Patient Ethics.

Lately, I’ve been thinking a lot about ethics; I’m not sure why, although I suppose it’s a common attribute of age: a way, perhaps, of appraising one’s own affect on the world. I’ve written before about the usual constituents of an ethical assessment: Respect of Autonomy -respect, in other words, for a different opinion; Justice -or fairness in decisions and judgments; Beneficence -acting in someone’s best interest; and Non-maleficence -doing no harm.

The value and importance of these principles is hard to deny. I suspect the thrust of them is much the same as that of politeness and consideration in dealing with others -a more complicated re-wording of the Golden Rule: the ethic of reciprocity that seems to have appeared in all of the great religions. It is a set of precepts that should apply equally to both parties in a relationship of whatever kind.

Ethics are certainly a requirement in a medical relationship: a doctor/patient duality. It is a recognized and appropriate expectation on the part of the patient, of course… But what about the doctor? Does the artificially engendered inequality ( the fact that it is his opinion that has been solicited) obviate the reciprocal duty to behave ethically in response? Or, put another way, do patients have an implied obligation to be polite -ethical- in their dealings with the person from whom they sought help? It is a vexing question, to be sure.

Of course there are those who will insist that the very inequality inherent in the encounter, the power asymmetry implied in the act of requisition, excuses the petitioner from the need to adhere to the same principles as the petitioned.

Perhaps my expectations are unrealistic, but it seems to me that it is reasonable to expect a complementary gain in my encounter with the patient. It is of a different kind, for sure, and no doubt is assessed as more trivial than hers, but it is, nonetheless, of value to me and therefore, in my mind at least, helps to neutralize the power inequity between us.

As I see it, understanding -or attempting to understand- another person is an experience that should not be trivialized, or underrated. It is a gift to be allowed the opportunity to share another’s world; it is not given lightly, nor freely. It is obviously a privilege not accorded to everybody, a recognition that the opinion sought is valued. Important. And although not immediately evident, thoughtful consideration of the relationship suggests there is reciprocity inherent in the transaction…

Or am I deluding myself in expecting a relational reward? Am I too bound by the process, too inextricably entwined to assess it impersonally? Objectively? Realistically? Is it even possible to judge from the other foot?

And yet… If I do my part, shouldn’t they do theirs? Do we not both share responsibilities as constituents of a contract -however loosely defined? Is there not a moral obligation to deal ethically with each other? Do I also have a right to feel slighted if we do not… Or more to the point, if my patient does not?

I suppose these are merely the ruminations of a person who expects civility to be reciprocal, responsibilities to be shared and ethics to be the warp and weft of a consultant practice. When they are not it is a disappointment that I sometimes feel more keenly than perhaps I should. Who would have thought that I would even have an expectation of bicameral courtesy in such a profession?

Thankfully, the vast majority of people -doctors and patients alike- share these values, but that only makes their occasional absence all the more evident and egregious. Respect for each other is important: something to embrace. It is what we expect of each other…

Virtue, perhaps, is nothing more than politeness of soul (Honore de Balzac). Who could disagree?


Is there ever a correct answer?

“Doctor, can I still get pregnant?” -a seemingly straightforward question, I suppose: quote her some statistics derived from her age, past history and current medical status. But in reality, it’s probably not a single question she’s asking. In many respects, it’s a philosophical question with many facets to consider; it requires a thoughtful reply.

Philosophy, as Michael Blake, a philosopher from the University of Washington once put it, is thinking in slow motion. I like that; it suggests that to answer something, to comprehend the various competing facets of a question, we need to take some time to consider both what is really being asked and whether our answer to it is relevant, sensitive, and in this context at any rate, representative of current thinking.

To make it through even a single day, we all have to make many unexamined assumptions about reality, not to mention about people and their beliefs, hopes and aspirations. Sometimes we assume they share our own opinions, see the world as we do, have the same or similar doubts, exhibit our own biases. But I suspect that this assumption will never properly address the question my patient posed. It may not even come close to answering it.

The question is a tree: it has roots and branches; and rather than existing in isolation, it is probably surrounded by other questions. To understand the tree, you have to understand the forest -or at least look at it in context.

