Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law, St George’s, University of London and the keynote speaker at our recent Medical professionalism matters event on ‘the doctor’s dilemma’.
The ThinkTank space at the Science Museum in Birmingham was buzzing last Wednesday evening as doctors, patients (and let us not forget that there is considerable overlap between these two categories), educators, students and more gathered to discuss the concept of ‘the good doctor’.
I began by turning my talk to something that, on the face of it, may appear unconnected to the moral dimensions of medicine, namely theatre. However, those who know me and who may have attended lectures and talks I have given will know two things: first, I am obsessed with theatre and can find ways of shoehorning it into every conversation, presentation and interaction and secondly, I remain convinced that there is always an insight that theatre and/or drama offers that is enriching and unique.
There may be no good options
In this case it was the concept of ‘the dilemma’ that interested me initially. How often is ethics a matter of resolving a ‘dilemma’ in its classical and strict sense? I would suggest that it is relatively rare. Most moral questions are not a choice, taken by one person, between two distinct options. It is altogether more nuanced, more complex and more subtle. Many ethical choices take place against a backdrop of uncertainty and systemic factors that both shape and limit what is possible. Many situations will involve a number of people and diversity of values and perspectives. There may be no ‘good’ options, but instead a range of possibilities of varying acceptability.
Moreover, how does one discern an ethical question in the first instance? Just as a patient’s diagnosis is discerned via judgement, reasoning and experience, so too is ethical awareness. Thus it was that I justified focusing on one of my favourite plays: Hamlet. For Hamlet is inherently a play about ethical choices. Yet, the identification of an ethical dilemma in medicine is more difficult than it appears in Hamlet where soliloquies denote the bold choices the hero is required to make. This was never clearer than when asking the audience to identify the number of ethical questions or issues in a short scenario.
Responses ranged from 0-5 to over 20. We all saw the same set of facts and yet we differed widely in the way we saw the moral landscape of the scenario. That is not surprising. Yet, it is surprising that it is rarely discussed. Most conversations start with the assumed ‘dilemma’ and attend too little to the negotiation of the ‘dilemma(s)’. Who gets to define an ethical issue and how?
Even assuming we could agree with the (slim) majority of the audience that the scenario I shared with them contained between 5 and 10 ethical questions, the challenge remains that those questions have to be prioritised and decisions taken (which will, of course, be informed by, and depend on, the recognition and prioritisation of the issues in the first place). I have argued elsewhere that the difficulties people experience in relation to behaving ethically are rarely because they don’t know what to do.
More commonly, it is the interaction between the individual and the system that makes it hard. Questions of time, exhaustion, stress, ambition and fears about career progression, compassion fatigue, burnout and professional loyalties are all powerful influences on an individual’s capacity to ‘do the right thing’.
Responding to ethical problems effectively
Yet, to continue the theatrical analogy, there are ways in which one can make it more likely that one will both recognise and respond to ethical problems effectively.
First, consider the character(s) involved. Who inspires and impresses you? How do they respond to difficult situations? Who are the role models in your professional life and who are more cautionary tales? Think more about characters: what sorts of people do you find it difficult to challenge? What is your own personal approach to conflict and disagreement?
Secondly, rehearsal in ethical practice is an invaluable tool. Just as you learned clinical skills by practising, you can also practise how to approach an ethical problem or question. Just like cannulation or cranial nerve examinations, you can ‘rehearse’ finding the words to speak up and articulate your ethical concerns and views. Everyone will, at some point, have had experience of challenging another person or differing from someone else’s point of view. It may not be in relation to medicine, but if you have ever complained to a company or told a friend that you disagree with them, you have the skills needed to express yourself ethically. It is a matter of confidence and, yes, moral courage to apply them in a medical setting.
Be kind, no exceptions
There are many complexities in, and influences on, ethical practice. Our capacity to engage with questions and issues depends on so much, including the extent of our moral awareness and ethical sensitivity, our ethical competence and confidence, emotions, personal beliefs and values, moral courage, context, experience and judgement. Yet, perhaps focusing on medicine’s ‘audience’ makes it somewhat simpler. For whom are you there?
As one participant simply asked: if we remember that patients come first, might the other conflicts and tensions recede? It was a wise question and reminded me of a postcard I have on my study wall. It reads ‘be kind, no exceptions’. It is simple and yet so difficult to achieve.
Every day I need the reminder.
Deborah Bowman is Professor of Bioethics, Clinical Ethics and Medical Law, St George’s, University of London and was the keynote speaker at our recent Medical professionalism matters event in Birmingham.
Our final Medical professionalism matters event of 2015 on ‘the compassionate doctor’ will be held in Cardiff on Thursday 19 November. Register your interest here. ‘The compassionate doctor’ will explore maintaining empathetic relations with patients and the howe we can recruit for the values of medicine.
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