Archive for the 'ethics' Category

Revitalising Professionalism

[Written over on the other site, but thought people might be interested]

Seggie J. Revitalising professionalism. S. Afr. Med. J. 2011 Aug.;101(8):508–509. PMID 21920118

This is yet another cracker from R&R in the Fast Lane via Sa’ad Lahri. There’s not a chance I would have found this paper otherwise so go check it out.

It’s a short, narrative review of some of the debate surrounding the nature of medical education and in particular the idea and definition of what it means for medicine to be a profession.

Some nice quotes:

professionalism is ‘a set of values, behaviours, and relationships that underpin the trust the public has in doctors’

learning of professional behaviour and absorption of professional values depends on strong, engaged relationships with positive role models

there should exist a moral contract between the medical profession and society

I want to talk a little bit more about the last one, about what the “moral contract” bit might mean.

I read a lot of a chap called Hauerwas and he describes medicine as drawing it’s moral authority from a society that refuses to abandon others who need help. Our society dedicates large amounts of money and some of its finest people to care for the ill – this in itself is a profound moral statement. Now I know that there are sound societal, economic reasons for doing health care but I really don’t think that’s why groups of humans do it.

The fact that medicine rarely cures many of the diseases that we attend to makes it even more morally significant.

For us to remain a profession (as opposed to being technicians) we must not neglect the moral aspect of what we do.

Here’s a Hauerwas quote for you to ponder.

Medicine is a profession determined by the moral commitment to care for the ill… The ability to sustain such care in the face of suffering and death is no easy enterprise, for the constant temptation is to try to eliminate suffering through the agency of medicine rather than let medicine be the way that we care for each other in our suffering… Indeed I suspect the increasing technological character of medicine with the correlative growth in specialisation reflects the attempt to substitue scientific expertise for the moral commitment necessary to maintain medicine as a coherent profession.

Suffering Presence 

Notre Dame Press: 1986; P17

Before anyone gets too upset, a moral commitment to care for the ill in no way prohibits technology or scientific expertise or so many of the things that I think really matter about emergency medicine, but in a rather twee and inadequate aphorism we need to be willing and open to care before we can cure.

 

UPDATE: Domhnall has written on something similar before so go read it too.

Something remembered from Paul Ramsey

I read this book called “Patient as Person” quite a few months back and I’d jotted this down and forgotten about it.

When talking about euthanasia and aggressive, intensive medical care in the face of a terminal prognosis, Ramsey suggest that these two, quite dissimilar things are really expressing the same thing. They are both expressing a denial of death.

To pursue aggressive medical means till the body is decaying is to deny that part of our human existence its end.

And to choose and actively pursue death either at the individuals choice or via a surrogate is an attempt to escape the death before us.

Bioethics in medical education

[I wrote this for my medical blog as a practice of saying something coherent about the idea of virtue ethics in medical training. This is one of the reasons I got interested in doing the theology masters. It should be fairly readable to non-medics. Let me know what you think]

Ethics is tricksy.

No way round it.

There are lots of reasons for that, the type of thing that keeps philosophy and ethics departments in good work.

Approaches to ethics in med school are always going to be hopelessly inadequate, it’s perhaps unfair to expect much else.

This paper discusses ethics and how to train people in ethics in EM. And they say lots of good things. It’s just that it’s a tad reductionist for my liking.

Ethics curriculum for emergency medicine graduate medical education. J Emerg Med. 2011 May;40(5):550-6. Epub 2010 Oct 2. PMID 20888722

Fig 1 from the paper

That figure may make a lot of sense to you. It certainly makes sense to me I’m just not sure it’s an entirely appropriate way to teach ethics or indeed practice it.

Or maybe it is. It’s probably a perfectly decent way to teach ethics if you believe that ethics is just another abstracted category to be put alongside physiology and anatomy.

The authors make this quote

a sound understanding of the principles of bioethics is necessary to become a compassionate and effective physician

Here I disagree. I do not know how an understanding of bioethics makes a doctor more or less compassionate.

Compassion in the context of virtue, character and humanity may be a learnable skill through the practice of a life lived but I’m not sure it’s teachable in the sense you can pass an MCQ at the end of it.

They do mention one thing that might be good material for fruitful reflection

Ethics education can be effectively provided, not only through behaviour modelling in the clinical environment, but also in formal didactic instruction

While I think the didactic instruction has its limitations as discussed above I think the “behaviour modelling” is fascinating.

