Thursday, April 12, 2012

The Best Lack All Conviction and Bioethics

The Best Lack All Conviction: Biomedical Ethics, Professionalism and Social Responsibility, by Jack Coulehan, Peter C. Williams, S. Van McCrary and Catherine Belling, published in the Cambridge Quarterly of Health Care Ethics 2003, Cambridge University Press is a thoroughly enjoyable article well worth the read by anyone interested in medical student education and the future course of the profession.
It begins by stating that 'the socialization process that occurs during medical training conflicts with and tends to diminish, many of the attributes and values usually associated with good doctoring - for example, compassion, reflectivity, curiosity, altruism, self-effacement, and social responsibility. Although these characteristics are often reinforced by the explicit curriculum in medical schools, the tacit learning that trainees receive in the hospital and institutional setting promote other and often conflicting ,personal attributes - such as detachment, entitlement, wariness, cynicism, an ethic of technique, and a moral myopia about the needs of the patients beyond one's immediate field of vision."
"Moreover, the introduction and development of biomedical ethics teaching in medical schools over the last 30 years has not significantly ameliorated this failure.."
At this juncture, rather than scrapping the biomedical ethics programs, the authors suggest rather enlightened alternatives and explanations with some good ideas thrown in the mix.
In this paper they focus on the 'social role of the physicians - that is , the moral responsibility of physicians as physicians toward the community in which they live."
Though young doctors argue that doctors should champion patients immediate and local interests they are 'unlikely to consider putting themselves at risk for their patients or advocating social change to help their patients in their community."
I can only agree. While I've been off in the areas of greatest need working in the very wilderness reaches of medicine and psychiatry at the cutting edge and front lines, way out beyond the wire, I've had to listen to the 'platitudes' of those whose cowardice keeps them safe in Ivory Towers surrounded by the intellectual and emotional mirrors.
A fascinating chimpanzee study showed that every once in a while a single relatively vegetarian chimpanzee gets the hankering to eat the brain of it's rhesus monkey neighbour. The vegetarian diet of the chimpanzee lacks the lipids they need which are rich in the brains of rhesus monkeys.  This individual then corrals an unsuspecting rhesus monkey and with the help of one or two or three of it's buddies kills the rhesus monkey.  These individuals, the actual killer chimp who bites the jugular and the others who stop the monkey's escape are at high risk and often injured in the struggle with the rhesus monkey who wants to keep it's life.  When killed these central characters set about taking their share.  However throughout this drama all the other chimpanzees have stood in the bleachers screaming and criticizing and carrying on with equal blood lust if less courage.  When the rhesus monkey is down the carpetbagger chimps descend on mass and try to push the tired wounded monkeys aside so they, the bystanders, can get a share of the brain.
Reading this characterization of the behaviour of our Darwinian forebears I've not seen much evidence of beaurocratic evolution despite our capacity today to put a man on the moon and cure cancer as well as extending woman's quality life expectancy by some 20 years.
The authors point out that there are two principle ways that ethics teaching occurs, one, following Beauchamp and Childress, principlist model, looking at 'respect for autonomy", "non maleficense", "beneficense", " justice" and  'sanctity of life' versus two, the case based teaching practice.
"In our experience, teaching based on the standard model conveys three relevant messages..."
1) "Respect for personal liberty" - "autonomy" to use Kant's expresion - 'the purpose of medical ethics is to protect individuals from each other and from institutions"
2) "Ethical questions or issues generally arise only in situations where there is conflict between parties or values."
3) "That doctoring is ineluctably infused with values is ignored. The conflict model also teaches that the law is the most practical guide to analyzing ethical matters. .....Under this model , turning to the law is seen as taking the work out of ethics."
Following upon this discussion the authors move on to discuss "Ignoring the call to Justice" pointing out that in the hierarchy of ethics values justice takes the hind tit.  "In the reductionist academic world, students learn that questions like "What is fair?" and "How should these resources be distributed?" fall outside the sphere of medical practice."
"The first difficulty with the narrow focus on individuals in a doctor-patient relationship is that that it distorts who an individual is in our society."
"The second problem with the myopic model of dyadic relationships is that it distorts the importance of social issues in medicine."
I remember when I was a resident in Community Medicine under the tutellage of Dr. Jack Hildes and Dr. Fish, I decided on a dual speciality in psychiatry being most interested in community psychiatry and cultural psychiatry.  I had the full support of the heads of psychiatry at the time Dr. Harry Prosen and Dr. Bill Bebchuck.  However, in the second year of my program the psychiatry departmental head informed me behind closed doors and very slowly that he did not respect any psychiatrist who was ambivalent about being a psychiatrist. His implication was clearly that my bottle and breast feeding had made me inadequate as a psychiatrist and I must 'make a decision'.  Indeed he told me he didn't like his residents to have families as he felt that psychiatry residency in his department required 100% focus. Any deviance from such a religious approach to the worship of psychiatry was evidence of inferority of character, brain matter and genital performance among other thihgs.
I mention this story.  It's true. I discussed it with Dr. Hildes and Fish who understood and accepted my withdrawal. In retrospect today I 'd have discussed it with Dr. Prosen and Dr. Bebchuck who would have provided the assistance I needed.  They were men of stirling character who were thoroughly committed to residents and advance resident training. They'd supported my goal for 2 years but I didn't give them the opportunity to support me further, simply being cowed and belittled by the all too common ethos of the day.
I point this out because is is 'normative' in the profession and routinely thereafter I've had senior people go to extreme lengths to have me share their fascination in a particular moth in their butterfly collection. Students who are fascinated by that moth get funding and support. Students who are interested in birds in contrast are left out in the cold.  The university is therefore a stiflying place for creativity that really principally supports hierarchy and rewards most those who goose step.
I've got to stop. A clinic calls.  I will return to this paper again. It's really excellent ,thought provoking and gets to the core of the problems of ethics in medical school educations. I sneeked forward and looked at the conclusions and was equally impressed with the solutions and ideas offered.
A really good read.  Well done, Cambridge!

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