make the courts look hallowed in comparison as well.
What's obvious though to me is the abscence of blood, and shit, and snot.  Even in my psychiatric office there is alot of snot and sometimes blood.  But the court and those who are advocates there principally deal in money and power and thought.  Guns on sheriffs in the court room contain emotion better than quiet rooms in asylums.  Hospital security can't kill people to keep the peace. There's no safety in medicine. It's raw and hidden.  Microbes are the experts in passive aggressive.
A patient expects their doctor to be their advocate. My patients, psychotic, brain damaged, personality disordered, often wholly incompetent, emotionally distraught, depend on me, as their physician, commonly to make decisions for them which they can't make for themselves. I commonly use the standard of 'would I want my mother or father's doctor to recommend this to my patient" or 'would I want my doctor to do this for me."  In fact I've been disappointed by some of my doctors and colleagues who have refused to go near me or near my sickest patients when they have been in greatest need.
It was in the early days of the Aids epidemic that I treated AIDS dementia biters and alone took paper bags off the heads of violent patients who had been chained by police and brought to emergency.
Yet as a 'medical advocate' I'm asked to be 'objective'.  I'm asked to be 'professional'.  I'm asked to have 'boundaries' and indeed I've noted that those who often are celebrated most actually 'treat' their patients as 'numbers' and make decisions without any consideration of the emotional and relational world of the patient.  They keep their eye on the politics and finances and I admire them their intellectualism even if at times it harkens back to nazism.
Our patients don't know that all of us who are doctors who 'care' 'too much' for our patients who 'cry' when one dies or who think about our 'work' on weekends are diminished by our superiors.  The new world order of medicine is not what it was. It's all corporate and glossy and long gone is the country family physician.  He or she is an anachronism like the family farm.  There's a lot of lip service towards this but the fact is any doctor who really truly cares, not in that smaltzy, politically correct, commerically relevant, consumerism caring, but caring, in an advocate sense will be punished.    Because a true advocate might well offer their life as ransom. And today even the ship's captain leaves the ship before the crew and clients. That's corporate professionalism. The country goes to hell in a handbasket but the CEO gives himself a raise and bonus.
However,  a long history of the heros in my profession's past did.just the opposite.  Many a doctor died living with his leper patients. . The war doctors and the missionary doctors didn't hide in rationalism.   All of those doctors gained the 'reputation' that we as physicians now stand on.  Those doctors I refer to gave us the 'brand' as the new world order would say.  But we're rapidly using up the good will in unholy alliances.
The courts ask us for 'legal advocacy'.  There's a lot of 'hair splitting' in this term and it's only beginning to be understood in a new way with a history of confusion as modernism, post modernism and ultramodernism compete as special relativity and string theory compete in physics.
The idea I garnered is that you must separate a man or woman from her ideas.  I can advocate for an idea but I can't advocate for a person. If I as a doctor say to a judge I believe my patient is sane and should be allowed to go free into the community, I am stepping on his robes. From what i gathered there's a tremendous 'parentalism' in the court and everyone is terrifed of the judge becuase he controls the sheriff with the guns and has inhuman powers granted by the emperor as opposed to a 'democracy' elected' prime minister whose first responsibility is to the people. The atmosphere among lawyers and in the courts is distinctly different these days and has indeed occasioned a recent serious book that says that Canada is no longer a democracy but indeed run by the Supreme Court.
Some have called the new world order a 'legal theocracy' with the Judge as the new God head.
The story of Dugald Christie is fascinating.. As a brilliant recently suspiciously killed Canadian lawyer he argued strongly that there was no justice for the poor in Canada and the year of his death was travelling to Ottawa to argue that there was no more justice for the middle class.
"Indeed in the 'occupy ' movements where there's the 99% and 1% economic debate the extension would be that there really is no 'court' and no 'justice' for the 99%.  The cost of 'justice' in Canada has made it no longer a 'public' utility but rather a 'commodity' and indeed a 'brand'. Naturally he was killed. They say it was a hit and run but these days everyone knows that such things are past because everyone can just 'hit and walk'.
