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Is Bioethics Really a Bully? Really?

11 Sep, 12 | by Iain Brassington

On his blog in The Independent, John Rentoul has a long-running feature called “Questions to which the Answer is No“.  In it, he examines the kind of screaming rhetorical-question headline much beloved of certain middle-market tabloids: “Is this photographic evidence of Nessie?”, “Does coffee cure cancer?”, “Does coffee cause cancer?”, “Does MMR bring down house prices?“* and so on.

Here’s the first in an intermittent parallel series from me: “Questions to which the Answer is Eh?  What are you on about?  No, really: what?“.  For the inaugural post, step forward Dan Sokol, the BMJ”s “ethics man”, who asks in his latest column, “Is Bioethics a Bully?”.  The answer to this is Eh?  What are you on about?  No, really: what?.

(A warning before I start: I’m about to go off on one.  Even by my standards, this is big.  You might want to go and make tea.)

The general thesis of the article is this:

Bioethics, in its current form, has bullying tendencies. Ironically, it often adopts a paternalistic attitude towards clinicians, treating them as an ethically deficient species.  Although bioethics should not shy away from pointing out ethical concerns in medical practice, sometimes forcefully, it must not give way to negativism or, worse still, to a zeal to condemn.  Clinicians are easy targets and, without a command of the fancy theories and language of the accusers, possess few means to respond formally.

Is the thesis true?

Well, to get things going, I’m just going to note my puzzlement at the first word of the second sentence.  Maybe Dan thinks (or is pandering to a audience that supposedly thinks: I don’t know whether it really does, though some of its members might) that bioethics is at least substantially reducible to banging on about not being paternalistic.  But, of course, that’s not what bioethics is.  Some bioethicists might spend time thinking about paternalism; and some of those some might reach the conclusion that paternalism is bad; and some of those some of those some might get as far as saying or writing something about paternalism.  But, still, many more have little to no interest in paternalism.  So there’s no irony here unless bioethics is basically about discouraging paternalism – or even campaigning for anything in particular – which it isn’t.  On the irony scale, I rate this part of the argument as scoring Alanis out of ten.

(I’m going to include clinical ethicists as a subset of bioethicists here, mainly because that’s what seems to be going on in Dan’s piece - but treating bioethics as being reducible to clinical ethics is another problem.  Clinical ethicists might be the closest most BMJ readers get to bioethicists; but that’s a bit like saying that builders of bird tables are the closest most people get to conservation workers, therefore conservation work is mainly building bird tables.  A curious bit of synecdoche.)

That aside, the article does raise at least one important point:

[W]hat makes a bioethics expert? If you need a bioethicist for a lecture or a report, where should you turn? There is no Royal College of Bioethics, no MRCB (bioethics) exam, and an MSc or PhD in the subject is no guarantee of knowledge or quality.

I’ve expressed my own worries about this point on the blog before.  It’s true that – just as anyone can call himself a nutritionist – anyone can call himself a bioethicist.  And there are some monumental charlatans passing themselves off as bioethicists, often (though not always) as a pretty obvious front for some particular cause.  Bioethics does have a low reputation among philosophers, and it’s not hard to see why.

That said, what about the rest of the article?  Let’s work through it, paraphrasing as we go.

Bioethics is a hotchpotch of disciplines, ranging from sociology to law. Although there is infighting about the dominant discipline within bioethics, philosophy is, arguably, king.

(Would that it were…)

The inclination of philosophy is towards abstraction. Modern medicine, on the other hand, is a pragmatic discipline. Abstraction is rare. This contrast between the theoretical and the concrete, coupled with the ever present temptation for academics to appear clever, creates a danger for bioethics: through the use of theories and esoteric language, bioethicists can obfuscate, confuse, intimidate, or antagonise the very clinicians and patients they seek to help.

