[Sent – 20 December 2019 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]
Greetings from St. Louis and WashU. For ‘Surgical Ethics Education Resources’ communication #26, I am sharing with you the second of the seven ‘Ethics 101’ promptings we distribute to our surgery clerkship students – one prompting every couple of weeks during their 12-week clerkship – as the foundation for the professionalism/ethics curriculum we developed for our surgery clerkship several years ago. (You received the first of the seven promptings with ‘Surgical Ethics Education Resources #8’.) We encourage the students to find a few minutes to consider the suggestions in each prompting as they rethink the tools they bring to the ethical challenges they are facing in clinics, in ERs, in ORs, in ICUs, and on the floors. The set of seven promptings can also be used with residents and fellows. I welcome your feedback. Doug
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Prompting #2 – How should ‘ethics’ be understood in the context of clinical realities?
Douglas Brown, PhD
Douglas Brown, PhD
‘Encounter’ is one of those everyday words in medicine. To encounter is to come upon another person face to face, often unexpectedly. To encounter is to meet another person suddenly, necessitating a decision to assert or to defer. Each day is a series of encounters – turning hallway corners, crossing lanes, reaching for an object, getting in line, looking up from a table, chasing a prize, competing for a position, . . . . Encounters make concrete and visible the set of values and the sense of purpose out of which we decide what we will do, how we will live. Medical school is no exception. Residency is no exception. Academic medicine is no exception. Private practice is no exception.
To be seen/treated by a surgeon as “the chest wound in Room One” or “the liver cancer in Room Two” or “the acute abdomen in Room Three” is not necessarily damaging. Excellent surgical care is evidence-based. The surgeon frames the patient with statistical associations that concentrate on damaged or diseased body parts. Differential diagnoses reflect plausible cause and effect explanations. The surgeon necessarily focuses on the patient’s immediate problem more than on the patient’s larger story. The surgeon must be sufficiently detached to achieve aequanimitas or balance.
However, at some point, clinically competent patient encounters cease to be respectful patient encounters. At that threshold, only by a surgeon’s being sufficiently disciplined to regard patients as individuals worthy of respect, compassion, and fairness can a surgeon avoid the indifference that degrades patient encounters into self-serving alienation . . . the indifference that leaves patients bruised, manipulated, exploited, dehumanized.
The environments for surgical education, surgical training, and surgical practice tend to depersonalize patient encounters. Listen to the chatter alongside rounds, note the tone in medical record entries, analyze call room conversations and physician lounge conversations, recall morbidity-mortality conferences, remember discussions about depositions or about productivity numbers, . . . .
For patient encounters to be truly respectful, a fourth professional language is required – i.e., the language of respect, compassion, and fairness. This fourth professional language is fundamentally distinguishable from clinical/scientific language, from risk management/legal language, and from billing/economic language. Fluency in the professional language of respect, compassion, and fairness is not required to successfully complete medical school, to pass post-graduate boards, to be rewarded by practice management, to secure hospital privileges, to pass recertification examinations, to be promoted, to be elected to national positions of leadership, even to be on a hospital ethics committee. Fluency in the professional language of respect, compassion, and fairness is, however, essential for sustaining the resolve to be a humane surgeon who cares deeply about patients – especially the most difficult patients -- and who brings a resolute social conscience to the practice of surgery. These promptings are designed to measure/strengthen your fluency in the professional language of respect, compassion, and fairness.
Each individual forms a personal sense as to what is of core/ultimate value and what is of lesser value. The core/ultimate values serve as a filter through which information is interpreted before being applied to life’s decisions. Certain relationships, experiences, circumstances, and objects are thus regarded to be of such importance to an individual that s/he is prepared to suffer great loss rather than to violate them.
Judgments about what ought or ought not to be done can usually be acted upon safely without much conflict. However, some situations require a collective judgment from a number of individuals with competing goals or divergent viewpoints. In such situations, a reflective approach to decision-making -- i.e., ethics -- is necessary. Ethics then has to do with the determination of what ought to be done in a given situation, all things considered.
Some differences in judgment can be traced to variations in reasoning patterns. For instance, one person may be very logical, deductive, abstract. Another person may be more intuitive, pragmatic, affective. In order for a thorough analysis of the conflict can be undertaken, the participants in the decision-making process must respect each other enough to listen carefully in order to recognize and understand the divergent paths to the conflicting choices under consideration.
Note -- this approach to ethics focuses on the way we make decisions, first in reference to core values and then in reference to the interests of others affected by our decisions.
Well-intentioned individuals may come to different judgments about what should be done in a given situation because they are considering quite different aspects of the situation and/or because they may be assigning different weight, priority, value to considerations they share. When I round with medical/surgical teams in various patient care settings, I take copious notes as I move with the team from patient to patient. Some member of the team -- a resident, or a nurse, or a medical student, or . . . – almost always pulls me aside at some point to ask, “What are you writing down? What are you hearing us say?” I often answer –
I am listening to how you and your colleagues are talking about the experience of caring for the patient. Not so much what you eventually write in the chart, but the discussion about the case that includes your adjectives, your adverbs, your emotions, your metaphors, your narratives, your whispered exchanges, your humor, your editorial comments. That discourse -- not the note in the chart -- reveals far more completely what you and your colleagues consider important enough to influence what you think should be done in caring for the patient.Remember -- it is imperative that individuals conflicted about what ought to be done hold tightly to the ‘well-intentioned’ assumption about each other as long as possible and only surrender the ‘well-intentioned’ assumption after careful/thorough examination produces overwhelming evidence to the contrary.
