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.

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