Now here’s the first big problem: the use of theories is not an issue.  It’s a good thing.  Criticising bioethicists for using theories is like criticising epidemiologists for using them; but without theories – the germ theory of disease, for example – there could be no such thing as epidemiology.  Neither could there be philosophy.  Theories are a lens the use of which helps us make sense of the world.  Theories are good.  Neither are they particularly esoteric.  For sure, there’s the occasional bit of jargon (and it is occasional); but good philosophy aims for clarity, and jargon is perfectly compatible with that.  It serves as a shorthand way of communicating a potentially rich idea.  For example: if I use the phrase “Formula of Universal Law”, then that’s a sign that I’m talking about the Categorical Imperative, and Kant, and doing things with a certain set of ideas.  There’s nothing exclusionary there: it’s just that, if you’re interested in a debate, you owe it to yourself and the other participants to furnish yourself with some background.  In just the same way, if a physician talks about amyloid plaques, there’s no reason why I can’t go off and learn a bit about them, and then participate fully in that debate.  It’s jargon, but it’s in the service of clarity, and anyone can learn it.  A sophisticated debate probably requires sophisticated language; moaning that it’s obfuscatory misses the point completely, and the idea that using it is an attempt to appear clever is a calumny.

And if I’m right on this, it explodes what follows:

Members of research ethics committees often complain that a researcher’s “participant information sheet,” replete with medical jargon, is incomprehensible to its intended readers. The same criticism applies to much bioethical prose. If the writing is aimed at ordinary clinicians, then it should be understandable to them. In the words of Raanan Gillon, one of the fathers of modern medical ethics, “ethics should be basically simple for it is there to be used by everyone, not just by people with PhDs in philosophy or theology.”

You don’t need to have a PhD to engage with bioethics writing: but you do need to have your brain switched on, and you do have to be prepared not to understand everything straight away because – gasp! – different disciplines require and reward different skills, different writing styles, and different styles of argument; and they take a lot for granted because starting each and every debate from first principles is just stupid.

Things get even stranger, though.

Clinicians are told (or possibly “advised”) what to do by bioethicists, in research and clinical ethics committees, lectures in medical schools and elsewhere, and books and articles. These instructions are given at a safe distance from the nitty gritty of practice. The emphasis is on legal and ethical barriers, medical errors, violations of this or that guideline or principle. The tone is negative, and a whiff of disapproval fills the air. It is not surprising that bioethicists are seen by some as so called ethics police, disempowering or threatening the medical profession with a barrage of criticisms.

The idea that practitioners are advised about what to do by ethics committees is hardly surprising: that is implicit in their function, inasmuch as that it’s an ethics committee’s job to approve certain things, and if they aren’t approved, then that committee will offer advice about what needs to be done.  What about the other stuff?

Well, things are a bit more complicated than they’re presented as being here.  We need first to be clear about what’s going on when an ethicist (allegedly) tells practitioners what to do.  At least a lot of the time, that isn’t really what’s going on; rather, a case is being made for a certain approach, or a certain course of action.  In the case of papers and books – by which I mean monographs, rather than textbooks - that makes perfect sense: noone in their right mind would treat a paper as an instruction – especially so if, as Dan himself admitted a bare few sentences ago – ethicists tend to deal in abstractions; and that isn’t what they’re for.  Of course, there’re sometimes thought experiments and hypothetical cases, and it might be that an argument will be presented along the lines that if conditions a and b obtain, it would be advisable to do φ and avoid ψ-ing.  (I did quite a lot of ψ-ing when reading the BMJ piece, by the way…)  And, of course, the writer of a book or paper might want in the end to change minds and practices.  But if it was a matter of telling people what to do, writing a book or paper would be a really odd way to go about it.  There’s a difference between making a case for something, and issuing a bare instruction.  Ethics - at least when it’s done well – belongs to the former category.

(I always tell students when I meet them for the first time that, by the end of the course, or lecture, or whatever, they’ll be more confused than they were at the start – but they should be confused in a richer and more satisfying way.  If a student leaves my seminar thinking that they know The Answer, I leave thinking that something has gone terribly - and maybe dangerously – wrong.)

In lectures, things might be a little different.  We have to take care here, though, because Dan is treating the business of bioethics as centering on regulation, and that distorts things horribly.  One of the functions of an ethics lecture – particularly in the UG curriculum, but the point applies to any that’s aimed at medics – is to talk not so much about what to do, but about how to think about what to do.  That’s for a couple of reasons: the first is that it’s interesting, and the second is that simply rehearsing rules, precedents and guidelines is a waste of time, since (a) it’d be more efficient just to provide the URL of “Duties of a Doctor“, and (b) if it’s true that ethics is about more than the issue of, and obedience to, bare instructions, what’s really important is the ability to interpret those rules, precedents and guidelines so that they can be put to use or dismissed as appropriate.

