{"id":3128,"date":"2017-02-06T13:48:51","date_gmt":"2017-02-06T12:48:51","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3128"},"modified":"2017-02-06T13:48:51","modified_gmt":"2017-02-06T12:48:51","slug":"professional-codes-and-diagnosis-at-a-distance","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/02\/06\/professional-codes-and-diagnosis-at-a-distance\/","title":{"rendered":"Professional Codes and Diagnosis at a Distance"},"content":{"rendered":"

This is the second part of my response to Trish Greenhalgh’s post<\/a><\/span> on the propriety of medics, psychiatrists in particular, offering diagnoses of Donald Trump’s mental health.\u00a0 In the last post<\/a><\/span>, I concentrated on some of the problems associated with making such a diagnosis (or, on reflection, what might be better called a “quasi-diagnosis”).\u00a0 In this, I’m going to concentrate on the professional regulation aspect.<\/p>\n

Greenhalgh notes that, as a UK medic, she is bound by the GMC’s Duties of a Doctor<\/em><\/a><\/span> guidance,<\/p>\n

which – to my surprise – does not explicitly cover the question of a doctor\u2019s duty towards a public figure who is not<\/em> his or her patient.<\/p>\n

[…]<\/p>\n

My reading of the GMC guidance is that in extreme circumstances, even acknowledging the expectation of how doctors should normally behave<\/em>, 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<\/em> paragraphs 53-56) that breach of patient confidentiality may be justified in order \u201cto prevent a serious risk of harm to others.\u201d<\/p><\/blockquote>\n

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.<\/p>\n

The more interesting thing for me is what the relationship is between the practitioner and the GMC.\u00a0 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”.\u00a0 But why should the GMC’s position be all that important?<\/p>\n

OK: I’m going to go off on a bit of a tangent here.\u00a0 Stick with me.<\/p>\n

A couple of days ago, I was introducing a new batch of students to moral theory for a course I teach here at Manchester.\u00a0 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.\u00a0 Divine Command ethics could be characterised as a deontological approach.\u00a0 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.\u00a0 You’ve just got a set of rules.<\/p>\n

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.\u00a0 And another problem is the Euthyphro dilemma.\u00a0 Does the deity command things because they’re good, or are they good because the deity commands them?\u00a0 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\u00a0would presumably be intellectually neater.\u00a0 If the latter, it looks as though the deity might be making stuff up on the hoof.\u00a0 And if that’s OK for the deity, why not us?\u00a0 (We can’t say that we mustn’t because the deity says so, because that command was presumably pulled out of nowhere, too.) \u00a0Correspondingly, the deity could perform a complete reversal on some commands, and there’d be nothing more to say about it. \u00a0On Monday, worshipping idols is banned; on Tuesday, it’s mandatory. \u00a0So it goes.<\/p>\n

Appealing to professional bodies strikes me as being vulnerable to similar worries.\u00a0 We believe in them, believe they’re interested in what we do, and so on; but a professional Euthyphro dilemma still seems to appear.\u00a0 Does the GMC command things because they’re good, or are they good because the GMC commands them?\u00a0 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. \u00a0Moreover, there might be times when the GMC is mistaken.\u00a0 If the latter, we need to say why the GMC’s rules are compelling, compared to any other putative rule.<\/p>\n

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.\u00a0 These conventions don’t have to rest on anything in particular.\u00a0 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.\u00a0 If you don’t like the rule, you don’t have to join. \u00a0The same may apply to medics and the GMC’s rules. \u00a0You wanna be a doctor? \u00a0Them’s the breaks.<\/p>\n

That has a certain mileage, I think; but there’re problems.\u00a0 For one thing, the cricket club’s rule doesn’t pretend to me a moral<\/em> rule; thus the question “What ought the rule regarding batsmen out for a duck to be?” has only limited currency.\u00a0 “What ought the GMC’s rules about confidentiality to be?” has much more.<\/p>\n

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.\u00a0 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\u00a0anything like that.\u00a0 When it comes to something like the confidentiality rule, though, such defences might be offered.\u00a0 Whether or not they’d work remains an open question; but they would be coherent.<\/p>\n

The GMC’s conduct rules are not – I take it – meant to be simply the rules of the club.\u00a0 (In this light, it’s tempting to discount the APA’s Goldwater Rule<\/a><\/span>: 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.)\u00a0 They’re supposed to hitch onto something bigger about proper conduct.<\/p>\n

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.\u00a0 “Whatever the GMC says” is, I’d hazard, a singularly poor answer to questions about what one ought to do.<\/p>\n","protected":false},"excerpt":{"rendered":"

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.\u00a0 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”).\u00a0 In […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1240,575,968,511,2152,328,2745,7988],"tags":[],"class_list":["post-3128","post","type-post","status-publish","format-standard","hentry","category-blogosphere","category-bmj","category-clinical-ethics","category-in-the-news","category-mental-health","category-philosophy","category-professionalism","category-regulation-and-regulators"],"yoast_head":"\nProfessional Codes and Diagnosis at a Distance - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2017\/02\/06\/professional-codes-and-diagnosis-at-a-distance\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Professional Codes and Diagnosis at a Distance - 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