A couple of weeks ago, the government announced that, from 2013, all nursing staff would have to be graduates.  ”Degree-level education,” said Health Minister for England Ann Keen,

will provide new nurses with the decision-making skills they need to make high-level judgements in the transformed NHS.

I’m not so sure of this. more…

Edinburgh, 20-22 November

Details here

This looks like it could be interesting…

Department of Philosophy, University of Bristol

This is an informal workshop on topics in the philosophy of medicine.

Everyone is welcome.

•09.45–11.00 Kevin Brosnan (Cambridge) “Does nothing in medicine make sense except in light of evolution?”
•11.15–12.30 Jeremy Howick (UCL) “Defining a role for mechanistic reasoning in EBM”
•13.30–14.45 Havi Carel (UWE) “Phenomenology and its application in clinical medicine”
•15.00–16.15 Alex Broadbent (Cambridge) “Inferring causation in epidemiology: mechanisms, black boxes, and contrasts”

The workshop will take place in the Common Room, Ground Floor, Department of Philosophy, 9 Woodland Road.

There is no need to register—it will be fine if you just turn up on the day. (If you do know that you are coming, it may be helpful to let us know, to ensure that we have a large enough room.) If you have any questions, please contact Alexander.Bird {AT} bristol.ac.uk.

I found myself yesterday at the Wellcome Collection, one of my favourite museums in London and somewhere I visit reasonably frequently (not being too big, and conveniently located on the Euston Road, it’s perfect to fill those odd hours between the end of the hangover and the train back to Manchester).  The permanent exhibition has a couple of things that I could happily go and see again and again, but it’s the temporary ones that are the real draw - and the current one, Exquisite Bodies, is something I’d thoroughly recommend.

In the 19th century, despite the best efforts of body snatchers, the demand from medical schools for fresh cadavers far outstripped the supply. One solution to this gruesome problem came in the form of lifelike wax models. These models often took the form of alluring female figures that could be stripped and split into different sections. Other models were more macabre, showing the body ravaged by ’social diseases’ such as venereal disease, tuberculosis and alcohol and drug addiction.

It’s these waxworks on which the exhibition primarily focuses - and they are remarkable.  Joseph Towne’s models, made for teaching purposes at Guy’s hospital, are more than just educational tools: they’re works of art in their own right, the clear ancestors of work by Ron Mueck.  The exhibition has clear echoes, too, of Gunther von Hagens’ Body Worlds shows, and of the Spectacular Bodies show at the Hayward Gallery a few years ago.

Some of the works on show would be used as devices to educate not just medics, but also the general public, about their bodies - they would be shown at fairs, and used for public “dissections” (with men and women being admitted to separate shows, of course…).  Representations of the effects of VD seem to have been popular - and, let’s face it, we know why: there’s the same ghoulish attraction today.  Perhaps that’s why some of the exhibits are behind a curtain, and why the show’s not recommended for under-18s.

For myself, these worries seem to be unjustified.  There was a couple of children there with their parents yesterday, and there’s nothing that’d worry me were my hypothetical children to see it; as a poster advertising a “dissection” in Boston, Lincs, points out - to the enquiring mind, there should be no taboo; facts are facts are facts.  Besides: if it’s images of genitalia that you want, diseased or otherwise, my guess is that a serious-minded museum isn’t going to be your first port of call.  Under-18s with access to Google know that, too…

For quite a while now, I’ve had the idea that I’d like to write something about the purpose of medicine - it’s something I’ve been adding on job applications for about 5 years, but I’ve not got around to doing all that much about it yet.  The question as I saw it was whether medicine is properly concerned with making us well, or with assisting us in our projects.  The latter may be a condition of the former - indeed, it may be a criterion of the former - but it’s not the same, because we could have all kinds of odd projects that’re only tenuously health-related.  For example, cosmetic surgery - and here I mean potentially quite extreme body modification - might potentially belong to medicine if we go for the latter option.  It might not be the sort of thing that medics should prioritise, but it could still be on their list of concerns.

Where’s this preamble leading?  Well, Alice Dreger has been considering a similar sort of question over on the Hastings Center’s blog.  It’s cosmetic surgery that worries her:

I’m not naïve; as an historian of medicine, I know that medicine has always advanced itself by offering improvements of patients’ social status, primarily by making patients healthier, but also by legitimizing their complaints.

But the noble profession has historically been primarily about something nobler than boob jobs and Botoxing wrinkles. The medical profession’s primary goal, historically speaking, has been prevention and relief of real suffering.