The second is that, if medics were really interested in the first, they’d have become philosophers, or studied ethics, in their own right.  A lot of the time, they want a nice handy guide to what the law says, and what they should do.  That’s fair enough.  But then a couple of things needs saying.  First, concentrating on “legal and ethical barriers, medical errors, violations of this or that guideline or principle” is the whole point, and errors and violations provide decent illustrations of what can go wrong, and of how the law and regulations have developed.  Second, if a big part of what medics want from an ethics lecture is a handy and easily-used set of instructions about what to do, then it’s utterly otiose to complain that ethicists are at their most visible when offering (or channelling) advice and instructions.

“To make matters worse,” the article continues,

 most professional bioethicists are not clinicians, so these bitter instructions are usually given by people with no medical qualifications. They are removed from the pressures of everyday practice, issuing commands like generals far from the battlefield. But unlike military generals, bioethicists have not fought their way to the top, rising up the ranks. They cannot say, “I’ve been there.”

So what?  Why does that make matters worse?  Not being a clinician doesn’t preclude being able to talk about how to spot and solve moral problems.  If a medic came to an ethicist for advice about how to separate conjoined twins, then the fact that the ethicist had no surgical experience would be a problem.  But a medic who came along with that question to an ethicist would be strange anyway.  What she might more productively ask is whether they should be separated, given that current medical knowledge indicates this kind of operative risk and prognosis and so on.  You don’t need ever to have done so much as apply an elastoplast to be able to offer useful and insightful things on that.  Maybe those things will amount to making a case for pursuing or avoiding a particular course of action; maybe it’ll amount to offering a way to think about what to do.

Being a medic and being an ethicist are different things.  They aren’t antagonistic.  Sometimes an ethicist will seek out a medic (or a medical paper) to get a fuller understanding of what’s going on in a particular illness.  But you don’t have to be an expert in medicine to talk interestingly about it – only to do it.

(When Dan says that “a good bioethicist should get his or her boots dirty by spending time in the muddy trenches”, I’m therefore tempted to wonder which muddy trenches he means.  If it’s ward practice that he has in mind… well, since he has not (to my knowledge) been a medic himself, this means that he must with this statement have torpedoed his own credentials as an ethicist.  In which case, why is he filing copy in an ethics column to begin with?)

And so, finally, we’re in a position to tackle the thesis of the article head-on.  Since it’s never actually explained what the alleged “bullying tendencies” of bioethics are supposed to be, it’s hard to mount much of a defence: but on the evidence presented in the rest of the piece, the main objections seem to be that bioethics can be technical, opaque to the outsider, and removed from day-to-day practice.  That being so, the response is threefold.  Yes, it can (and that’s not a bad thing); yes, maybe (but only because it has to be technical - and, anyway, tu quoque); and yes (but that doesn’t matter, because it’s a different thing).  The second-rank objections seem to be that bioethics is abstract, and that it’s directly interfering.  The response to these is also threefold.  It can’t be both at once; abstraction is an indissociable part of thinking about conduct; and direct “interference” is a response to the demands of the medical profession.

There is no zeal to condemn – though cases in which things have gone wrong are much more interesting than cases in which nothing does, and are so much more likely to generate papers and comment.  Clinicians are not particularly easy targets – if they feel picked on, they should see some of the volcanic rudeness that philosophers reserve for each other, both in person and in print.  Complaining about “fancy theories” is basically a rehearsal of the travelling preacher’s complaint against booklearnin’.  And complaining that there are few means to respond formally is simply false: write a paper, and send it to a journal (especially one like the JME, which is avowedly catholic in its list of contributors).  If it’s good – and sometimes even if it isn’t - it’ll be published.

But don’t, whatever you do, write Uriah Heap-ish straw-man articles in the BMJ.

*Not actually a real headline.

