Posted by: Witch Doctor | November 19, 2009

A message for Iain….

witchround

The Witch Doctor has just tried to post a comment on one of the BMJ blogs. However she was asked for a user name and password.

We witches treat User Names and Passwords with disdain and so I have posted my comment to Iain below.

Now, The Witch Doctor appreciates this is a weird comment, so you will have to put it into context by reading the original post.

DOES MEDICINE – AND MEDICAL ETHICS –HAVE A PRO-LIFE BIAS?

“Dear Iain,

I suspect the comments in your blog over the past few weeks are providing you with interesting teaching material for the future.

For the first 15 years of The Witch Doctor’s life she asked “why?” many, many times. Following this was a ten year period of very deep thinking. After that first quarter century she made a decision to stop thinking deeply, because she recognised this could turn the brain into mince and furthermore it was counterproductive to the “projects” of her life and the lives of others. Instead she set about getting on with the mundane matters of life, like surviving, living, working, grabbing the occasional pleasure, and has done so ever since.

She regards this as a very clever philosophy indeed.

However, you have raised the question that as doctors, perhaps we should consider ourselves to be “underwriters of projects.” Are you suggesting, therefore, that part of our training should be to define the projects of life? To classify them? Having defined and classified them, do we then set about identifying and classifying our patients’ projects?

How do you propose we do that?

Even if we could define and classify an individual patient’s projects, do we then judge them?

How do we do that and is it wise?

If we judge them, to what end?

Mince…….

WD

Those readers of this blog may recollect that The Witch Doctor in the past had one of her comments dismissed as not suitable on a BMA blog.

The whole of the witching community were hopping mad!

P.S.

I notice, My Black Cat, that Dr No managed to post a comment. I wonder if he was required to submit a user name and password.

I doubt it.

Is the BMA just discriminating against witches?

redapple.jpg a red apple ……………………

The Witch Doctor – Link to a random page

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LINK TO UK MISSING KIDS WEBSITE

LINK TO MISSING PERSONS WEBSITE

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Responses

  1. WD – Dr No was able to post this time on the BMJ blog, but on other occasions he has been blocked by the username/password screen. It maddens him too, especially as the blocking results in the comment going south. So he always copies the comment before submitting it, just in case.

    I think your comment may nonetheless turn up on the BMJ blog by way of that trackback thing(y).

    Your comment to IB is as ever very to the point – but what I am not sure about is your remark “We witches treat User Names and Passwords with disdain” given that I need username/password to comment on your blog!!

  2. Some of Dr Grumble’s distinguished colleagues, all on ethics committees, recently went on an ethics course that by all accounts was embarrassingly awful and a complete waste of money. (It was not at Manchester.)

    I suspect all these ethicists are a bit out of touch with the real world. They may be able to introduce medical students to the topic but they seem never to have had to make a challenging ethical decision themselves and plainly have very little understanding of the real world of medicine.

    It was interesting in that context to read this comment on Iain’s blog from Keith Taylor who does not appear to be a doctor himself so has no medical ‘bias’:

    “One of the problems with medical ethics and law courses is that they have little or nothing to do with the real world of health care. Manchester is particularly divorced from reality…”

    The other thing that worries me about these ethicists is that they seem to have the idea that they are right and everybody else (and doctors in particular) is wrong. Ethics is just not like that.

    The implication that doctors have a bias towards life in all contexts is arrant nonsense. Dr Grumble often finds himself spending time gently explaining to relatives that the life of their nearest and dearest is coming to an end and that the kindest thing would be for care to be focussed on keeping them comfortable. Battling to persuade those that want to die that they should live is hardly a common problem. The cases that hit the headlines or reach the courts are rare in day-to-day practice.

    Until the government messed up out-of-hours care many GPs were very well aware of their duty to keep the dying comfortable. Mrs Grumble was always prepared to go out at all hours of the day and night whether on call or not when she had a dying patient. If you cannot prevent death, easing the process is the most important thing a doctor can do for his patient. I suspect many GPs still do this. It’s not something you can rely on a doctor in a taxi to do well enough for all sorts of reasons.

  3. Dr No,

    It is odd that sometimes usernames and passwords are asked for in the BMA blogs and sometimes not. I only tried once, maybe I should have persisted.

    My blog : U/N and Password is nothing to do with me Guv, it’s just the guys behind the scenes at WordPress tempting you to join them.

    Dr G

    What is worrying me particularly at the moment relates to the teaching of medical students. Who exactly is teaching them medical ethics and what on earth are they being taught? In my day, as far as I can remember we were taught medical jurisprudence and that was all. The ethics of medical practice was felt and experienced rather than rationalised. It probably was a hybrid of the “conscience,” (now taboo!), the Hippocratic Oath (also taboo), decency, empathy, the behaviour of other respected clinicians, and above all numerous close contacts with patients as individuals.

    I don’t think a formal course on ethics can improve upon that.

