A compilation of posts from the popular 'Illusions of Autonomy' blog on medical ethics.
Full Introduction: I wrote these blog posts to explain the words and actions of doctors in ethically challenging situations. It was a cheeky thing to attempt, as I could not pretend to speak for others in presenting the results of my own reflections. However, feedback from medical and non-medical readers alike confirmed that the descriptions reflected their own experiences, which came as a huge relief.
The posts fall into eight categories, but they have a common theme - a desire to explore how doctors balance their human qualities and frailties with what is expected of them. I focus on the way normal men and women react - How do they maintain compassion and reason despite repeated exposure to the misfortune of others? How do they move between emotionally intense scenes without allowing the impact of the first to colour the outcome of the second? How do they discuss end of life care sensitively when time is short and the right thing to do is ‘so obvious’? How, on a bad day, do they make patients feel central in their thoughts…when their thoughts are miles away?
One method is to take the essence of a real situation (drawn from my years of experience as a hospital doctor) and to enlarge it, dissect it, using imaginary dialogue. Another is to make a quick survey of the literature, or to examine a particularly hard case known to all in the media. In one, I analyse the evidence given in a case at the Court of Protection (‘Quality of life projections: do doctors have any idea?’). In ‘A Never Event and the chain of blame’ I construct a fictional set of lethal circumstances. Throughout, care has been taken to dissociate fictional patients from those who were actually involved in the historical scenario that stimulated the essay. Confidentiality is never compromised.
Decisions taken with patients towards the end of life are developed within the framework of 'Good Medical Practise' (GMP), a series of guidelines published by the GMC. If all decisions adhered to GMP there would be no controversy. Every management plan would result from mutual understanding between patient and doctor. Their goals, their understanding of risk, burden and benefit, their fully informed consent to treatment, would be ascertained well in advance. If they lacked mental capacity, those factors would be agreed by those who knew them best. If only it were that straightforward. Many of these blog posts were generated by my reflections on scenarios that did not fit easily into that scheme; situations in which major decisions about life extending treatment had to be made quickly, in the absence of background information, in isolation from patents' representatives… At times like these accusations of paternalism can arise; and autonomy becomes just an illusion. The good intentions of doctors making those decisions have to be presumed, and the sensible application of their years of experience respected.
Something happened in 2012 to undermine that presumption of goodness - the Liverpool Care Pathway controversy. It was my horrified reaction to accusations of immorality and systemic euthanasia as they multiplied in the press that spurred me to begin writing. I could see trust in my profession eroding, and unjustifiably (in my opinion). The furore has died down now, but I believe that there is much rebuilding to do. Perhaps, by being open and honest about the way doctors handle ethically complex situations, these posts can contribute in a small way to that recovery.
PART 1: THE PSYCHOLOGY OF DOCTORS
PART 2: COMPASSIONATE CARE
PART 3: AT THE COALFACE
PART 4: ASSISTED DYING
PART 5: MEDICAL ERROR
PART 6: CARE TOWARDS THE END OF LIFE AND RESUSCITATION
PART 7: QUICK, TOPICAL MEDICAL ETHICS OVERVIEWS
PART 8: THE LIVERPOOL CARE PATHWAY CONTROVERSY
Full Introduction: I wrote these blog posts to explain the words and actions of doctors in ethically challenging situations. It was a cheeky thing to attempt, as I could not pretend to speak for others in presenting the results of my own reflections. However, feedback from medical and non-medical readers alike confirmed that the descriptions reflected their own experiences, which came as a huge relief.
The posts fall into eight categories, but they have a common theme - a desire to explore how doctors balance their human qualities and frailties with what is expected of them. I focus on the way normal men and women react - How do they maintain compassion and reason despite repeated exposure to the misfortune of others? How do they move between emotionally intense scenes without allowing the impact of the first to colour the outcome of the second? How do they discuss end of life care sensitively when time is short and the right thing to do is ‘so obvious’? How, on a bad day, do they make patients feel central in their thoughts…when their thoughts are miles away?
One method is to take the essence of a real situation (drawn from my years of experience as a hospital doctor) and to enlarge it, dissect it, using imaginary dialogue. Another is to make a quick survey of the literature, or to examine a particularly hard case known to all in the media. In one, I analyse the evidence given in a case at the Court of Protection (‘Quality of life projections: do doctors have any idea?’). In ‘A Never Event and the chain of blame’ I construct a fictional set of lethal circumstances. Throughout, care has been taken to dissociate fictional patients from those who were actually involved in the historical scenario that stimulated the essay. Confidentiality is never compromised.
Decisions taken with patients towards the end of life are developed within the framework of 'Good Medical Practise' (GMP), a series of guidelines published by the GMC. If all decisions adhered to GMP there would be no controversy. Every management plan would result from mutual understanding between patient and doctor. Their goals, their understanding of risk, burden and benefit, their fully informed consent to treatment, would be ascertained well in advance. If they lacked mental capacity, those factors would be agreed by those who knew them best. If only it were that straightforward. Many of these blog posts were generated by my reflections on scenarios that did not fit easily into that scheme; situations in which major decisions about life extending treatment had to be made quickly, in the absence of background information, in isolation from patents' representatives… At times like these accusations of paternalism can arise; and autonomy becomes just an illusion. The good intentions of doctors making those decisions have to be presumed, and the sensible application of their years of experience respected.
Something happened in 2012 to undermine that presumption of goodness - the Liverpool Care Pathway controversy. It was my horrified reaction to accusations of immorality and systemic euthanasia as they multiplied in the press that spurred me to begin writing. I could see trust in my profession eroding, and unjustifiably (in my opinion). The furore has died down now, but I believe that there is much rebuilding to do. Perhaps, by being open and honest about the way doctors handle ethically complex situations, these posts can contribute in a small way to that recovery.
PART 1: THE PSYCHOLOGY OF DOCTORS
PART 2: COMPASSIONATE CARE
PART 3: AT THE COALFACE
PART 4: ASSISTED DYING
PART 5: MEDICAL ERROR
PART 6: CARE TOWARDS THE END OF LIFE AND RESUSCITATION
PART 7: QUICK, TOPICAL MEDICAL ETHICS OVERVIEWS
PART 8: THE LIVERPOOL CARE PATHWAY CONTROVERSY