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  • http://www.facebook.com/adam.hedgecoe1 Adam Hedgecoe

    Ian, I’ve only just started your post, but kudos for the Alanis reference.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    Tee hee!
    I have a feeling that you aren’t going to go along with everything I say here…

  • http://twitter.com/BioethicsUK Nathan Emmerich

    I think Sokol means bioethicists behave paternalistically towards clinicians and healthcare professionals. Not that they just bang on about medical paternalism.

  • http://www.facebook.com/adam.hedgecoe1 Adam Hedgecoe

    No, I actually agree with most of this (I like your point about the importance of theory. Remember, the straw man ‘it’s just a theory’ is used by creationists to attack evolution-by-n.s. Something being theoretical doesn’t make it any less true). I was pretty confused by Dan’s paper to be honest. It left me rather ‘meh’.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    But it’s no less baffling if that is what he means, since there’s nothing paternalistic about what bioethicists get up to – not obviously, anyway – and it’s strange to think that paternalism should be so easily associated with bullying, or even a bad thing at all. After all: “paternalism” in normal usage is a benevolent thing.
    Maybe he means that bioethicists treat medics as not being expert on ethics, and needing help. But the first part of that seems pretty unobjectionable – there’s no reason to think that being an expert in, say, oncology would help you solve moral dilemmas, or even spot them. And if you accept that, then the second bit seems to be at least reasonable. (I mean, if the GMC is going to offer ethical advice, determine codes of practice and so on, it isn’t complete lunacy to suppose that ethicists might be exactly the sort of people you’d want involved in the process…)

  • http://www.facebook.com/adam.hedgecoe1 Adam Hedgecoe

    Oh this is point where I disagree with you: around the idea of ethicists as ‘experts’.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    Thanks for this.
    (If it shows up as having been modded, it’s because I’ve played with the formatting: certain comments – those sent via phones especially – appear very odd here; I’ve taken the liberty of correcting for that.)

    I think you’re right to want to avoid going on at length; and I agree with you about a need for introspection. But I really still don’t buy your point about experience on the wards: at most, it seems to be a call for a sensitivity to the realities of clinical practice – but that’s quite a small claim, and it doesn’t seem to me to be a necessary part of doing good bioethics.

    I agree with the stuff about offering verdicts in the media, too: I think that it’s tempting, and the temptation ought to be resisted a lot of the time. But don’t forget that a verdict is what producers and editors positively want a lot of the time. Again, I think your particular worry might be avoidable if it’s clear that we’re making a case for such-and-such, rather than saying that we have The Answer.

    As for telling students “Do that” or “Don’t do that”: do you really? Wow. OK.

    One quick final point, related to the last one: it may be true that many bioethicists frown on paternalism. But that doesn’t mean that bioethics does. Bioethics no more has opinions than does mathematics.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    Yeah – moral expertise is a tricky one, and I expected that to get picked up. There’s a whole sub-discipline in sorting that one out. I have in mind something along the lines of expertise being a matter of being better at making persuasive and sound arguments about conduct – though I admit that that might just multiply the number of loose ends. (Rationalistic? Ach, maybe. You say that like it’s a bad thing.)

    Still: I’m satisfied that some people are poor ethicists, unable to generate a sound argument if their lives depended on it, and that they’re poorer at this skill than others; which implies that there’s some standard of assessing the quality of ethical work – and that, in turn, implies that there’s some point at which we could say that someone possesses expertise.

    But: yeah. Slippery.

  • http://twitter.com/rocza Kelly

    Alanis out of ten – massive thumbs up!

    “Bioethics does have a low reputation among philosophers, and it’s not hard to see why.”
    Er, well. Anyone can call themselves a philosopher, too – it’s not like that’s a regulated term, so I don’t really think this “it’s not hard to see why” really correlates. (I do think philosophy has issues with bioethics, but it’s more of the money and attention type, not accreditation societies.)

    “bioethicists can obfuscate, confuse, intimidate, or antagonise the very clinicians and patients they seek to help”
    I suspect he means lawyers, not bioethicists, there. (Okay, yes, bioethics has jargon. But, especially in clinical ethics, one of the main functions is to serve as a communication point – you can’t do that if you speak in jargon the entire time. Are there clinical ethicists who do? Sure – and they’re probably not the best at their job. Just like there are people who are bad at their job everywhere, unfortunately.)