So the doctor entering the temple of law must remember that he can argue what he believes is right about his patient but he dare not tell the judge what he thinks he should do. How dare he speak to a judge that way.  Naturally expert witnessess don't know the whole context and academically the judge is absolutely right to maintain that he is the judge and she is there to make the final decision.  But it's interesting because if I say, "I believe my patient is right and they should win the lottery" becausse I want the world for my patient, if only to get them out of my hair, then I'm 'crossing a line'.
The best message to be gleaned from the discussion is not what is 'right' or wrong but rather that if a person wants to 'advocate' for their patient then they can do it best by bringing the teacher an apple. The courts are telling doctors what best 'sways' them as arguments and what is best for their patients. At this level the judges and courts are genius. However at another level they are 'dictating' to experts in science as to how to present their postions and seeing that any who don't do the will of the judge are to be punished.
I couldn't help but think of the great arguments of days gone by and all the emotional joy in expression that people made to the point of begging judges to see the patient freed.
To be clear there are 'expert' witnesses. These would be free of conflict of interest if they were hired by the courts.  They are not.  Someone else pays for them, one side or the o ther. But money talks though in this world of influence and prividge even that is 'psychotically denied' or 'psychopathically denied' or simply the way business is done.  Witnessess are sometimes 'bought' but we must ignore this. In fact so much is 'ignored' that 'selective reasoning' best describes the rationalism of the court.  As researchers have shown cloudy days affect the decisions of the stock market we can only hope that sunny days will affect the courts.
There must be authority.
But if you are the 'treating physician' and indeed you are not paid the questionable sums that expert witnesses can command then the whole issue of 'advocacy' is a different matter.
Indeed the issue of 'unholy' or 'illegal' or 'unethical' advocacy hinges on 'motive'.  The motive for a doctor is the well being of his patient.  And if you say to a judge that if you put my patient in jail he might die as a doctor and a human you are doing your job correctly.  Naturally today's judges in comparison to their former 'brand' don't wnat to carry that responsibility and don't want a physician to say something that the 'media' might glom onto and embarass the individual judge. There are to be no other gods but me. .
Wheels within wheels.
Yet this is only 'unethical' if I have indeed been 'paid' by the patient, or had sex with her ,or was in a real estate contract with them, or was considering that my patient was the 'Queen'. and that future work with the Royal family might be jeopardisd. especially considering the consequence of this. now that Prince Phillip has confessed that he personally is of the blood line of Vlad the Impaler.  Why he should have to tell the world this now is itself grist for the mill.
So legal advocacy would say that a doctor should argue for his viewpoint regarding his patient without telling the courts how to do their business and indeed respecting the judge.  The Bible spoke most highly of Solomon and Jesus loved the Father but called him Papa to the great frustration of the Jewish lawyers of his day. Indeed Christianity respects justice but says that without mercy it is Philistine.
The Bible actually says that the judge has his authority from God.  Given that the judge's aruthority is from the Canadian people through PM Harper I certainly respect him and accept that when I go into another 'frat' house in the arts wing I must respect them because the 'arts' students have always had more numbers, more money, more power and the prettiest wingiest girls from fine arts departments. All I have is nerdy geeky stuff, bombs, biological weapons, paradigms and such. As a scientist I'm more and more an anachronism everywhere in what are increasingly termed the 'economic dark years'.  Faced with economic threat even Prince Phillip reverts to his wild darwinian dna. Naturally judges would be afraid and must worry that their sheriffs might turn  their guns on them
As a Christian I might look to God. But then Jesus questioned the authority of the father at the end crying out 'My God, My God, why hast thou forsaken me".  The greatest healer and greatest advocate was alone in the end.  It's the Christmas season and time to consider advocacy in the light of Christ.
it's difficult in the world where the rules change with whim and people forget what they want to forget and those of us who remember will remember Kruschev pounding his shoe for Russia and Kennedy whacked on pills and Marilyn bringing the world to the brink of annihilation.  Einstein never believed that God played with dice.

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