Desmond O’Neill: The ethics of advocacy

Desmond O'NeillThe infant’s eyes are huge, the profile of its tiny cheek bisected by a naso-gastric tube and its ugly adhesive patch. Peering from the corner of the billboard, the image aches with vulnerability and fear, a message reinforced by the slogan—Sick Children Are Out Of Time. Arising from a recent major publicity campaign by a Dublin children’s hospital for building cancer and cardiac units, the synthesis of the three high C’s of fund-raising in healthcare – children, cancer, and cardiac disease—with such potent images and slogans is striking.  

And indeed the journalist from the Irish Times describing the campaign was moved to emotion, if not to critical reflection as to the functioning of the hospital’s maintenance department, by the conditions she encountered—door handles falling off and dripping taps among the many faults listed—of the clearly outdated children’s hospital, the largest in Dublin.

Yet many Irish doctors I have met have expressed unease at the thrust and timing of this campaign but would be disinclined to articulate this in public. Who willingly invites portrayal as an ogre with a Scrooge-like heart of flint? This is particularly the case in a close-knit country with a population no bigger than some NHS regions, and with stormy medical politics arising from a recent competition to combine the three children’s hospitals in Dublin on a single site co-located with an adult hospital.

Most Irish paediatricians welcomed this co-location even allowing for the major compromises involved: however, vociferous opposition continued, particularly from retiring and retired senior staff from one of the hospitals unsuccessful in the competition. The new hospital project has recently run into a significant hitch with the planning section of the city council, but otherwise has a time span to completion of 2016.

Apart from the campaign launching so close to this reverse with the city planners, a source of discomfort is that it seeks to build facilities in a hospital due to close down with the completion of the new hospital. Having experienced the run-down of the physical fabric of an inner-city hospital while awaiting the delayed transfer of a green-field site, I am sympathetic to any service crumbling whilst awaiting a similar transfer: but might not the money and attendant goodwill of the public find a more portable and transferrable form in a wide range of deserving service developments for children rather than in bricks and mortar in this instance?

At a deeper level, the issue struck a chord with me in terms of ethical and professional education. When developing an ethics module with a focus on everyday ethics [1]—confidentiality for prisoners, students’ own experiences—I was struck by how little space was dedicated in text-books and Medline to the potential for ethical dissonance from our personal vested interests, whether through income or payment systems, or among groups of doctors by maintenance of hierarchies of power, esteem, influence, and convenience through public advocacy.

These issues are important—one of the few available studies shows markedly different prescribing for private and public patients in Irish general practice. [2] Some helpful debate arose from the introduction of managed care in the USA, where incomes and untrammelled clinical freedom were circumscribed in a manner akin to much European medicine. One perceptive (and pilloried) commentary highlighted the degree which the many opposing managed care failed to give due recognition that “best care for my patient” was also a proxy for “optimal reimbursement for my practice.” [3]

Sources outside of medicine provide the most helpful literature on professional vested interest and public advocacy. A paper from the wildlife sector provides this insightful quote: “knowledge and expertise are not the neutral scientific elements emphasized by traditional theory but political resources in the battle for power and status.” [4] An equally helpful reflection from the social sciences  points out how advocacy directed by professionals can become divorced from the palette of needs of the vulnerable and marginalized. [5]

The generic concept of Illich that the original altruistic goals of any institution become diverted to varying degrees to the needs of those running the system should be a constant presence in our efforts at public advocacy, even if his expression of his ideas in the medical context ran to frequent unhappy hyperbole in his Medical Nemesis. [6]

Just as with clinical practice, advocacy is not a pure process, and when raising funds there will always be pragmatic compromises between what is possible and what is desirable. As a profession however, we need to do better in terms of more formal reflection, discussion, and research into how we undertake public advocacy and more reflection as to who is benefitting and whether our advocacy is unwittingly skewing the provision of healthcare and reinforcing existing gaps in attentiveness of the health services. [7]

Our credibility as a profession in the longer term, and the maintenance of the trust of the general public, mandates no less than this, for in some ways we are all out of time.

1. Russell C, O’Neill D. Developing an ethics of competence, care, and communication. Ir Med J 2009;102:69-70.
2. Usher C, Bennett K, Feely J. Prescription patterns in the elderly population–“new” versus “old” medical card holders. Ir Med J. 2004;97(8):234-6.
3. Hall MA, Berenson RA. Ethical practice in managed care: a dose of realism. Ann Intern Med 1998;128(5):395-402.
4. Gill RB. Professionalism, Advocacy, and Credibility: A Futile Cycle? Human Dimensions of Wildlife 2001;6:21–32
5. Samuel J. Public advocacy and people-centred advocacy: mobilising for social change. Development in Practice 2007;17:615-21.
6. Illich I. Medical Nemesis. Lancet 1974;1(7863):918-21.
7. Pendlebury ST, Rothwell PM, Algra A, et al. Underfunding of stroke research: a Europe-wide problem. Stroke 2004;35:2368-71.