  4. I have had the very same thoughts, Dr No, though until now I have thought it expedient to keep them under wraps. I have also been fortified by the overt cynicism of the students themselves who spot these armchair experts a mile off. Medical students are always unimpressed by people playing charades.

    Like you I learned ethics by experiencing real ethical issues on the wards being tackled by real experienced doctors. Ethical problems are there everywhere and they take so many forms you can’t really be taught the right answers. You can just be taught how to think the problems through and it is best not to be guided by anybody feeding you hard and fast rules. As I was implying above, there are no right answers in ethics. Unfortunately some of the ethicists seem to think that issues such as the KW case are not the shades of grey that most of us in the real world seem to understand. They accuse us of being black and white on the issue of death just because we unlike them can see shades of grey. Doctors are very good at dealing with greyness.

    The trouble with ignoring these people in the belief that nobody will take them seriously is that, amazingly, people do actually take them seriously. Notice that it is these armchair experts that have the status of tightly controlled blogging spaces at the BMA. The BMA doesn’t invite jobbing doctors like Grumble, Dr No, the Witch Doctor or even the Jobbing Doctor himself.

  5. Sorry, WD, my reply was really intended for you. I got muddled as to who had said what! Anyway I think we are all essentially agreed.

  6. There’s no discrimination against witches at the BMJ that I know. It’s just WordPress being a bit odd. (I’d’ve commented here sooner, but WP demanded that I generate a whole new profile first. Meh.)

    Right… as to your questions: well, the answer to the first is “No”, so the rest are moot.

    As for the stuff about ethics teaching in the comments, I can’t help but to wonder whether the general line is reducible to the idea that ethicists are somehow irreducibly bad at ethics, not despite, but because of our profession. And that’s clearly nonsense.

    (I can’t make sense of the idea that you learn ethics by doing medicine. It wouldn’t work the other way around; why accept it here?)

    For what it’s worth, we’re not about giving answers. We’re about raising questions. I’m absolutely open with my students at whatever level that, by the time I’ve finished with them, they’ll be much more confused than they were at the start – but confused in a richer sort of way. And I’m absolutely certain that, if they leave at the end of a course thinking that they have THE ANSWER, something’ll’ve gone terribly wrong.

    This speaks to some of the “shades of grey” talk expressed here, too, and to the concerns that motivated the Kerrie Wooltorton post on the JME blog. The whole point of that post was that something like the KW case is ethically interesting just because it’s hard to come up with a satisfactory answer (and its you three, Dr G, Dr N, and WW, who seemed to want a clear one-way-or-the-other answer). Now, I’m not sure I’d class this as a shades of grey thing, because I think that that mischaracterises the problem – but inasmuch as ethics is interesting just when it’s hard and the answers are not self-evident, I’m willing to join any crusade against dogmatism.

  7. We are agreed you can’t learn medicine sitting in an ethics classroom. Contrary to what some educationalists seem to think, you can’t learn medicine just sitting in a medicine classroom either. Similarly you can’t learn to do rectal examinations just by examining a porcelain bum in a skills lab nor can you learn to put up a drip just by practising on a rubber arm.

    By the same token I cannot see how you can possibly learn ethics from an armchair. It’s learnt, as WD says, by wrestling with the many ethical issues that get flung at you in the clinical setting which you solve using an amalgam of conscience, the principles of the Hippocratic Oath, decency, empathy, knowledge of how other respected clinicians behave, and experience of numerous close contacts with patients as individuals.

    It’s that latter point about experience of patients as individuals which worried me about the KW case because I can imagine the sort of patient she might have been. Repeatedly turning up in hospital when apparently trying to kill herself is not consistent with really wanting to die. The note she wrote seemed more like the way some unusual personalities can try and antagonise a system which they know to be programmed always to act in their best interests. In the case of the unfortunately KW for once the system failed to help her as it always had before. I bet she didn’t realise they would take her at her word.

    We shall never know. But if you work from an armchair how you could even guess what KW might really have been thinking? That’s why the lawyers and the ethics professionals think that it was right that KW was allowed to commit suicide while many doctors have grave doubts.

  8. Dr G writes:
    It’s learnt, as WD says, by wrestling with the many ethical issues that get flung at you in the clinical setting which you solve using an amalgam of conscience, the principles of the Hippocratic Oath, decency, empathy, knowledge of how other respected clinicians behave, and experience of numerous close contacts with patients as individuals.

    That has to be wrong – or, at best, incomplete. How do you recognise an ethical problem to begin with? How do you know your conscience is a reliable guide, given that it’ll be informed by the popular prejudices of the time? Why turn to Hippocrates, and what is it that makes that particular Athenian cult better than the others? All of Hippocrates, including the bits about not being paid and not telling patients what’s wrong with them? If not, how do you decide what to ditch?

