How Ethical is Ethical Compromise?

What to do with a minefield? Once it is there, is it sufficient to avoid it while we investigate and map it –mark it off as terra incognita- or must we act immediately to attempt to remove all mines even if we do not fully understand their distribution or destructive capabilities? Even if we may miss some and our initial enthusiasm was deemed naïve?

This is an admittedly inadequate metaphor when applied to ethics, to be sure, but in many ways is illustrative of the pitfalls of being too quick to judge; or, alternatively, of assuming there is only one approach –and that the one chosen is perforce the correct and appropriate one.

Unfortunately, majority opinion often quietly assumes the mantle of indisputability in a culture, no matter its importance or suitability elsewhere. And even to question the legitimacy of the assertion is to question the legitimacy of the social norms to which its members unconsciously adhere. It may not necessarily intend to negate them, or overtly dispute them, but by subjecting them to investigation, it may seem to disparage their sanctity.

It is difficult to step out of our societally condoned patterns of thought and our long-hallowed mores; it is troubling to observe customs that seem to violate what to us are ingrained standards of morality. It is difficult indeed, to accept that we may not be in sole possession of moral rectitude –that there may be alternate truths, alternate moralities, even alternate equally valid perspectives.

I raise this with regard to the increasing awareness and condemnation of female genital mutilation (FGM). To be clear from the start, I do not condone FGM nor feel that it should be perpetuated; indeed I have to confess that I have great difficulty viewing it as anything other than a culturally-imposed abomination -misogyny writ large. I was, however, intrigued by a paper published in the Journal of Medical Ethics that sought to assess the issue in a more critically constructive fashion than I have seen before:  It is really a very thoughtful and enlightening paper and I would strongly suggest that it is worth reading –if only to learn more about FGM and its cultural significance stripped of any pre-loaded societal baggage.

I was impressed by several things in fact. They sought to classify the procedures in terms of degree, medical issues, the ethical underpinnings of FGM, cultural sensitivity, and whether or not any form of the procedure would constitute gender discrimination or the violation of human rights. I will let the reader judge how thoroughly these fields were covered, but caution against our usually self-imposed wall of confirmation-bias that often precludes a dispassionate consideration of views that don’t fully accord with what we ‘know’ to be the correct ones… -this brief article from the CBC is perhaps a more assimilable and balanced –albeit nuanced- summary of the arguments.

I suppose the issue is not so much whether the practice should ever be acceptable –although neonatal male circumcision seems to have made it through the gate- as whether by outlawing it, the procedure will be driven underground as seems to be happening currently. If it is so important to a culture –whether justified by mores, or religion- that there seems to be an imperative to have it performed to allow an individual’s acceptability to be confirmed in the community, then wouldn’t it be better to acknowledge this, but mitigate the harm?

The authors have attempted a classification of FGM into 5 categories, the first two of which are thought to have minimal if any permanent effects on the girl -no effects on sexual pleasure, functioning, or reproduction. And, of course, if accepted, could be done under an anaesthetic, rather than by test of courage. Its acceptance could serve to assuage the cultural imperatives while essentially eliminating the greater severity and mutilating effects of the more complicated forms of the practice. It would be an intermediate –and hopefully temporary- step on the road to complete elimination of the procedure.

To be sure, the objection raised is often the one of argumentum ad temperantiam –the fallacy of assuming that the truth –the resolution- can be found in the middle ground between the two conflicting opinions. The problem, of course, lies in the validity of the opposing claims. Should one really be looking for the middle ground between information and mis (or dis) information? Sometimes the distinction is easy, but sometimes it is the minefield I discussed above. Primum non nocere –first of all do no harm- is the guide. As the authors state: ‘… analysis of issues in medical ethics generally regards principles as being prima facie in nature, rather than absolute. Therefore, important emotional and social considerations can trump minor medical considerations.’ In fact, because of the extreme and negative connotations of the term female genital mutilation, the authors even propose an alternative, less pejorative name: FGA (female genital alteration).

Without trying to push the concept and its acceptance too strongly, let me quote the summary of their intent: ‘Since progress in reducing FGA procedures has been limited in states where they are endemic and the commitment of people from these cultures to these procedures has led to their persistence [even in] in states where they are legally discouraged, alternative approaches should be considered. To accommodate cultural beliefs while protecting the physical health of girls, we propose a compromise solution in which liberal states would legally permit de minimis [a level of risk too small to be of concern] FGA in recognition of its fulfilment of cultural and religious obligations, but would proscribe those forms of FGA that are dangerous or that produce significant sexual or reproductive dysfunction.’