I can’t believe I even have to assert that. If the great men and women of medicine could come back from the dead and watch television today, what would they make of the fact that a large percentage of the medicine that is represented is cosmetic?

They might conclude, reasonably, that this reveals medicine’s success. Only in a world of astonishingly good anesthetics, infection management, and surgical technique would patients dare seek these procedures. But they might also reasonably conclude that something very strange has happened.

There’re some interesting considerations raised in the piece - I do recommend it.  However, there’s also a couple of things with which I’d pick a dispute.  The conclusion doesn’t strike me as powerful, for example.

Let’s just call these practices what they are: barber surgery. That way, when one of my idealistic, smart, principled students hears that the student next to her is going into “cosmetics,” she can just answer, “Really? And here I thought we were in medical school.”

Dreger is fairly clear that she goes along with the first of my options above - that medicine is about wellness - but I’m not sure that that’s right: I don’t think I see wellness as an end in itself.  Rather, I see it as something that’s valuable (and comprehensible) only within the context of a certain set of projects.  So it’s those projects that do the work - in which case, cosmetic medicine (or barber surgery - call it what you will) is, if not exactly back on the menu, at least chalked up on the “Specials of the Day” board.  The “and I thought we were in medical school” retort wouldn’t stick.

And I think that the tone of the article more generally suggests something important and interesting about the cultural background of bioethics as pursued on the other side of the Atlantic. more…

Here’s a poser: imagine that your patient comes to you reporting the canonical symptoms of a condition that is untreatable.  You agree that this patient is suffering from something, and that the reported symptoms tally with those that are reported by other sufferers.  However, the reason that the disease is untreatable is that - frankly - there’s no such thing.

Or, rather, there is a medical condition associated with these reported symptoms, but there’s no evidence for it being anything other than psychosomatic.  Frankly, anyone suffering from this “disease” is delusional.  And yet “sufferers” are well-organised, and by no means stupid; they are convinced not only that they’re ill, but that at least parts of the medical establishment are being (at best) pig-headed in ignoring their plight.  Welcome to the world of Morgellons.  (According to some, it’s very close to the world of Chronic Fatigue Syndrome.  Both conditions are medically controversial, both lead to undeniable suffering, both boast active lay activists, and so on.)

Being told that they are not deserving of medical attention risks alienating sufferers and will not make them abandon their false beliefs; and, besides, it would miss the point.  Noone denies that putative Morgellons patients are suffering from something debilitating: it’s the identity of that something that’s open to doubt.  Besides: there is something medicine can do.  It can provide placebos, for example.  Or it can provide anti-psychotics.  Of course, a patient who’s convinced that there is something organically amiss won’t take kindly to being given anti-psychotics - so you’d have to lie and say that they were something else.  Result: patient gets better, but the disease “diagnosis” gains some gravitas: if people can suffer from it, and it can be treated, then it looks like a proper illness.

So there’s a pragmatic worry, with an ethical dimension, that we may associate with this course of action.  But there’s also a couple of more direct ethical worries.  In the first place, in prescribing antipsychotics, you’d be prescribing a powerful drug that would be unnecessary.  Well - hang on: would it be unnecessary?  if it shifts a debilitating condition, and is the most immediately effective way of doing so, what’s the criterion of necessity here?  (Granted, psychotherapy of some sort might get the same results, but that’d depend on the patient accepting that psychotherapy was in order, and turning up to the appointment.)  But it would be prescribed under false pretences - as would a placebo - and this raises questions about truth-telling.  (Martin Robbins has more on this.)

It seems that we might be getting into noble lie territory here: the idea that doctors may distort the truth in order to achieve results that all would agree are desirable.  Note that “noble lie” is a translation of gennaion pseudos, and the verb pseudesthai means originally not to lie, but to twist.  Twisting is what would be going on here: medics would be treating a real problem - just not quite the one that the patients think they have, and not in the way that they think it’s being treated.  Still, implicit in going for medical help is the expectation that you’ll be made better, and if a little twisting is necessary for that, then what’s the problem?  Anyone - doctor or patient - who wills the end of health presumably infallibly wills also the means necessary thereto.

The point is this: it’s very easy to get carried away by the need for truthfulness - but claims made about the importance of truthfulness may potentially come a cropper when people have a strong belief in an illness’ existence and effects on them.  The notion of valid consent, which requires truth, seems to demand that the patients have something like a truth-tracking lebenswelt.  If that’s not the case, then many bets seem to be off.  In such cases, when claims about the nature of an illness are (as far as anyone can tell) systematically erroneous, then there may be a case for ditching truth in favour of something more like truthiness - the quality by which one’s statements have the emotionally satisfying ring of plausibility without actually having all that much to do with reality.  The occasional noble lie might have a place in decent medical practice.

