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.



April 2020