Saturday, March 31, 2012

Bioethics and Responsibility as a meta virtue

I've just read this paper, Responsibility as a meta-virtue; truth-telling, deliberation and wisdom in medical professional" by Y M Barilan, Journal of Medical Ethics, 2009 35:153 to 158.  I fear criticising it because it's so obviously the work of an academic and my experience is that academics are the most barbaric infighting politically correct personally ambitious and intolerant of criticism.  It would be 'wise' therefore to praise and celebrate this 'big boy' whereas it would be 'truth-ful' to critical of his writing.  Indeed he is sufficiently learned that he might even take comfort in the idea that anyone has taken the time to read him.  Academics group in like minded cults in contrast to clinicians who face the 'maddening crowds".
His paper is unnecessarily byzantine with jargon.  He uses language in an exclusive way like a dictionary salesman might.  Yet he has true nuggets in the rubble that are well worth the read.  Despite a deliberate read I wasn't quite sure what his 'agenda' was by the end of the paper.  His topic was 'Responsibility as a meta-virtue" and frankly I enjoyed his discussion of the aspects of Responsibility and the history of responsibility. He became circumstantial and tangential after that.  It's like there were three papers crushed into one as if a salesman wanting to get customers put a fish and a lollypop and a single french fry in a jar in hope of selling the fish.  Odd.  The ribbon he put around the jar was "the new discourse on Professionalism and Responsibility'.
He begins by talking about the Medical Professionalism charter 2002.  I don't know this.  It's a 'multi group effort from both sides of the Atlantic.  I became suspect there. He likes 'multi group' activity. He likes stuff thats on both sides of the Atlantic. What about the genius of a single mind and that which is on both sides of the Pacific.  I am never alone in a committee but as a physiican or a patient I am alone or at most with one other.  I'm not the sort therefore that likes ghettos or regiments.  Out in the wilderness my encounters are lonely affairs.  Academics are safe in bed at night when the real work of medicine is happening in split seconds. When they are themselves ill they might not even be present to consult the doctor who decides to keep them alive because that's the truth he has when they are in a coma.  Of course if he has a 'living will' fantastic! But without a living will he's often making decisions for both himself and the patient at the time of greatest loneliness.  Later a committee will decide his decisions with all the genius and arrogance of committtees. And academics will talk of committees in committes and be safe till that day they face truth.  It was a practice of the 19th century to record the dying words of great men. I would love to know the dying words of academics, perhaps especially bioethecists.
The charter contains a list of 'responsibilities' referred to as 'committments' to replace the words 'duties", "obligations' and "oaths'.  I'm a dinosaur and fear rises up inside me reading this because I know that the first victim of Nazism and Communism was 'language'.  Barilan celebrates most 'flexibility' and loves 'liberalism' so I think he's is one of those academics but I don't know.
He captures my heart when he goes on to focus his discussion on 'truth telling and responsibility' .  The next section is an entertaining look at the history of the word 'responsibility' and it's use philosophically.  He records the various meanings of the word. I have a love of the great Oxford dictionary that gives the multiple meanings of a word with the origins.  The word simply means 'accountability' but I'm not sure how this relates to professionalism.  His discourse is about the relation between doctor and individual patient yet it doesn't get to the crux which is the changing nature of the relationshiip in context. I've already said that when I am alone with a patient in coma with no previous history I am 'alone' in my decision making accountable to myself and my ethics.  When I am with a compis mentis patient discussing plastic surgery I am at the mercy of the vanity of the patient and the relationship is no different from that of a hair dresser.
There's a wandering romp through history which I don't exactly buy as it is so ethnocentric and assuming of all manner of historical presumptions that I feel like a hypnosis patient being asked all along to accept a thousand ideas about history and relationships before we get into the gist of whatever he's trying to say.  I know enough history to see his 'selection bias' through this part of his paper and to know that "the divine right' of kings was no different than 'survival of the fittest' of Darwin.  I'm king and you're not is all the bully needs to know and philosophers who live in the real world ape the big kahuna.  There's a different take on reality than that of Alexander Hamilton as I prefer the idea of Abraham Lincohn anyway . He said the 'price of greatest is responsibility'.
It irks me when he says words like 'evolving' technologies. Being on the Pacific Ocean versus the Atlantic Ocean I am not so limitted by the idea of 'evolution' either divine or Darwinian.  Yet I am asked to accept this and accept such expressions as 'pacification of the west'.  What has this got to do with 'responsibility, I ask reading this entangled and unpacked jargonesque hodge podge of convoluted reasoning.
Somewhere in this I find pearls like definitions of Jas Jonas 'formal responsiblity' and 'substantive responsibility'
Then there's a leap to summarization, more I think for the writer who has lost his way than the reader who must be another philosophy academic to have lastded this far.
1)Responsibility to fulfil promises
2)Responsiblility for our actions
3) Responsibility to committ ourselves to contribute to the redress of injustice
Whoa!  Stop the train.  That shopping list is simply Responsibility is 1 and 2 and we all agree with that and then suddenly this political radicalism assuming injustice and angry still at daddy leaps in literally out of nowhere.  I'm sorry I am a responsible person but I may disagree with you as to what you consider injustice and that's a whole other discussion a bit like the weird history lesson you ascribe to as normative.