    “they should see some of the volcanic rudeness that philosophers reserve for each other, both in person and in print”
    Or, you know, just bioethicists. Gotta admire the grudge matches that get going there,…

    Okay, comments directly to what you wrote aside, what caught me about Sokol’s piece is that he seems to be saying “do as I say, not as I do.” Which, okay, sometimes it’s really valid to say HEY LET ME TAKE THE BULLET DON’T REPEAT MY MISTAKE. But other times, it’s sort of necessary to examine why that is being said – and in this case, it seems to mirror what I see here in the States (and what I mentioned to one of your colleagues): a lot of older bioethicists seem to advocate for exclusionary practices that would favour their experience and history and lock out the young newbies that are coming up through the ranks. Trying to limit the field with accreditation societies that, for example, grandfather in “established” people, or by trying to severely limit the people who can speak as a bioethicist (as Sokol appears to be doing), is a way of trying to keep king of the castle just a wee bit longer.

  • http://twitter.com/idmonfish David Hunter

    Hey Daniel
    I agree with this “My view that articles, written by bioethicists and aimed at ordinary
    clinicians, should be understandable to them does not mean that the ideas
    and concepts should be instantly understandable. They should be
    capable of being understood without having recourse to specialist texts
    of philosophy, law, sociology or whatever background that bioethicist
    comes from.”

    But I think you are mistaken about how many articles are aimed at ordinary clinicians. It would be a mistake I think for example to take all the papers in the JME as being so, even more so papers in journals like Bioethics.

    I think you are conflating theoretical bioethics and what I refer to as translational bioethics – which mostly happens in medical journals. I take most of the papers in bioethics journals as written for bioethicists, and rightly so because it is important to get the arguments and claims straight before trying to communicate them more broadly. I’ve even argued (admitted mostly in jest) that bioethics needs secret journals to stop idiocy like the public outrage about “that paper” in the JME, and to enable people to speculate without being taken seriously too fast.

    In regards to Ethicists giving verdicts, yes I think we all agree this is problematic, but as Iain points out it is a systemic problem rather than with bioethics – simply put what gets published is easy and simple straightforward answers if they are given by someone who argues for them forcefully. Hence we get the public bioethicists (figures, celebs and everyone else) that the public deserve. Sadly as Bertrand Russell put it: “The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts”.

    Anyway perhaps we can all start shaking our heads at this: http://www.huffingtonpost.com/tom-koch/bioethics_b_1873995.html

  • http://twitter.com/idmonfish David Hunter

    I’ve never seen the problem with acknowledging some moral expertise. Sure if we are claiming that expertise means makes infallibly true moral claims, well we don’t need to look much further than the Pope to see how much trouble claims about infallibility can get us into. But this doesn’t seem to me to be the claim.

    It seems to me that someone who has spent time studying a subject, becoming familiar with the issues and various arguments is going to be able to helpfully weigh in on a debate about that subject – even if it is mostly to point out where things have gone wrong, to pick up on weak arguments and the implications of claims.

    That strikes me as enough to consider that person to have some moral expertise.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    Crikey. *shakes head at HuffPo*
    It’s too soon for another long rant, though. I’ve got real work to do…

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    I don’t disagree with any of that.

  • Keith Tayler

    ‘Theories are good‘. Some of us have doubts their use in ethics. One of the problems with bioethics is that it is rotten with theories, or at least opinions that are passed off as theories.As for ‘Theories are a lens the use of which helps us make sense of the world.’ Some might, but we must always question this assumption even when making an observation. Theory laden observation is a big problem in bioethics. As for ‘Theories are a lens the use of which helps us make sense of the world.’ Some might, but we must always question this assumption even when making an observation. Theory laden observation is a big problem in bioethics.

  • Mikey Dunn

    I think there is much that could be said here, most of which you deal with very well, Iain. One point I do feel very strongly about, though, is that any person who is involved in teaching ethics to medical students or clinicians, and who is prepared to state categorically what should or should not be done in light of the details of any given situation discussed in an education setting, should be immediately frogmarched out of the classroom.

