Professional Codes and Diagnosis at a Distance

This is the second part of my response to Trish Greenhalgh’s post on the propriety of medics, psychiatrists in particular, offering diagnoses of Donald Trump’s mental health.  In the last post, I concentrated on some of the problems associated with making such a diagnosis (or, on reflection, what might be better called a “quasi-diagnosis”).  In this, I’m going to concentrate on the professional regulation aspect.

Greenhalgh notes that, as a UK medic, she is bound by the GMC’s Duties of a Doctor guidance,

which – to my surprise – does not explicitly cover the question of a doctor’s duty towards a public figure who is not his or her patient.

[…]

My reading of the GMC guidance is that in extreme circumstances, even acknowledging the expectation of how doctors should normally behave, it may occasionally be justified to raise concerns about a public figure (for example, when the individual is relentlessly pursuing a course of action that places many lives at risk). Expressing clinical concern in such circumstances seems to involve a comparable ethical trade-off to the public interest disclosure advice (Duties of a Doctor paragraphs 53-56) that breach of patient confidentiality may be justified in order “to prevent a serious risk of harm to others.”

Well, to be honest, it’s not that much of a surprise to me that the GMC guidelines doesn’t stretch to public figures – but that’s a minor point.

The more interesting thing for me is what the relationship is between the practitioner and the GMC.  Greenhalgh ends her post by saying that she “wrote this blog to promote further debate on the topic and invite the GMC to clarify its position on it”.  But why should the GMC’s position be all that important?

OK: I’m going to go off on a bit of a tangent here.  Stick with me.

A couple of days ago, I was introducing a new batch of students to moral theory for a course I teach here at Manchester.  I was working my way to a brief explanation of how Kantian thought works, and noted in passing that there’s more than one way to be a deontologist.  Divine Command ethics could be characterised as a deontological approach.  Your deity of choice requires some things, and forbids others, and that’s that: there’s no appeal to outcomes or character or anything like along those lines.  You’ve just got a set of rules.

But one of the problems here is that you have to believe in a deity, who’s a deity of the right sort, who cares what we do in the right way, who’s comprehensible to us, and so on.  And another problem is the Euthyphro dilemma.  Does the deity command things because they’re good, or are they good because the deity commands them?  If the former, then an appeal to the deity is a mere detail: we can talk about good and bad without any appeal to any deity, and talking in that way would presumably be intellectually neater.  If the latter, it looks as though the deity might be making stuff up on the hoof.  And if that’s OK for the deity, why not us?  (We can’t say that we mustn’t because the deity says so, because that command was presumably pulled out of nowhere, too.)  Correspondingly, the deity could perform a complete reversal on some commands, and there’d be nothing more to say about it.  On Monday, worshipping idols is banned; on Tuesday, it’s mandatory.  So it goes.

Appealing to professional bodies strikes me as being vulnerable to similar worries.  We believe in them, believe they’re interested in what we do, and so on; but a professional Euthyphro dilemma still seems to appear.  Does the GMC command things because they’re good, or are they good because the GMC commands them?  If the former, then it’s not clear why we need the GMC to tell us what to do – that is, an appeal to GMC guidance adds nothing to moral argument.  Moreover, there might be times when the GMC is mistaken.  If the latter, we need to say why the GMC’s rules are compelling, compared to any other putative rule.

One possible line of response here is to say that in becoming a doctor, one voluntarily takes on a set of rules: one agrees to the conventions of the club.  These conventions don’t have to rest on anything in particular.  By analogy, I once knew of a cricket team that had a rule about anyone who was out for a duck: the unfortunate batsman had to run around the boundary with a crochet duck hat, quacking.  If you don’t like the rule, you don’t have to join.  The same may apply to medics and the GMC’s rules.  You wanna be a doctor?  Them’s the breaks.

That has a certain mileage, I think; but there’re problems.  For one thing, the cricket club’s rule doesn’t pretend to me a moral rule; thus the question “What ought the rule regarding batsmen out for a duck to be?” has only limited currency.  “What ought the GMC’s rules about confidentiality to be?” has much more.

For another, while one might have reasons to ignore the duck rule – say, on grounds that it’s humiliating – the rule and the humiliation are pretty trivial.  Equally, if someone chooses to ignore it, it’s unlikely that he’d be able to count on the support of his peers on the grounds that the rule doesn’t apply in this case, or is badly-framed, or anything like that.  When it comes to something like the confidentiality rule, though, such defences might be offered.  Whether or not they’d work remains an open question; but they would be coherent.

The GMC’s conduct rules are not – I take it – meant to be simply the rules of the club.  (In this light, it’s tempting to discount the APA’s Goldwater Rule: given the legal context in which it was drawn up, it’s tempting to think that it’s a clubhouse rule, made with half an eye on avoiding legal action, more than a reflection of anything more fundamental.)  They’re supposed to hitch onto something bigger about proper conduct.

And in that sense, it strikes me that simply to appeal to what the GMC says when working out whether something is permissible runs the risk of undermining moral agency.  “Whatever the GMC says” is, I’d hazard, a singularly poor answer to questions about what one ought to do.