Which brings me to this paper:

A Window on Professionalism in the Emergency Department Through Medical Student Narratives. Ann Emerg Med. 2011 May 28. [Epub ahead of print] PMID 21624702

Medicine is a lot like apprenticeship. In the sense that personalities and relationships are a key part of our learning and skill development. I model the behaviour and knowledge and skills that I find in my seniors.

These guys called the modelled professionalism by seniors “the hidden curriculum” which is kind of a neat name. Basically the students take on the habits of the senors and the practices observed.

I am deeply grateful to the people I have worked with both for the things that they have taught me to do and the things that I have seen them do and vowed never to repeat!

The term “holistic” is in vogue when it comes to talking about patients. It’s unfortunate that it’s become a buzzword as it’s actually a useful reminder that we treat people, not just patients, and certainly not conditions.

To think of ethics training and the practice of medicine as easily definable and teachable components that can be formed in an algorithm is something I find quite inadequate.

Some (tongue in cheek) conflicts of interest:

  • I think medical training is there to produce people capable of caring for the suffering, sick and the dying. These people need to both retain their own humanity and help their patients retain theirs. (This need not be in conflict with the good science and practices that fill medical research journals)
  • As background to this I am not a materialistic determinist. I have problems with a lot of the assumptions modernity has given us. I am a confessing Christian and a big fan of virute ethics. Though I’ll gladly admit Aristotle was a bit bonkers on a whole range of things…
  • I’m starting a masters in theology in the hope of exploring this kind of thing a bit further. And hopefully make it in some way intelligible and not just vague allusions to Macintyre

The Patient as Person – 1

To continue on Ramsey

He adapts quotes from this article (remember this was a 1970 book)

all of us in the age of enlightenment need to recognise death’s growing remoteness and unfamiliarity, the masks by which it is suppressed, the fantastic rituals by which we keep the presence of death at bay and our own presence from the dying, the inferiority assigned to the dying because it would be a human accomplishment not to do so, the ubiquity of the fear of dying that is one sure product of a secular age

Comfortably Numb

I’m reading the patient as person by Paul Ramsey, trying to get the most out of my access to TCD’s library before they kick me out in April. I found Ramsey through Hauerwas who both praised and gave some serious critique to “patient as person”.

Ramsey speaks very positively about consent. With plenty of good reasons, however i’m not sure I agree with his “canon of loyalty” and joint adventuring (borrowed from Reinhold Niebuhr) as it seems to suggest that as long as it’s consensual then people can commit all kinds of violence against themselves.

With that in mind I was listening to the wonderful Joe Lex in a talk called “who was ringer and did he lactate?” (a medical joke…) where he goes through the history of some of the big names in the history of medicine.

Most amusing was the story of Bier (of the block) and Hildebrandt who were investigating the use of cocaine in spinal anaesthesia, and indeed attempting to inject cocaine into the space surrounding the spinal cord (I’m not sure even the most inventive crack addicts are into this).

Like all good medical stories, they used each other as subjects. First Hildebrandt performed a spinal tap or lumbar puncture (LP) on Bier only to find that the syringe of cocaine didn’t fit the needle and the procedure was abandoned while their friend Luer (of Luer lock fame) came up with the appropriate adaptor.

On their second attempt Bier performed the LP on Hildebrandt with success and attained profound anaesthesia of the lower limbs. Note that Hildebrandt was fully conscious, just couldn’t move or feel his legs

Let me quote

After 7 minutes: Needle pricks in the thigh were felt as pressure; tickling of the soles of the feet was hardly felt

He followed this by sticking needles into the thigh till he hit the femur and then stubbing out cigars on his legs and recording the heat but not pain felt by his friend.

Pulling out pubic hairs was felt in the form of elevation of a skinfold; pulling of chest hair above the nipples caused vivid pain

And to quote a New Scientist article on the experiment

He smashed a heavy iron hammer into Hildebrandt’s shin bone and then, when that failed to have any effect, gave his testicles a sharp tug. In a final burst of enthusiasm, Bier stabbed the thigh right to the bone, squashed hard on a testicle and, for good measure, rained blows on Hildebrandt’s shin with his knuckles.

Following the LP Hildebrandt developed the well-known post-LP headache and had to take the day off work, he never mentioned how sore his legs were, never mind any other unmentionables.

God as a retard

[Apologies for the non-book or song related title for the blog but it was too good not to use.]

Following on from the last post:

Now for some leaps of logic and thought (at least on my part)

If those with the learning difficulties bear the image of god what does that mean for me to know God as someone with trisomy 21? (incidentally – great photo when you follow the link)

God’s face is the face of the retarded

Suffering Presence P178

I confess God’s face is far more like mine. Mine after some ace photoshopping at least.