Then there's this division into self -centred responsibility and 'other centred moral language and I'm lost.  "Self centred" comes with a shopping list and I can't help but think my teachers in philosophy and religion, some of who are experts on the examples in the shopping list would look askance at having Thomas and Aristotle included in one group or the other.  "Self centered ethics and other centered ethics do not necessarily contradict each other;yet they embody differences in language and attitude , such as the difference between charitably helping or eradicating slavery." He says Weber calls this the "ethics of responsibility'.
Then he quotes Barth and Kierkegard as holding the 'self as essentially reflective'  I was frankly surprised to see my dear friends Kierkegaard and Karl Barth mixed into this pirates cast .  Bit like adding garlic and onion to a bland vegetarian soup.  Better for the taste at least.
Then he jumps around to an interesting notion of 'Three Kinds of Moral Problems and the Examples of truth telling.
Stern and Papadikis lay out three examples of 'professional attitude'.
1) student tempted to cheat on his exam
2) a medical clerk who is tempted to copy the residents notes
3) a doctor who contemplates deception in order to make an insurance provider pay for a mammography.
Kant he says (and I do love Kant) "psychological strength to resist the non moral inclinations as the essence of virtue.' He makes an aside here that essentially says the world hasn't changed much.
He sees the first two as easy but disagrees with lumping the third into this.  He argues there's a moral argument on the side of deception. As a clinician I don't think he gets the idea that a 'mammography' isn't 'treatment' and that the three examples are indeed all of a kind. Instead of a mammography a doctor can do daily breast exams and have relative benefit. he can hold a fund raising for the price of the mammography. There's a lot of choice. I know because I've been faced with this. Further my female colleague felt that mammography was abuse of women and thought women should be offered herbal compresses instead so it's far more complex .
But he's an academic and academics love to appeal to the ladies and mammography was a 'brand' until it was shown that mammography was causing unwarranted surgery and possibly in and of itself dangerous.  Oops.
Now out of the middle of this somewhat convoluted again discussion we leap back to
The Various Meanings of Responsibility in Medical Care.
(I just came from a trial lawyers conference where the judge waxed poetic about the irrelevance of so much information to the case in hand - I feel like her at this point - I thought we were discussing responsibily in Medical Care. Isn't this a medical ethics paper.)
It is to be recognised that doctors reading this paper might be better putting their attention to finding a cure for cancer or reading the latest copy of Nature or Science.  I'm not sure I'm going to feel good at the end of this paper. It's become like one of those cop television shows where you watch it and the ending comes and you realize it was completely unbelievable and filled with spoilers and everyone knew the butler did it and didn't Hitchcock do this already).
1) Responsibility as committment to excellence, holistic state of the art efforts - see I get the committment to excellence but don't get how this is a what 'responsibility' is necessarily but even if I accept this and 'state of the art' the word 'holistic' has a very chequered past in the medical community. "Holistic" health care providers were advocating eating cat poop for the treatment of diabetes and other such nonsense for years before 'evidence based' practices shut down their charlatanry.  At the same time other 'holistic' pratictioners were doing some good things. But it's this word put in this list that raises my hackles. I wrote papers defending holistic medicine at one time till I saw the unruly behaviour of some holistic practieoners and stood at the graveside of their 'clients' and 'customers'.  It's big business 'holistic' is and as 'packed' a terms as 'organic' to doctors who intrinsically have to know the 'truth' and want to avoid 'weazel' words and want to know what exactly you are saying.  Because we deal in dosage. A nanosecond off and a death occurs. It's a 'precise science' this art of medicine and this waffling wandering convoluted mishmash of terms is at times frightening.
Then we hear "the deliberative method unofficially adopted by bioethics is coherence oriented - reflective equillibrium." Whoa.  "unofficial' 'adopted' 'equilibrium'. The emperor has no clothes. Why not buy this spicy set of jargon.  Worse I suspect this person would want me to listen to their explanation of this and I'd be again amonst 'born agains' asking each other if they were 'baptised in the blood of the lamb' and who was born again enough to be a Christian  or whatever hair splitting cherry picking "I 'm in, you're out" argument they could get into. Where are Arendt and Buber when you need them.
So excuse me I'm not buying that 'the chief instrument of responsibility is deliberation.' "broad inclusiveness of participants and an ambience of mutual respect and freedom of expression combined with richness of argumentation have been shown to be conducive to successful deliberation."  What are you smoking? Are we all going to sing kum ba ya right here and then do a break dance.  What gives.
I am responsible when I cut this tumor and I don't cut the artery beside it.  The patient is responsible when he lives or dies.  Get real.  This is where the rubber meets the road in medicine.