Compromises are always difficult; no one gets all they want, and yet each gets something. I raise the issue of female genital mutilation/alteration mainly for information but also for discussion. Sometimes, we need to know something about what we oppose. Always, in fact…

The Uber-obvious in Medicine

I don’t know what atavistic urges compel me to rail against reporting the obvious as if it were something new -something clever. Reporting something as if the rest of us would do well to take note of it and spread the revelation to the uninformed like evangelists. Of course I don’t mean to confuse the concept of ‘obviousness’ with ‘commonplace’ or even ‘conspicuous’ -things one might see every day, as opposed to those that might stand out noticeably in the bushes like, say, a lion. It would seem prudent if not Darwinian to report the presence of danger nearby. No, I refer, rather, to the inexplicable need to wrap something as a gift when it isn’t. To present common wisdom as an epiphany. To accede to the Delphian urge to award some observation like ‘It is good to breathe’ with a profundity it neither deserves, nor has.

My ever-prowling curiosity was twigged by an article in the BBC News. It is a ready and inexhaustible cache of articles that run the gamut from fascinating to bizarre and yet often flirt with the self-evident, not to mention the banal. The one that caught my attention a while back was one that revealed that the doctors in the province of Quebec could now prescribe exercise! And the privilege comes with the added bonus of special prescription pads. Uhmm… It is good to breathe, eh?

I don’t mean to be critical of the advice to patients; we are all in need of exercise, and perhaps overweight and obese patients especially. It’s just the fact that it was even considered newsworthy… No, actually I think it was the prescription pads! “Doctors are showing that they take this seriously,” said Martin Juneau, director of prevention at the Montreal Heart Institute. “It’s not just advice. This way, it’s a medical prescription.” Really? Are patients so naïve as to think that just because it is written like a prescription on a little official piece of paper, it is in the same esoteric medical league as an antibiotic, or a statin? That, unwritten, it is less important? Or that, by extension, other prescriptive advice such as cutting down on smoking or drinking carries less weight because there is not a name at the top and a signature at the bottom of a prescription pad? I wonder if it is the doctors who are naïve.

Anyway, I couldn’t resist trying the concept on one of my patients. She had come to see me for what she was certain was a menopausal symptom: her seeming inability to lose weight. She had tried all of the magazine prescriptions for dietary choices, restrictions, and cleanses, and finally came to the conclusion that what she really needed was hormones. It made perfect sense to her; she had never been heavy when she was in full possession of her own hormones so, like insulin for a diabetic, she needed to replace what she was lacking. The fact that she had gone through the menopause several years before and was no longer having any other symptoms of hormonal diminution seemed beside the point. She needed a prescription and she would not take no for an answer. She even resisted taking no for a discussion. A compromise.

We talked at length about other possible options for weight loss, but when she folded her arms across her chest and glared at me I began to lose hope of ever convincing her of my opinion. After about 30 minutes of trying, unsuccessfully, to slip a more reasonable assessment of the physiology of menopause under the locked door of her face, I suppose the smartest thing to do would have been to acquiesce: re-discuss the risks of hormone replacement therapy, reiterate that I didn’t think they’d work, and then write her out a prescription for, say, a three month trial. But I wasn’t at all happy with prescribing what I felt were unnecessary and possibly dangerous placebos for her.

I could feel her eyes follow my hand as I reached for a prescription pad. “So, if I understand you correctly, Lana, you would like me to write you a prescription for something that will help you solve your weight problem?”

She tore her eyes from the prescription pad and dragged them onto my face. She looked suspicious. “I’m just a little heavier than I want to be, doctor. I wouldn’t call it a problem really… Would you?”

I smiled and put down the pen I was holding. “Not at all, Lana. If it were, I think we’d be having a different discussion about cardiovascular things -blood pressure, cholesterol levels, and so forth.” She seemed relieved that I wasn’t that concerned. “Those things” -I purposely emphasized ‘those’- “would require detailed investigations. Different medications.” I let the point sink in for a moment. “The idea is to match the treatment to the problem. Not the other way round.”

She nodded sagely. At last I was listening. Then her eyes narrowed; she smelled a trick. “But you’ll write me a prescription, though?

I smiled and picked up the pen. “But remember, sometimes our treatments are really just trials. They don’t always have the desired effects. Sometimes we have to move on to something else. The guiding principle is always to start simple and then if that doesn’t work, try something more complex -but more likely to have unwanted side effects, perhaps.” She nodded in agreement, all the while keeping an eye on my pen as it seemed to move closer and then recede from the prescription pad. “And, of course, we have to make sure it will not make things worse.”