    What counts as decency? Isn’t demanding decency without further conceptual examination empty formalism? How do you know which colleagues are worthy of respect? And what should you do with that knowledge? (Surely ethics can’t be a matter of copying your seniors simply because they’re senior…) In your contacts with patients, how is that supposed to be action-guiding? Why should it be?

    What happens when your inputs are in tension with, or contradict, each other? How do you resolve those matters?

    What’s the proper relationship between behaviour and the law? What’s the proper relationship between the right and the good?

    There’re about 3000 other questions I could ask. None of them would be answered by your list, and most of them indicate problems with your list.

    Now… get out of the way. I need somewhere to put my armchair.

    🙂

  9. It’s reassuring to see that you have some insight, Iain.

  10. Iain,

    Welcome to The Coven and to WordPress.

    I am thankful that you think as a doctor I don’t need to identify the projects of life and classify them after all. That presumably means I don’t need to let someone die because they don’t have enough projects or society deems them to be of poor quality.

    That makes life much easier.

    “Are ethicists bad at ethics because of their profession?”

    I suppose, as in every other walk in life some are good, some are bad and others are mediocre. I would have thought that being faced with all the nuances of real live ethical problems every other day when the decision-making buck stops with you alone, would focus the mind to the extent that some might become really good ethicists. Most ethicists don’t have to do that, although I suppose a few do.

    “I can’t make sense of the idea that you learn ethics by doing medicine. It wouldn’t work the other way around; why accept it here?”

    It wouldn’t work the other way round because medicine is very hands on. Consider medical training and ongoing professional development as an apprenticeship on hands-on applied ethics as well as an apprenticeship on hands-on diagnosis, treatment etc. The two go hand in hand. I have a couple of lads coming soon to build an old stone archway in my garden. I am more interested in the informal apprenticeships they have served at the feet of the master stonemason, and the archways they have since built on their own, than any certificates they may or may not have. I have not seen any of their certificates and indeed don’t know if they have any, but I have seen them in action and my judgement tells me the archway will not fall down.

    “We’re not about giving answers. We’re about raising questions.”

    “They’ll be much more confused than they were at the start”

    Confused with no answers is not a good state of mind for a doctor to be in when faced with a hands-on clinical problem that has a strong ethical component.

    “Shades of grey”

    Don’t agree. Death is irreversibly black and white – apart from that most medicine is grey. The lawyers and ethicists saw KW’s suicide as black and white. The patient said she wanted to die and so be it. That is the law. Self – determination in the competent patient – that is the supreme ethic. Black and white. It is the doctors who have considered the shades of grey.

    “The whole point of that post was that something like the KW case is ethically interesting just because it’s hard to come up with a satisfactory answer”

    The difficulty in coming up with a satisfactory answer is one good reason why a patient should not be allowed to enter the black and white irreversible state of death.

    “Conscience,”

    I have no evidence that my conscience is particularly informed by the popular prejudices of the time. But then, we witches don’t creep.

    “Why Turn to Hippocrates”

    Why not? Why turn to Iain Brassington or your colleagues in preference to Hippocrates? Did Hippocrates have an inferior brain?

    “Not being paid and not telling patients what’s wrong with them”

    Answering this will be long-winded. I have views on both of these points that you might find difficult to swallow. I might do a post on this way down the line but it is not a priority at the moment.

    “3000 other questions”

    I’m sure you have 3000 questions. If medical students and doctors were asked to think about these 3000 questions and find answers acceptable to all the ethicists and philosophers then they might not be able to do their job in the face of the ensuing paralytic and confusional state.

    And that is when the brain turns to mince. And that is the reason why the witch doctor’s deepest philosophical thoughts were put out to grass at the age of 25.

    When she does occasionally find herself edging into deep thinking mode, she pinches herself in order that she sees it for what it is – self indulgence.

    Like ironing.

    This philosophy of life has served her well.

    WD

  11. It’s good to know the the Royal College of Physicians has become aware of our concerns. Perhaps important people really do read our blogs.

    This is from an editorial in the current issue of Clinical Medicine (2009, Vol 9, No 6: 512-513):

    We wish to highlight two implications of the RCP’s views. First, that ethics education needs to be closely related to practice and second that it should be a component of education throughout the professional life of a doctor. This leaves open, however, several questions about what is the best way of preparing medical students for this lifelong learning. To what degree should ethics education focus on the realities of ethics in current practice? To what extent should it focus on key ethical principles and how should it provide students with the experience of developing the reasoning skills which will enable them to engage effectively with the (as yet unforeseen) ethical problems which will arise in their future practice.

    At the heart of an effective ethics education is the need to provide medical students with the opportunities to practice (sic) during their training the skills of practical ethical judgement that they are going to need for the future. This suggests that ethics education should be close to practice from the start.

    They also ask whether ethics should be taught by experienced clinicians or by people with academic training in ethics or by people at the cutting edge of bioethics research. It is not a question they answer though the way they phrase the question leads Dr Grumble to believe that they are thinking what he is thinking.


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