  • http://twitter.com/prof_goldberg Daniel Goldberg

    In addition, as you (Iain) point out in the post, the article is really targeted at clinical ethicists, which is somewhat irritating given that there are large and growing numbers of people who self-identify as bioethicists who have very little to do with the practice of medicine per se. I interact with as least as many public health professionals as I do with doctors, and even when I do interact with the latter it is typically to discuss matters of public and population health (and I work in a medical school).

    So even if the article’s arguments were persuasive, which they are not, they are at best only targeted to a specific subgroup of professional bioethicists.

  • Daniel Sokol

    Mikey,

    The answer, surely, is that the appropriateness of a categorical answer depends on the question and the context.

    Teaching junior doctors in a lunchtime lecture at the hospital, or a medical team on a Friday morning departmental meeting on matters of pressing concern to them, is different to teaching first year medical students. I usually do try to stimulate thought and debate (I wrote a column on teaching junior doctors a few years ago – http://www.medicalethicist.net/documents/junior%20doctors%20BMJ%20May%202010.pdf?ijkey=9elD2WeSsBP9Emv&keytype=ref ), but if a doctor asks me a question in a lecture whose answer is quite clear from his or her professional guidelines (GMC, BMA, etc.) and the law, that is the answer I will give. If there is time and if I think elaboration will not detract from the message I want them to remember (i.e., if the situation you have described arises, my strong advice – based on the current GMC guidelines and case law – is to do this or refrain from doing that) then I may explore the subject in a little more depth.

    Daniel

  • http://twitter.com/idmonfish David Hunter
  • http://twitter.com/idmonfish David Hunter

    This is almost certainly just a view point difference thing but Keith, is there non-theory laden observation? I think no, and the the problem is unreflective theory laden observation rather than observation per say. I see no reason to think that bioethicists are likely to be more unreflective than others about their observations and some reasons to hope that they will be more reflective.

  • http://twitter.com/idmonfish David Hunter

    “should be immediately frogmarched out of the classroom”.
    Mikey, you bully!

  • Keith Tayler

    I said ‘theory laden observation is a big problem’. Obviously I was not suggesting there could be a non-theory laden observation. I see little evidence that bioethics is particularly aware of the problem. Indeed, Iain’s remarks are quite typical of the rush to theory that does not appear to recognise the problem.

  • Mikey Dunn

    Hi Daniel,

    Thanks for the reply (and for the email heads up!). My concern is with the teacher providing answers to practical questions about what should or should not be done in relation to any given issue, rather than with equipping practitioners (or trainee practitioners) with the skills required to think through, reason and justify such answers. This will, at times, involve making judgments about arguments, but it will never involve issuing ethical edicts. I have no problem with the teacher giving categorical answers to questions of what is legally permissible or not, or to questions about the type of actions that will likely incur professional sanction. Whilst I take it that this second set of questions may not themselves have straightforward or categorical answers, they are certainly very different kinds of questions. Indeed, I would add that exploring the relationship between questions of normative justification, legal permissibility and regulatory authority is a component part of equipping doctors and medical students with the kids of skills relevant to making judgments in their work, by, for example, subjecting the law, or a legal case, to ethical scrutiny.

    I agree with you that the way of approaching a practical issue will be different when it comes to running an ethics session for 1st year students and a session for senior clinicians. But I think the difference is one of emphasis and detail rather than substance. I maintain that it would be inappropriate to recommend what should or should not be done in both situations. So, if a registrar in elderly medicine takes the Martin Amis approach and claims that it is right to kill all patients when they reach 65 in order to preserve resources for younger patients, I’d be happy to facilitate a discussion about the arguments that would support (or not) such a claim. Pointing out that the law would see such an action as murder, or that the GMC won’t be very happy with you, seems to me be a secondary and somewhat less important learning outcome.

  • Mikey Dunn

    Touché, David!

  • Daniel Sokol

    Mickey,

    I suspect we have different styles of teaching, although I now
    teach mainly doctors and rarely medical students (to your relief, no
    doubt).