“Can I still get pregnant?” -the very construction of the sentence suggests some of the worries and concerns that she has. It is, on first consideration, merely a question about her ability to conceive and if answered in that framework, is a number. A percentage. It is the product of an algorithm into which you feed her age, past history of pregnancies or diseases, and her current medical status and a type of answer appears. It is a type of answer, because it is really only a statistic -useful for a population of 40 year olds, say, but not necessarily this 40 year old. And what does 20% or even 50% really mean? The question, after all, was “Can I get pregnant?” -not, can a forty-year-old woman get pregnant. Not really; she is asking in effect: “Given what you know of me  and my circumstances, my health, my body, do you think I can still get pregnant?”  And she is asking for your opinion, not a legally binding statement. She is asking what you think…

And “still get pregnant” is important. In itself it hints at other questions: “At my age, is pregnancy even advisable?”; “What might be the problems I will encounter if I do become pregnant?” And “What would a pregnancy under those circumstances look like for me? And for the baby?”; “Are there disadvantages -long and short-term- that you can foresee, doctor?” Once again, you are being asked for an opinion -perhaps even a personal perspective (with all it’s biases and cultural nuances).

There is an uncertainty built into the very question that demands consideration. Perhaps she is unsure about whether even to consider pregnancy; perhaps it was something someone else had asked her -or even demanded she ask. Maybe she is asking for permission not to become pregnant…

What is inserted into an equation, determines it’s answer; the background of a question, the milieu -the forest in which it lives- should suggest the thrust of the response. There is often no correct solution; in fact that may not even be what is sought. Sometimes a question is more of a search for someone to listen, a hope for acknowledgement, a quest for agreement, than a need for an accurate reply. The skill is in recognizing what is being requested; listening not so much to what is being asked, as to what is meant by the question in the first place.

So the importance is in properly and sensitively analysing the question; recognizing that it is a series of probes for which a thoughtful response is required. It is usually not just a number that is wanted -although that may help to give some perspective to the subsequent analysis- it is a respectful appreciation of the concern and a realistic appraisal of the context. “Can I still become pregnant?” requires not only a judgment -even though that is certainly a part of it- but also an opinion: a thorough appraisal and a considered response; it is not necessarily even final: things evolve -questions as well.

It is thinking -and answering– in slow motion.

Sex Selection… or Any Selection

Another day, another march. This time it was the March for Life in Ottawa where the usual Pro-Life rhetoric was rebranded as being against sex-selection abortions. A worthy cause, for sure, and probably more universally palatable than condemning all abortions -whether done for medical, genetic, or even social reasons- as they have in the past. And by aligning themselves with the Feminist movement -protecting female fetuses and ‘more progressive human rights movements’ as the news media report it- they are no doubt hoping to appeal to that segment of the public that has hitherto merely watched from the sidelines.

As a member of that Public for many years now, I am intrigued to say the least. I am -and remain- firmly pro-choice, and yet I cannot deny my concern about sex selection. Quite apart from any argument about the sanctity of life or the morality of abortion, sex selection seems a self-defeating concept. I don’t wish to state the obvious here: like the huge loss of potential, the necessity of a female perspective to balance that of -what?- Testosterone? Or even the more obvious one: who would have the next generation’s children if there were no women? I just think it is inappropriate and short sighted to select on the basis of gender. It simply does not make any sense to me; it wouldn’t in a male-dominated society either: why would they want even more competition..?

I realize these are rather superficial observations on a topic that deserves a much deeper analysis, but I am struck by the emphasis in all this protestation on what we do not have in common. It is perhaps one way to capture attention and engender Media headlines but I would submit that confrontation usually entrenches positions more solidly. If nothing else, it defines an us and a them –a line to cross. It necessitates a backing down by one side -a loss of face, if you will- before there is a victory. And indeed, even to see it as a victory rather than a change is to diminish the other side and those that were adherents. In a way, it is to colonize that other world.

Drawing attention to a cause is one thing; convincing and educating an otherwise indifferent opponent is another. I think that all too often, the terms of battle are such that winning means incorporation: absorption of the entire spectrum of views and opinions of the successful side, and denigration -or at least abandonment- of those of the opposition. Colonization by default, if you will. It’s all politics: you have to convince the Public before you legislate. No smoke-and-mirrors. If there is an imposed settlement, rather than one achieved by both enlightenment and then consensus, it is a short term gain and one that will likely be resisted and maybe even eventually overturned again.

Even my dim recollections of History attest to the wisdom of compromise after conquest: the Roman empire was stabilized over the years almost as much by the accretion of foreign customs and religions as by the continued imposition of force.

I’m not trying to assert that obtaining such important and inalienable goals like Women’s Rights -or Human Rights- are somehow akin to foreign conquests; that we must always be satisfied with compromise. That we must always and forever sacrifice some issues to achieve others. But let’s face it, there truly is a wedge effect: achieve one thing and it often makes it easier to move on to the next on the list. I suspect that those gender selection protesters in Ottawa are well acquainted with that possibility.

