Julian Sheather: Francis—the ethical challenge

Medical ethics has positioned itself as a decision making tool, a philosophical spanner if you like in the clinician’s toolbox. For understandable reasons it has concentrated on practical dilemmas: even those landmark legal decisions—the removal of treatment from Anthony Bland comes to mind—are buttressed by intense philosophical scrutiny. In the process medical ethics has attracted some good minds from academic philosophy, pleased no doubt to see some practical pay-off from their more abstract deliberations.

Inevitably it is the exceptional issues that generate the most philosophical speculation—and for good reason: if the problems were commonplace, custom and practice would normally have worn a path for them. Conjoined twins, embryonic research, physician-assisted suicide—these are the issues that grab attention. And yet, interesting as they are, few health professionals will have much to do with them. Most enquiries from doctors to the BMA relate to data sharing—not an area traditionally associated with philosophical fireworks.

Predictably enough the Francis report triggered calls for more ethical guidance. And yet understandable as this was, it missed the point. It is hard to imagine a health professional reading Francis and not being able to spot that some of the care was appalling. The Francis report asks a different question: not about what we mean by good care, but why hospitals and health workers failed to deliver it.

On the face of it, this does not look like a question for medical ethics, forced like just about everyone else to fall back on truisms: respect, dignity, agency. Partly this is because on even the briefest examination Francis asks more than one question. When it comes to the outcomes of highly complex systems like the NHS, tools sharpened on questions of identity, personhood, and the scope of personal autonomy fail to get a purchase. It just doesn’t look like a philosophical sort of problem.

And yet this is a mistake, a mistake brought about by the success of medical ethics with more typical problems. After Francis we will hear a lot about the impact of permanent political revolution on NHS care, we will hear about conflict between managers and clinicians, about shortages of funding, about de-skilling, about targets. All of these and more. And rightly so. But we also very badly need to hear about motivation. Complex systems create the conditions in which people succeed and fail, but bad things also happen because of what people do—or more often because of what they don’t. People get forgotten in systems. Forgetting about what sick, bedridden people needed was at the heart of what happened at Mid Staffs. But good people working in complex systems can also get lost. Responsibility becomes fractured and dispersed. Because it can be difficult to solve problems in complex systems we don’t take ownership. Cracks open and people fall into them. And given that systems are unlikely ever to be infallible, we need also to ask how professionals can resist the corruption of good practice by failing institutions: how can we strengthen motivation?

There is a very old and honourable philosophical tradition—about which I wish I knew more—that is concerned with, among other things, motivational states: virtue ethics. Part of the reason I don’t know more about it is that it hasn’t made deep inroads into the more practical end of medical ethics which is where I sharpen my axe. This is because, as I’ve said, medical ethics has tended to focus on problem solving. When confronted by a problem, chances are a virtuous person will reach either for the available philosophical tools or for those morally acceptable deliberative procedures for resolving problems: better then to focus on the tools and the procedures. But Mid Staffs is different. One of the urgent questions it asks is how does the ordinarily good person—the good doctor, nurse, manager, healthcare assistant—(we are not interested in moral saints here) continue to do what they know to be the good or right thing where systems are corrosive of it?

Virtue ethics breaks the surface in contemporary medical ethics most often in relation to professionalism. It is a notoriously vague concept, more an umbrella term under which shelter a loose bundle of skills, aptitudes, values, attitudes, and dispositions. But vagueness does not mean unimportance. Professionalism can bind individuals to good practice, but it can also help health professionals, both individually and collectively, to push back against failing systems. No, professionalism will not, on its own, solve all the problems of the NHS, but it will be part of the solution. So we do not need to wait for consensus on what professionalism means before we start an urgent debate about how the aptitudes, dispositions, and behaviours necessary to deliver good patient care can be preserved, can even—hell why not strike an optimistic note?—be permitted to flourish in modern healthcare.

Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.