 

 

Suffering Presence – 2

In Suffering Presence Hauerwas quotes Alasdair Mcintyre (a bit like Lewis quoting Macdonald)

any account of morality that does not allow for the fact that my death may be required of me at any moment is an inadequate account

The above quote is understood not to suggest we are moral because we suffer but we suffer because of our moral convictions.

 

You can do better than me

I have of late developed something of an interest in theological ethics. So I figured reading some relevant material on the principles of philosophy and ethics might be useful.

Perhaps typing “philosophy and ethics” into the Trinity College library was a bit of a simplistic place to start but I figured it was a start.

I found this book – Philosophy and ethics of medicine – by Michael Gelfand.

Being published in the sixties by a guy who lived and worked in the country formerly known as Rhodesia didn’t make me that optimistic.

I was not to be disappointed. Or impressed.

It was kind of weak on the philosophy bit, and the ethics bit wasn’t too hot either, and I really wasn’t sure about a lot of the medicine…

Early in the book he defends “medical epistemology” as being best because it follows the scientific approach with no argument to justify why this might be best  approach. Or even that other approaches exist.

This was one of my particular favourite quotes

what should the doctors attitude towards telling his patient the true nature he is prescribing for him other risks invovled in an operation he has advised? The problem is a complicated one. Firstly the doctor should avoid, if possible frightening the patient or the family lest he refuse the treatment and so endange his life

It’s much better that the medical profession should endanger your life rather than let you endanger it yourself…
Truth telling is good as long as they do what we think they should do.
And the specific drugs he was considering warning the patient about in the above quote were named as emetine (a drug that eventually ended being used to induce vomiting and is now abandoned even for that purpose), arsenic (enough said…) and antimony (which used to be used for treating parasitic diseases but we gave up on it cause it behaved a little too much like arsenic…).
Hmmm

Suffering Presence – 1

[A few thoughts on reading through this collection of essays]

Hauerwas talks alot about how medicine as a moral act is difficult to sustain in a society as morally confused as the one we exist in.

To illustrate it I found this quote:

we blame physicians for keeping us alive beyond all reason, but fail to note that if they did not we would not know how to distinguish them from murderers.

Those of us who have been involved in talking about end of life issues, either in the church or in the public sphere, will realise how such conversations can go. The multitude of opinions found (and how uncomfortable we are with them and the language we use to talk about them) gives light to the moral confusion we live under.

 

Learn to live with what you are – 4

I’m not so much scared that theology will lead me to do things I know in my heart are wrong. Apart from the ones I’m already complicity in a modern health service that occasionally and even frequently struggles to give its patients dignity.

The Spirit does not just guide choices but makes us into people who make right choices.

It’s more that I struggle to fill in the theological gap between what I practise (and believe to be the best thing most of the time) and what I can articulate.

 

Suffering Presence – 1


I should have read this book sooner I know. Those who were at MCC’s forum a few weeks ago will remember me proposing exactly the question Hauerwas makes here (on the first page)

 

 

 

we may be able to keep an extremely premature child alive, but should we, since the very means to sustain may also injure

Me and Stanley – we’re like that (makes crossed fingers sign…)

 

Learn to live with what you are – 3

I’ve talked about the image of God a lot in these few posts. Though I’m still not sure quite that means. It is definitely something of significance just not clear what.

Yes we bear the image of God.

But we are broken images.

Does this then confuse our talk about being in the image of God?

Which bits of our humanity are fallen and which are in the image of God?

We tend to talk of sin and death when we talk of how the fall has affected humanity so do we view those who are considered to be in poor health to be less in the image of God? Do they reveal less of God’s image to us?

So the question is not just what does it mean to be made in the image of God but also what does it mean to be a broken image?

Learn to live with what you are – 2

As a follow on from the recent post, let me try to simplify where I’m at, or at least my confusion.

Perhaps using the example of a severely ill infant is too rare and specific a case to be useful in articulating a theology of medicine. My bigger interest lies in how we treat the frail elderly and care for people who may or may not be dying sooner than others.

Death is our enemy and a horrid thing, but it is not medicines job (and definitely not in our capability) to eradicate death. That is guaranteed elsewhere.

Anyhow.

If it is so that the severely ill infant of the last post – who by all appearances seems to be dying – should continue to be resuscitated and treated aggressively because they bear God’s image then it surely follows that we should continue to resuscitate the frail elderly with severe pneumonia (who will almost always have lost capacity to decide for themselves due to their acute illness).

