What Can Doctors Do?

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.”

One of the reasons that he offers for this is that

it is plausible to argue that patients’ autonomy is often diminished by strong social or peer pressures. A female friend once told me how fat and ugly she felt after reading a popular woman’s magazine. She was neither fat nor ugly. A drug company promoting a drug for hair loss—an issue close to my heart—urged balding men to consult their doctor. In a leading website on hair loss, sponsored by a drug company, a poll asks: “Have you felt less attractive since you started losing your hair?” Women seeking cosmetic genital surgery often bring pictures of their ideal vagina from advertisements or pornography.  Creating or exploiting insecurities is a lucrative business.

That’s perhaps true; but the normative power of the point is – I’d suggest – moot.  The worry that Dan expresses is that perhaps some could be cowed – and this is true.  But then we have to ask ourselves where this leaves us.  We could interpret matters in such a way as to imply that doctors should be at least hesitant to respond to requests for treatment from people whom they have a reason to believe to be unduly influenced by some external factor.  Fine – but this looks formalistic, leaving wide open as it does the question of what would count as undue: after all, all of us are malleable.  That’s part of being human.  (And when it’s pointed out that “[a]dvertisements for cosmetic surgery are also manipulative” – well, yup.  That’s how ad. men earn their money.  Clever, aren’t they?)  It also looks a bit weak as a claim: would anyone really think other than that doctors ought not to provide treatment to those whom they have a reason to believe to be pressured into it by others?

Another possible interpretation would be that doctors ought not to perform certain procedures period, just because of the likelihood that people might seek them for the “wrong” reasons (whatever they turn out to be).  But that looks too strong.  The thought goes like this: that, even if you think cosmetic surgery in this (or any) instance would be stupid, still, all else being equal, there is a right, or entitlement, or whatever you want to call it, that agents possess to do or have done to themselves whatever stupid thing they want.  (We might cash this out quite straightforwardly by an appeal to the harm principle, or something along those lines.)  To rule out certain procedures on the grounds of an appeal to people’s possible vulnerability seems to be as much as to say that I can legitimately be prevented from doing that to which I have a legal and/ or moral right because of worries about what might happen to another person.  And that seems to mislocate the problem – or, rather, say that a problem that that other person had can legitimately be mirrored in me: that doesn’t seem correct.  (“Fair enough,” we might say.  “Do something to protect the easily-cowed.  But leave me and my entitlement to do stupid stuff out of it.”)  Problems of undue pressure, it seems, could be avoided or minimised by a period of cooling off.

(Incidentally – on the subject of wanting treatment for the right reasons, I’m reminded of the doctor from the final series of The League of Gentlemen who bullies his patients to the point of tears just to check that they aren’t malingerers.  *Wanders off to YouTube*)

 There’s another interesting point that Dan makes, which is related to the Hippocratic Oath.

As medical science progresses, the oath retracts further into the communal consciousness of medicine, a distant star whose brightness is fading. Many medical students now only know its name. We should not let it fade, for it is the medical profession’s guiding star. Although some parts of the oath are out of date, others contain unchanging truths: “I will use treatments for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm or injustice I will keep them.”  The key phrase is “for the benefit of the ill.”

It’s admitted here that much of the oath has been ditched, and the world seems no worse a place for that.  On what grounds, though, should we keep other aspects of it?  Even if it’s true that doctors have a role to play in curing illness, it doesn’t follow that this ought to be the limit of their role.  It seems to me that there’s two ways we could go with this: one would be to say that, irrespective of the opinion of  a long-dead and semi-mythical Greek bloke, there’s more to medicine than curing people – and the WHO definition of health would seem to reflect this.  Maybe, that is, we could have an account of the iatrike tekhne that can accommodate a wide sense of tekhne.  If people believe that they’d feel better after labioplasty or anything else, what would be so deeply crazy about allowing that better feeling to inform the role of the medic?

Or perhaps we don’t have to be that radical.  I’ve suggested elsewhere that there’s no apparent reason why a surgeon shouldn’t, from time to time, be able to take off his medical hat and put on something more… well… artisanial.  A surgeon is someone with a certain set of skills.  He might well put those skills to one use for some of the time, and to another use the rest of the time.  After all, surgery was once something that came hand-in-hand with the entirely cosmetic pursuit of shaving men’s faces.  Labioplasty is different in extent – but I’m not completely convinced that it’s different in kind.

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