Primum non nocere as Dr. Google puts it,” she said with practiced condescension, obviously content that she could contribute meaningfully to the conversation.

The smile never left my face as I reached for the prescription pad again, scribbled something down, and handed it to her.

Her eyes suddenly opened like the cover on a barbecue and I could almost see the steam rising. “What’s this, doctor?” she stammered angrily. “Exercise?” She threw the red hot coals of her glare squarely on my face and dropped the paper. “This isn’t what I asked for!”

I sat back in my chair and tried to ignore her expression. “Well, actually it is, Lana. You agreed that you wanted an effective treatment for your weight that would not have dangerous side-effects. Primum non nocere, remember? ‘First of all do no harm’ is what it means.”

She began buttoning up her coat and I could see her fingers trembling. “I’ll just go to another doctor, you know,” she said as she stood up. “What you have written here is not a prescription; it’s a suggestion…”

I sighed and met her eyes half way. “If it works, then it’s a prescription isn’t it?”

She started for the door and then stopped and slowly turned around to face me. She examined my eyes for a moment, undecided. “You’ve got a lot of nerve, doctor,” she said with an unreadable expression, and then hesitantly reached for the prescription I’d written. “But also a lot of conviction… I like that,” she said as she winked and then turned and walked to the door. “I’ll let you know, eh?”


The Ethics of Counselling

Primum non nocere -First, do no harm. I remember the phrase was used in one of the first lectures I attended in medical school and it nested -sometimes uncomfortably- in my conscience as the lectures and the years progressed. It would signal me from the back seat in Pharmacology lectures and tug on my sleeve in Physiology labs when we would be asked to subject laboratory rats to unconscionable ‘experiments’ whose outcome was already known and whose purpose would have been questionable even had we been seeking a Nobel Prize rather than a passing grade.

It especially fought for my attention after I’d graduated, when my decisions would actually be accorded credence. I would be asked to see someone in pain -with endometriosis, say- who had decided she’d had enough and wanted a hysterectomy. Often she would have been aware of other options -medications or ablative surgeries- and have tried them all unsuccessfully; sometimes she might be speaking out of frustration or desperation. But in none of these situations would she have felt in control, a full and willing participant in her destiny, able to make a reasoned, or at least equitable decision for herself.

One might argue the role of the dispassionate physician here: the person who can consider the ramifications of each option, present them in a reasonable and sensitive fashion, and help the patient decide. And yet, one might also point out the possibility that the patient might be unable to make a truly informed decision for herself under duress. There’s a term used in Medical Ethics that we were also taught in medical school: non maleficence. This is a concept that suggests that it is important -no, necessary– to consider whether a particular decision might do more harm than good, no matter how well-intentioned. It is yet another version of the primum non nocere phrase that so influenced me.

If I feel the patient actually understands the ramifications of her decision, and has at least considered and then rejected other possible pathways, then I am more than willing to accede to her request and help in whatever way she feels would be in her best interest.

But I have always believed that informed, or at least insightful empowerment -if I dare use that overworked and voguish neologism- is the key to compassionate decision-making. It’s object is not so much to convince or direct, as to allow her to come to an appropriate and acceptable decision, as much as possible unencumbered by all the trappings and emotional accoutrements of pain and frustration… As I have already mentioned, the problem of counselling someone in dire straits is that her pain or anxiety, quite apart from its obvious distraction, often permeates her entire being and impedes her ability to look out for her own ultimate best interest. Sometimes, the person can hear nothing but her own suffering. Counsel has to be heard as well as given.

I’ve explored many techniques to help the person help herself: meditation, relaxing exercises, music… But apart from the latter, they do not lend themselves readily to a half-hour appointment in a busy gynaecological office. And although music is my constant companion through the day, it is often background noise, if heard at all, for the patient stressed by more immediate problems. Most are unwilling, or more likely, unable to believe that meditation or relaxing exercise, will contribute anything to the resolution of their particular issues. It is difficult for them to see through the fog of their distress, and in many circumstances they do not need to do so.

If the problem does not admit of any other solution, then action of some sort is required. If the patient has a ruptured ectopic pregnancy and shows up in the Emergency Department, the solution is obvious and immediate. If she is hemorrhaging from a miscarriage, an explanation of a reasonable approach to the problem and then a D&C is appropriate.