My reaction to the severely ill infant is to aggressively resuscitate but to the elderly patient with severe pneumonia my reaction is to not aggressively resuscitate. I seem to be following a different ethic in each of those situations.

i find these two points that to be in conflict:

1) it is a good thing that you exist. You are in God’s image. Your existence blesses mine

2) it is good that you are not suffering. It is good a thing that you are not in pain

I cannot bring about 1) without going against 2) and I cannot pursue 2) without struggling to maintain 1)

Without bringing in harm/benefit ratios and a generalized utilitarian ethic I find it impossible to resolve them, though I am well aware I may be missing some fundamental point.

And I don’t mean to say that considering harm and benefit in the decision making process is necessarily a bad thing I just feel it dangerous to give them primacy.

There is no doubt a logical fallacy somewhere in there so help me out.

Thoughts people?

 

Learn to live with what you are – 1

In Church we have this little meeting sometimes on a Sunday night called Forum. We sit in the office and drink dodgy coffee and try to work out some theological topic relevant to the contemporary world.

A few weeks ago, I led a discussion about end of life and theological implications following on from our involvment with modern medicine. This blog summarises a lot of my take on it.

Last night myself and Mrs Steffi Knorn were leading one on the interaction of ethics, theology and modern medicine in issues pertaining to the beginning of life.

What follows is not exactly the minutes of the meeting, more like how the discussion flowed from my point of view and my reactions to it. Be aware that it contains some very distinct Christian assumptions about image bearing, and protection of the powerless and voiceless in society.

Bottom line we seem pretty bewildered and confused on the whole thing. On a spectrum from where we believe life begins to what we do with extremely tiny premature babies we struggled to articulate an ethic or theology that was somewhat separate from what modern medical ethics tells us to do.

We retreat to defining what is good based on a balance of harms and benefits with a presumption that survival is the positive outcome to be chased and disability (in the case of extreme pre-term births) is a negative thing that sways us against active treatment.

When it comes to defining when life begins most of our discussions resolved around various different scientifically defined points. When I think of where life begins it takes me a while to realise that this is a poor question when it is abstracted from a theology of relationship, image bearing, sex and community.

I struggle to know what it means to care for an extremely low birth weight 24 week gestation infant. I struggle to know if active and invasive intervention is the best way to love them and honour their image-bearingness.

200 years ago an extremely low-birth weight infant was fairly easy to care for. You kept them warm and the you buried them.

We now find oursleves in a bit of a different situation.

The question I find myself asking is that if we can do something why should we do something?

Followed to its logical conclusion this is kind of a scary question, cause it throws virtually all medical interventions in the air.

Hargaden’s point (which he was making up as he went so see it as that, rather than a finely tuned postion) was this (forgive me if I make a hames of it) – if we accept that all life is holy (which is the orthodox Catholic positon as I understand it) then life is inherently good and worth preserving. Therefore we should fight to preserve life. This has particular relevance for the powerless and voiceless (infants and those with severe disabilities) because if we acknowledge their lives as holy then we have a duty to protect their lives as no one else will. There is a risk that the powerless are silenced by the powerful and wiped from the earth. It is our repsonsibility to fight on behlaf of the powerless.

Follow this out and it seems that if life is holy then the right thing to do is to fight to preserve it, aggressively if necessary.

The situation for those with a voice is somewhat different as they are able to acknowledge and choose that their lives are not of ultimate value and therefore they can choose to forgo life-saving treatment.

It is at this point that I struggle.

I find it hard that an ethic that is designed to protect the powerless results in us causing pain and suffering.

It breaks the golden rule (do onto others as…) or Kant’s categorical imperative. If i was a 25 week premie with massive IVH (bleed into the brain) and bilateral pneumos (punctured lungs on both sides) and florid sepsis (an overwhelming infection) and had already failed multiple treatments I would not want further life-preserving treatment. This would be my choice.

So this ethic seems to need refinement. We cannot fight to preserve life out of fear (a reasonable fear) that we will silence the powerless, because in preserving life we will end up doing violence to them.

Indeed perhaps the whole problem with this, why we find it so hard is because we don’t really know what life is for.

We reach for medicine as the framework to answer these questions by because we have no better answers.

Medicine will at least give us some kind of an answer (though we still find it hard to swallow) that life is most flourishing when we are conscious, without pain, autonomous, and have many years before us.

This question will remain unanswerable in the church till we become a people with an alternative definition that values and understands all the image bearers that this world is peopled with.

Comments, criticims and rants welcome.

Get real get right

As the church should we:

A) seek to know the right thing to do

Or

B) be formed into a people of character who do the right thing

Or maybe they’re the same thing.

(if there’s anything life has taught me is that difficult questions are best answered using simplistic binary variables…)

 

 


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