    Like you, I want to teach doctors how to work through
    problems themselves, to reflect on their practice and assumptions, and to focus
    on the strengths and weaknesses of arguments for and against particular courses
    of action, but occasionally you are asked a pointed question (perhaps in the
    Q&A at the end of the session) which you know – through experience or ‘feel’
    - is a practical one, a question whose answer may well determine what they do
    in ‘real life’, perhaps that very afternoon.
    They may even have attended your session, or walked in half way through between
    seeing two patients, just to ask that one question.

    In those circumstances, “facilitating a discussion” or “encouraging
    them to reflect” feels grossly inappropriate, even insulting, and is usually
    unhelpful. They want a categorical
    answer (or, rather, ‘advice’) and, if I can give solid advice based on my
    knowledge of the relevant literature, the latest GMC and BMA guidelines, and
    the law, then I will (with appropriate caveats, naturally). If not obvious – and time permitting – I
    might briefly explain the rationale for the rules and point them to helpful
    sources of information.

    Of course, sometimes I won’t be able to answer the question there
    and then, and I will make that clear: I
    may not know what the GMC says about that issue (or be worried that a new
    edition of a particular booklet has come out), or the legal permissibility of a
    particular action, or the question may simply be too technical, and I will then
    explain why I cannot answer it and advise the person to call the BMA ethics
    helpline or to take the issue to a CEC.

    Perhaps there is no disagreement there, Mickey. My default position is to stimulate
    debate and discussion, even when the pressure is on to give them “answers”, but
    I am not locked into that position. I am
    not against giving clear-cut answers (with only slight elaboration on the
    ethical justifications) when the question permits it and the context, in my
    judgement, demands it.

  • http://twitter.com/idmonfish David Hunter

    But if it is theory laden all the way down I’m not sure what the problem of theory laden observation actually is nor what is problematic about rushing to theory? Could you elaborate?

  • Keith Tayler

    There is a lot about the theory laden problem in the philosophy of sceince – too much for this post.. There is also a lot of philosophy about the problem of theory in ethics. (I have posted stuff about this in the last three years and do not have time to repeat again) Suffice to say philosophers that have questioned the rush to theory in philosophy and ethics include Nietzsche, Wittgenstein, Heidegger, Berlin, MacIntyre, Williams, Taylor, McDowell, Nussbaum….etc.. I am not saying we should abandon theories – that’s silly – but they are all inconsistent, incomplete and limiting, so we must always be aware of this and not declare them as being ‘good’. They can do some work, but as with battleplans, the real world quickly makes a mess of them.

  • http://www.law.manchester.ac.uk/aboutus/staff/iain_brassington Iain Brassington

    Forgive be for butting in, but you seem to be talking about situations in which someone asks a question about GMC guidance, or the law, or whatever – and in that case, rehearsing a particular rule is probably all fine and groovy. But it doesn’t really answer Mickey’s point, which had more to do with making claims about what is or is not right irrespective of what the guidelines happen to say.

    Nor do I really see why it would be insulting, when faced with a “should-I-do-this?” question, to turn things around and simply say that things’re maybe more complicated than the questioner thought, and that a categorical answer just isn’t on the menu.

  • Daniel Sokol

    Iain,

    Mickey writes in his post: ‘it would be inappropriate to
    recommend what should or should not be done in both situations [i.e., running
    an ethics session for 1st year students and a session for senior clinicians]’. I did not read into this an exclusion of
    questions involving guidelines, regulations, rules, law, etc. Indeed the example he provides at the end of
    his post is one where guidelines, etc. are tremendously relevant.

    If a categorical answer is not appropriate because it would
    be so simplistic as to be misleading or negligent or if a clear answer is not even
    ‘on the menu’, then clearly you should not give one. If it is on the menu, however, then feed the hungry
    clinician! Don’t dangle it temptingly in
    front of his or her nose, or hint that it may be on the menu, or ask him to
    guess what is on the menu. That approach
    may be fine (and fun) in some teaching contexts (“ah, before we go further,
    what does that tell you about the changing
    nature of the doctor-patient relationship?”) but completely inappropriate (and positively
    infuriating) in others. My own view is
    that you cannot teach the subject in the same way to everyone. A good teacher is sensitive to context, and adapts
    his or her teaching and delivery according to the audience. My contention is that there are some contexts, perhaps only a few, in
    which a categorical answer is both possible and desirable.

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