But you know, even if it stops somewhere -as it always must in a diverse, multicultural and multifaith society like ours- it is an accomplishment. A blend of opinion, a mixture of viewpoints is ultimately to everybody’s advantage: no one will accept everything -our society is simply too heterogeneous to be of one mind. And ultimately, hopefully -probably, even- in the fullness of time, we and even our presently-held viewpoints might become different shades -ripples- in the melange that bathes us all.

If I may be allowed to cut-and paste from Shakespeare (Antonio in The Tempest): We all were sea-swallow’d, though some cast again (And by that destiny) to perform an act Wherof what’s past is prologue. We must resist the things we cannot abide and advocate for change. But whether, as things progress, we still feel the same or even settle on a middle ground, the expression of the opinion is what is important. A Society grows by increments; it is a work in progress -never finished, never complete. Nor are we, the Public, meant to be displayed for all time in a stone carved years before.

As with Evolution, whatever happens can only be judged in context and we -and even our opinions- in the larger scheme of things, are contingent…

The Objective Doctor

Is there objectivity in Medicine? Is it even possible? Can there ever be a decision or an opinion that is not contingent and shaped by something not currently obvious? If we engage with someone, are we not also conversing with their past? And are they not interacting with our own shadows? I ask this because I have always wondered about just how independent our thought processes are. We play at being rational but how realistic is it? Is it just a conceit -a cosmetic we apply to hide the wrinkles even from ourselves?

Perhaps I can be provocative -and a devil’s advocate.

Take the Holy Grail of Evidence, as an example. In Medicine, we like to think that our treatments are evidence-based, objectively derived and statistically valid. This validity would issue from a series of measurements gleaned from a dispassionate consideration of  the symptoms and a treatment, compared with either another standard, recognized approach, or something similar but known to be ineffective. The patients are usually uncertain which treatment they are receiving (single blind) and hopefully so are those conducting the experiment (double blind). The methodology would seem to be objective and foolproof.

And yet… How do we decide whether we are comparing apples with apples? Previous experience? Theoretical considerations somehow divorced from confirmation biases? Can we actually envision or entertain theories that don’t, at least in part, embody remnants of what we already believe – that we suspect obtain because of the way we have modelled the problem or the way we asked the question? That we hope obtain… Is that why we chose to study it and not something else in the first place? What baggage did we bring along with it -or at least what was hiding within it? And how do we know it’s actually baggage, or that what we conclude about it is not tainted. Skewed? Biased?

I’m not trying to be malevolently iconoclastic here; I’m just trying to sift wheat from chaff. Because if I can’t be truly objective and can’t be sure whether Nature or Nurture is dictating inside my head, then perhaps any therapeutic regimen I suggest to a patient isn’t objective and unbiased either. If I only read those articles in journals that confirm my hopes -or what my professors taught me in medical school- or if, indeed, only those types of articles find their way into print… Well, you can see the problem.

And if one of my better-informed patients suggests a treatment based on her reading of whatever literature to which she is privy -or inclined- then who’s to say what I should do with that information? Especially if it is dissonant with mine – i.e. the evidence-based, objective, statistical stuff that I have decided to collect and treasure because it agrees with what I have come to believe. Should mine triumph merely because I am the authority? Or would it make more sense to talk it through and, like a politician, arrive at some sort of middle ground? After all, in medical ethics, the concept of Autonomy is predicated on respecting the opinion of those who’ve come to us for ours.

So if I can’t be certain whether what I believe is stained with history -personal or otherwise- and if the patient brings a similar bias to the table, where do we go? Now that pharmaceutical companies are able to advertise their brands on television and the internet -and to me, of course- and now that Google has more answers than a medical textbook that are readily assimilable by anybody with a mouse, this is not simply an academic exercise.

Politicians may have something to teach us here: they often get their way by obfuscation. Doctors, I submit, do not sink to quite this level, but we pontificate; we preach; we admonish. We call upon higher authorities to validate our decisions. Even our explanations are sometimes confusing. I don’t for a minute believe that this is an attempt to conceal, or mislead, nor is it likely even a conscious process. We’re taught to be opinionated in our fields, to analyse and treat accordingly. And in many things, one and only one opinion and only one course of action is necessary and appropriate: treatment of a ruptured ectopic pregnancy is not a subject for debate. But the type of contraception -or even the brand of contraceptive- may well be. Under these circumstances, there may only be opinions, inclinations. And so they should admit of compromise. We do not lose authority by listening; we do not lose credibility for considering another approach. Compromise assumes that both sides take each other seriously and common ground enhances compliance. As long as safety is not at stake, does it really matter whose bias triumphs?

My mother thought cod liver oil cured everything -maybe she was right.