Caring Responsibility is another heading
Here I am impressed because there's a clearer consideration of what he says are 'first order' virtues and 'second order' virtues. My clinical practice is a deluge of instant by instant choices made under the fire of illness and time and the pressure of a hundred judges all watching.  Surgery used to occur in theaters with dozens of on lookers.  Judges today resist cameras in their courts. Will ethicists one day be put in reality television studios and asked to make a decision which if right results in patient living and if wrong results in patient dying.  I don't think so. Critics are a dime a dozen but very few want to take the position of the doctor or patient.  It's a lonely lonely business.
Of course in those great instutions called universities and private rich practices where money is no concern and everyone has foresight, it's marvellous to sit down and put the feet up on the desk and have a good round table discussion. I love it if I'm paid for it as much as I'm paid when I have a knife in my hand. I love it when there is no other demands. It's probably why retired doctors and old people like myself love ethics. Bit like old soldiers winning the wars they lost first time round.  Great place to gather and avoid a golf game.
"the substantive good of the patient takes precendence over the minor good of the doctor."  I held my bladder and bowels to save lives and didn't sleep for days to keep babies alive.  Missed eating more often than not so now eat more than I should.  I am told I was a 'workaholic' and that 'I was 'sick' to sacrifice myself and my health for my patients. My patients lived mind you.  There was a tremendous amount of 'neglect' going on at the time. I remember I was the only doctor who would go to the north despite a recruitment campaign for 2 years. I saw thousands of Indians and Inuit and got TB and went through the ice and nearly drowned and walked wet across the tundra, sometime there was a plane crash. Not that long ago I saw a murderer , last week Ithink, threatening on crack and angry because his partner died.  I don't know what the sickness is that my street people bring. So many have new untreatable viruses and bacteria. Some of my family and friends won't visit me where I work. It's too dangerous for healthy people.  Few doctors come there. I remember when I worked in the provincial asylum I only saw the administrator leave the 'administration' bunker and come on the wards , once.  Let's face it good people don't like the sick. There's all the stigma too.
I like that he sees that 'free market providers strive to persuade consumers to accept less and pay more.'
Then he goes on to say Doctors Responsibility is a 'meta virtue'.  I don't know why it's suddenly 'meta' when it's still in doubt that it's a 'virtue'.  Its certainly not a 'virtue' of beurocracy or academia where if the shit hits the fan everyone is in cover your ass mode instantly and passing the buck is the norm.  Doctors always are there with the patient or the patient is alone with a loved one closest.
Good discussion of virtue though .A "virtue is chosen and cultivated habit of action and of perceiving the world and reacting to it emotionally'.
He argues weakly , because he seems to know that 'flexibility' is a popular buzz word, that 'flexibility will allow doctors to regard the occasional deviation from the norms and virtues as a virtue in its own right and not as an onslaught on their core identity and communal values."
"If this sounds like a call to anarchy" he says, then goes on to say essentially anarchy is okay in moderation but take two pills and call me in the morning.
Funny business.
Lets please everyone and make everyone happy and include everyone and slither and slide to avoid being caught holding to any position.
Yet everyday I have a prescription pad and the medication I prescribe is deadly and I ask 'prescribe or don't prescribe'.  The herbalists and holistic doctors and masseuses and ethicists don't deal with life or death moment by moment. Every prescription I write carries the potential to do harm or help. Every few weeks I encounter an allergy that I didn't know and my patient has a reaction to some thing that hasn't been reported and I ask myself again and again could I have told. My old surgeon friend finds it harder to enter the ring.
"They must also need to deliberate in a formal professional setting such as an ethics committee."  (Here's the brand that's being sold.  Here's where we need less nurses and less MRI's and less doctors and more ethicists and administrators and oh yes, more committees.
Yet I'm still waiting for the committee , meta analysis, which indicates the apriori decision of ethics committees coupled with evidence based outcome measures.  I know several decisions that came from ethics committees that ultimately lead to the death of the patient. I am asking of course that committtes hold themselves to the same accountability and responsibility standards as individuals.
Would a medical ethicists accept say 1/6th of the lawsuit cost as part of the committee decision making when one false decision in an otherwise illustrious career can cause a doctor to have to leave medicine. My favourite, greatest obstetrician colleague gave up medicine completely taking early reitrement because he couldn't afford insurance.One US state, millions of people were without any obstetricians because the standard that that state held the doctors to was 'perfection'.  Mothers therefore had to travel to other states to deliver babies much like marriages are done in Israel.
I recommend you read this paper if only because the author is from Tel Aviv. I think Tel Aviv is one of the greatest cities in the world and this paper raises a great many concerns.  Like most things doctors are having things done to them behind their backs and decisions are being made about 'profesionalism' and 'virtue'  Scarey stuff really.
I find no one asks the soldiers what they think and rarely do the doctors in the front lines get asked what they think and sick patients aren't that forthcoming.
This paper would be best separated into three papers and the paper given in it's parts to a random selected group of patients and doctors who would then be asked what they read. If there is any evidence of consensus on reality then perhaps the author could be described as a person who knows a duck is a bird. At this point I'm not sure anyone outside an academic bubble would have a clue what he's saying or be able to agree or disagree with him because he's really wanting to please everyone.  Yet life and death are simply not weazel words.

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