GB Shaw..a profession is a group of people who band together to hide their own shortcomings.....

GB Shaw

..a profession is a group of people who band together to hide their own shortcomings..

Preface to The Doctor’s Dilemma

Illness as metaphor

• Illness is the night-side of life, a more onerous citizenship…everyone holds dual citizenship

• Impossible to take up residence unprejudiced by the lurid metaphors with which it has been landscaped

• Upstream ethics

• Towards an ethics of care, communication and competence

• Emphasis on personhood in old age and dementia

CompetenceCare CommunicationReflective practice

EthicsSocietal Contract

Law

Code of practice

• Philosophy

• Habit

• Aesthetic

Why?

• Special position of trust

• Not like repairing a car

• Can do lasting harm

• Huge fiscal implications of practice

What underpins?

• Judaeo-Christian

• Prejudices

• Human failings

Major ethical issues

• Inadequate resource

• Inadequate dignity and communication

Barriers I

Non-prioritization by profession

Media obsessionwith end-of-life/hard issues

Strangers at the bedside• Lawyers• Some non-clinician ethicists

Vulnerable groups

• Tuskegee

• Prescribing habits for poorer patients

The Ballad of Reading Gaol

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

And every human heart that breaks,In prison-cell or yard,Is as that broken box that gaveIts treasure to the Lord,And filled the unclean leper’s houseWith the scent of costliest nard.

Cloverhill Remand Prison 456 beds

Wheatfield PrisonDesign capacity 320

Bed capacity 368

Prisoners and health

• Worse than general population

• Older prisoners even worseCollins, 2006

Novick, 1997

• Trebling of older prisoners in UK 1990-2000









• Doctors, medical students and prisoners

Personhood, prisoners as patients

• Role model



• Role model 2



• A student in prison

Students in UK

• 47% placed in a situation where they had to act unethically

• 61% observed a teacher acting unethically• 3 main types

– Conflict between medical education and clinical care

– Responsibility exceeding student’s capabilities– Involvement in care perceived to be

substandard

Hicks, BMJ, 2001

Intimate examinations

• A survey of students in one medical school found that intimate examinations had been done by second and third year students in situations that they found disconcerting

• It also found that a quarter of examinations in anaesthetised or sedated patients seem not to have adequate consent from patients

Coldicott, BMJ, 2003

What students see..• Communicative violations

– (to or about patients or other health care professionals)

• Role resistance – (individuals chafing against constraints or expectations of their

perceived roles)

• Objectification of patients – (ignoring patients or treating patients as vehicles for learning)

• Accountability – (to colleagues or patients, including avoiding patients, failing to

disclose information, or failing to treat appropriately)

• Physical harm – (to patients or others)

• Crossfire – (being put in the middle of a struggle between superiors)

Ginsburg, Academic Medicine, 2002

How they incorporate it…

• Sense of witnessing (n = 34) • Knowing about (n = 4)• As opposed to self-reported (n = 10)

Clinical clerkships USA

• 58% reported having done something they believed was unethical

• 52% reported having misled a patient• 80% reported at least one of these two

behaviors• 98% had heard physicians refer

derogatorily to patients

• 98% had heard physicians refer derogatorily to patients

• 61% had witnessed what they believed to be unethical behavior by other medical team members

• Of these students, 54% felt like accomplices

Feudtner, Acad Med, 1994

• More likely to experience erosion of own ethical principles or act improperly– Evaluation fear– Fear of not fitting in

Since, for the most part, students believe that they behave ethically, they are

less likely to see the need for medical ethics education. So, unlike philosophy programme education, the first hurdle for

professional schools ethics education is the

establishment of its importance and its relevance

R Rhodes, 2002

….(medical students) showed a levelling process of their moral

reasoning. This finding prompts us to ask whether a hidden curriculum

exists in the structure of medical education that inhibits rather than

facilitates the development of moral reasoning.

Patenaude, CMAJ, 2003

No easy rule-based solutions...

“Well, actually, they are written in stone”

No easy algorithms...

• MedLine Ethics



Talleyrand

• Loyalty is a matter of timing

• Ethical probity a matter of timing?

The one that got away

Prisoners in A/E

• 20/20 assessed chained to prison officers

• Including 65 year-old, 5’ 2” , acutely dyspnoeic after MI

Upstream ethics

• If we don’t get the every day discourse right….

• Small abuses lead to larger abuses

Prisoners in A/E

• Risk assessment• Liaison between hospital and

prison• Secure facilities• Urgency prioritization



Capital Punishment

Disallowed actions include:• Starting intravenous lines for lethal

injection drug• Determining death during execution• Administering the lethal drug• Supervising personnel who give the

lethal drug

Capital Punishment

Disallowed actions include:• Ordering lethal drugs for the prison

pharmacy• Maintaining or inspecting lethal

injection devices • Monitoring vital signs during execution • Selecting injection sites for lethal drugs

Physician Attitudes about

Capital Punishment• 80% indicated that at least 1 of the disallowed

actions was acceptable

• 53% indicated that 5 or more were acceptable

• 34% approved all 8 disallowed actions

AMNCH Survey

• 76 consultants and 139 NCHDs

• 184 responded: 60% of the consultants and 100% of the JHDs

• 98% had treated prisoner patients at some stage in their career and 90% had done so in the last 2 years.

• 60% felt uncomfortable whilst examining patients who were prisoners

• 181 (98%) were unaware of any guidelines in place for the treatment of prisoner patients in general hospitals

Breaches of confidentiality

• 7% always

• 88% sometimes

• 3% never

Asking prison officer to leave

• 4% always

• 65% sometimes

• 31% never

Inquiring as to risk

• 14% always

• 57% sometimes

• 29% never

Examining patient while restrained

• 16% always

• 67% sometimes

• 17% never

Balanced score-card

• Self-evaluation and awareness accepted in medical profession

• Need to develop structures and guidelines appropriate to professional practice with prisoners

I never saw a man who lookedWith such a wistful eyeUpon that little tent of blueWhich prisoners call the sky

The Ballad of Reading Gaol



• Reason..must approach nature [science] in order to be taught by it: but not in the character of a pupil who agrees to everything the master likes, but as an appointed judge who compels the witnesses to answer the questions he himself proposes

Kant, A Critique of Pure Reason

Scientism

• ..science’s belief in itself: that is, the conviction that we can no longer understand science as one form of form of knowledge, but rather must identify knowledge with science

Habermas, Knowledge and Human Inquiry

Profession

• Develop articulacy

• Make case for adequate resource

• Deal with prejudice

• Self-critical

• Strive for evidence base

• Avoid artificial dichotolies

Priorities

• Develop ethics of– Communication– Competency

• Research

• Shake complacency

• Joint working of clinicians/philosophy

GB Shaw..a profession is a group of people who band together to hide their own shortcomings.....

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