Oh - incidentally: if you’re an ME or Morgellons sufferer and you want to post an angry response, please note that I’m going to be away for a week, so I won’t be able to get back to you too quickly.  And if you’re going to complain about my Greek - well, you wouldn’t be the first.  It’s terrible.

Daniel Sokal has been busy again Success from surgical checklists breeds idea for ethical checks suggesting that clinicians ought to consider adopting an ethics checklist to use on their rounds.

more…

Sort-of-fresh in my inbox this morning was a notification that SUNY Stony Brook is advertising for an assistant/ associate professorial level job as a clinical ethicist.  I’ve blogged about this kind of role before, and I have to say that the wording of the advert sort of confirms my suspicions about clinical ethics consultancy.

The primary responsibilities of this person are threefold: clinical ethics consultation, education, and leadership; curriculum development and implementation for medical student clerkships and residency programs; and research and publication. It is also expected that the candidate will have modest practice responsibilities as negotiated with the relevant clinical department. The position is tenure track at the level of assistant or associate professor, to be determined by the candidate’s professional background and accomplishments. To qualify for an appointment as an Associate Professor, the candidates must meet the School of Medicine’s criteria for Appointment, Promotion and Tenure and must have an established reputation and record of research or scholarly activity.

So far, so good.  But what’s odd is the list of requirements to be met by the successful candidate:

The candidate must hold an M.D. degree, be board certified in a clinical specialty, and be eligible for a New York State medical license. Candidates must demonstrate substantial experience in clinical ethics case consultation; excellent interpersonal skills; the ability to work successfully in a team with other professionals; and a record of teaching, service, and scholarship appropriate to academic rank. Preferred: The candidate should have experience in medical school curriculum development, program development, and an ability to interact with faculty across a large and diverse university. 

That is to say - a clinical ethicist would be expected to be a doctor first, second and third.  (Remember that the job description implied that “clinical ethics consultation, education, and leadership” was the primary task of the position-holder.  And in a job for a clinical ethicist, one might be forgiven for expecting that “curriculum development and implementation for medical student clerkships and residency programs” would refer to an ethics curriculum.)  Ethics gets a brief mention in fourth place in the list of requirements, notwithstanding that no formal ethics training is required; all that we’re told is that experience of clinical ethics case consultation must be “substantial”.  But what does that mean?  To my mind, it doesn’t amount to much.  After all, anyone who’s ever sat on an ethics committee will know, first hand, that there are people involved in such bodies who quite frankly oughtn’t to be.  Experience of clinical ethics case consultation is no indication at all that you’re even in the vicinity of cutting the mustard as an ethicist.  The world is full of people claiming ethical expertise because they once thumbed through Beauchamp and Childress and think that ethical decisionmaking is reducible to the 4Ps.

Granted, the job also includes medical responsibilities - but, to that extent, it’s not an ethics gig.  It’s a medical gig with a bit of ethical stuff as well.  And even if what’s wanted is, in the final analysis, a medic with awareness of ethics… well, even then, wouldn’t some formal evidence of that be a good thing?  Or have I missed the point entirely?

*takes deep breath*

Well, I guess that’ll be my application on the fire, then…

An area of research with which I’ve been toying for quite a long time now is to try to provide an answer to the question “What are doctors for?”.  (Admittedly, the possibility of a cheap’n'nasty Heidegger pun in the title, Wozu Doktor?, has a reasonably high place in the list of the project’s attractions…  Ho-hum.  It’s probably been done already, of course…)  Are they there to provide health, or function, or to make us feel good, or what?  All these things may imply, entail or relate to each other, of course, but they’re separable, and may be put into any order of importance.

As is the way with these things, the project has been on the back burner - or forgotten about completely - for a while; but it was brought to mind again by reading this piece in the BMJ concerning cosmetic surgery (and labioplasty in particular).

Lest Daniel Sokol, the author, think that I’m tracking and attacking everything he writes here as it appears - I’m not: I think that there’s a lot to admire about his line of thought.  Nevertheless, I’m not sure I agree with every aspect of his argument, or his claim that, in the light of requests from women who “are requesting surgery to alter their intimate appearance[...] medical professionals, whether working in the private or public sector, should not succumb to these requests.” more…