I am not so concerned about the conditions that do not beg for a decision, or ones that cannot be resolved in any other way -conditions for which choice is mandated by necessity. But for those afflictions for which options are available and for which none are paramount, there should be other constraints to the decisions made. These are questions of ethics again: autonomy -the patient has a right (and indeed a duty) to decide for herself, and beneficence –the doctor should act in the best interests of the patient. And sometimes this requires techniques to enable the patient to exercise this right, and the doctor to feel he is in fact acting in her best interests.

Hypnosis is one approach to this that lends itself to an office setting. It is not for everybody, nor is it necessarily attainable in each and every patient, however willing. But I feel that in my office at least, it should be a non-directional tool if it is used at all -one that seeks not to influence or counsel, but merely to engender some symptomatic relief. It is an easily teachable skill, and because the relaxation is so readily apparent to her once she has encountered it, probably an effective one that she may well decide to try again. And with some goal-direction.

I am reminded, however, of the time when I initially began to use the technique. I seemed to attract rather unfortunate referrals then. At first the referrals were for innocent things: stress relief, panic attacks… even smoking. I had to quickly disavow myself of these consultations: although gynaecology entails a lot of psychology, I don’t see myself as the answer to panic attacks.

Then, undiscouraged, they began to send me more difficult problems: warts (yes there exists a body of literature of immune enhancement to engender a bodily response to the viral scourge of warts, et alia), endometriosis, PMS… anything for which the family doctor felt she was losing the confidence of her patient.

I have always felt more comfortable dealing with topics for which I am nominally trained, so I attacked the gynaecological issues with contemporary skill and knowledge. Only on the third or fourth visit and when all else seemed to have failed would I delve into the alternative toolbox in desperation. Sometimes it worked; often it helped. Visualization was especially popular I remember. Endometriosis? Right: visualize a field of flowers and with each breath in, you pick some, and with every breath out, you throw them away. Yes, the flowers are endometriosis implants.

When planetary eco-consciousness took hold, I had to modify the picture, however and switched it to picking up litter on the street then depositing it in a suitable refuse container… Anyway, same idea, same results if they remained enthusiastic adherents. Placebo? I don’t know, but even placebo works for a while, doesn’t it?

The problems worsened from the die-hard family doctors, however. Elated by the success of diverting their problems to me I began to get referrals that really made no sense. One that stands out particularly colourfully in my mind was the woman who was sent to me because she was anxious.

At first I assumed there was a gynaecological reason for the visit, but she quickly informed me that she was actually healthy: normal non-painful periods, no mood swings, no pelvic pain… Her pap smears were even normal and up to date, and she’d just had a mammogram.

I was beginning to despair of helping her when she admitted the reason for her visit: she was running for public office in the Philippines and was anxious about getting up in front of a crowd and speaking. She’d heard about hypnosis and wanted to try it.  Although a little out of my line of work, I thought maybe I’d try a little standard hypnosis to alleviate her anxiety since she was in the office anyway.

She looked relieved and smiled at me. “Thank you doctor,” she said relaxing in her chair. “I’ve tried everything I could think of -even tranquilizers- but I’m still terrified each time I get up there to speak.”

Although I sometimes try to explore the reasons under hypnosis and help the patient to recognize what might reasonably be expected to work for them, I decided to ask her beforehand if there was anything in particular that  worried her about speaking in front of an audience.

She didn’t give it a moment’s thought. “Oh yes, doctor. It’s in the Philippines, you know…”

I nodded pleasantly, and assumed perhaps the venue, or maybe heckling from the crowd was her concern.

“And there’s a lot of opposition to my stance on Birth Control, you know.”

I assured her we run into the same thing on occasion even here. “Sometimes it’s hard taking a stand on something isn’t it? You can never please everybody, can you?” It was so banal a comment I immediately regretted saying it, but she seemed to take some solace from my words.

“No you can’t please everybody, it’s true. And I’m glad you understand; that’s exactly where my problem lies. It’s why I want you to teach me hypnosis.”

I smiled the doctor smile, satisfied, benevolent, convinced that I was perceptive and could recognize her difficulty despite our difference in cultures and gender. I could help.

“Yes,” she continued, ” Every time I get up to speak in front of a new crowd in a strange village I’m afraid I’m going to get shot.”

I believe in counselling and I try to take the time to listen for what they sometimes cannot verbalize. I like to believe I can make a difference, but I don’t think I really helped her, you know… Maybe I should have referred her to someone else, but she left the office happy. Beneficence sometimes trumps non-maleficence, I guess -even if it’s only in the beholder’s eyes.