Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Uncertain about responsibility
- Stephen Bowler (5 March 2005)
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Coping with uncertainty by sharing responsibility
- Hazel Thornton (8 March 2005)
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Re: Uncertain about responsibility
- Stevie M Gamble (9 March 2005)
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Regression theory
- Stephen Bowler (14 March 2005)
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Stephen Bowler, Lay Member South Sheffield Research Ethics Committee
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The notion of ‘uncertainty in medical evidence’ as advanced by Griffiths et al (1) confuses the subtle dynamics of the doctor/patient relationship with the less subtle dictates of evidence-based medicine. That the former has been eclipsed by the latter reflects the demise of authority in general, with profound consequences for public and private alike. But for medicine the collapse of norms of legitimate authority is a particularly acute problem, for it is the foundation upon which the moral division of labour of the doctor/patient relationship rests. In a post-Bristol context many have welcomed the demise of medical paternalism and celebrated the ‘empowered’, ‘autonomous’, and even the ‘expert’ patient. But doctor and patient are not moral equivalents. Indeed, a patient is a person diminished in their totality, and therefore in need of a most intimate kind of help, rather than a risk assessment administered by a technician. If the ‘myth of certainty’ is as sinister as the authors imply, then what of the placebo effect, or the function of ‘the doctor himself as a therapeutic agent’?(2) To ‘acknowledge uncertainty and to negotiate provisional decisions’ is to duck the higher responsibility of the doctor to the patient as a suffering individual, always ‘the measure of his own normality’(3). Many years ago Karl Jaspers noted the damage done when a doctor surrenders his authority by communicating his uncertainty: ‘the patient’s anxiety will grow and as a result of this unreserved honesty the doctor will find it impossible to be a doctor in this particular situation. For this reason doctor and patient instinctively adhere to authority as something reassuring.’(4) Of course, the idea that authority might be reassuring is anathema to many today. But the patient stands in need of much more than information. The sick regress – physiologically, personally, morally – which is why society allocates a special and temporary role to them and authorizes doctors to say who can and who cannot be so classified. ‘(T)ruly to include patients in decision making’ is to truly evade the responsibilities vested in medicine by society. In any case, ‘the graver the patient’s illness, the less likely the patient is to want to make medical decisions.’(5) In accessing and understanding the patient’s ‘myth of himself’(6) a doctor constructs an alternative myth of his own. To see this only in negative terms is to misunderstand and devalue one of the last, and most valuable, kinds of trust left in an already too-cynical world. (1) Griffiths, F., Green, E., and Tsouroufli, M. (2005). The nature of medical evidence and its inherent uncertainty for the clinical consultation: qualitative study. BMJ 330, 511-. (2) Brody, H. (1997). The Doctor as Therapeutic Agent: A Placebo Effect Research Agenda. In "The Placebo Effect: An Interdisciplinary Exploration" (A. Harrington, ed.), pp. 77-92. Harvard University Press, Cambridge, Massachusetts, Houston, W. R. (1938). The Doctor Himself as a Therapeutic Agent. Annals of Internal Medicine 11, 1416-25, Spiegel, D. (2004). Placebos in practice. BMJ 329, 927-928. (3) Goldstein, K. (1939). "The Organism: A holistic approach to biology, derived from pathological data in man.," American Book Company, New York. p.433 (4) Jaspers, K. (1963). "General Psychopathology," Manchester University Press, Manchester. p.797 (5) Schneider, C. E. (1998). "The Practice of Autonomy: Patients, Doctors, and Medical Decisions," Oxford University Press, New York. p.41 (6) Browne, K., and Freeling, P. (1976). "The Doctor-Patient Relationship," 2/Ed. Churchill Livingstone, Edinburgh. p.59 Competing interests: None declared |
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Hazel Thornton, Independent Advocate for Quality in Research and Healthcare "Saionara", 31 Regent Street, Rowhedge, Colchester, CO5 7EA
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The qualitative study by Griffiths et al [1] clearly shows the difficulty that doctors and patients have in consultations in accepting and coping with inherent uncertainty when attempting to achieve satisfactory decisions for both parties. As Keeble stated: "The experiential fact of uncertainty is incontrovertible." [2] This is a difficult truth for anyone to accept. Bowler, "uncertain about responsibility", apparently prefers "reassurance" at the expense of acknowledging uncertainty when imposing his beliefs about decision-making in the patient-doctor relationship. [3] rather than heeding current available evidence. For example, a national survey [4] found that the public thought it was important to be informed, have clear values, make choices that matched with the values, and be satisfied with the decision. Qualitative research that informed the UK randomised trial of shared decision-making in General Practice, [5] showed that important aspects of the consultation for the patient included feeling respected as a `player` who has made a meaningful contribution to the discussion in the decision-making process; the need for available and accessible extra information sources for better assessment of the information given; the opportunity for involving others; continuity of care, including clear arrangements for review of treatment decision. Desire for information should not be confused with desire to make decisions. The patient-doctor relationship and attitudes to authority that Bowler describes have changed considerably since the 1963 findings that he quoted. As a member of a research ethics committee he would do well to study the latest research evidence about shared decision-making. [1] Frances Griffiths, Eileen Green, Maria Tsouroufli. The nature of medical evidence and its inherent uncertainty for the clinical consultation: qualitative study. BMJ 2005; 330:511-5 [2] N.H. Keeble. Introduction, p.xix, The Pilgrim`s Progress. Oxford University Press, 1984. [3] Stephen Bowler. Uncertain about responsibility. bmj.com. http://bmj.bmjjournals.com/cgi/eletters/330/7490/51199603 accessed 6th March 2005 [4] O`Connor AM, Drake ER, Wells GA, Tugwell P, Laupaucis A, Elmslie T. A survey of decision-making needs of Canadians faced with complex health decisions. Health Expectations, 2003; 6:97-109 [5] Hazel Thornton, Adrian Edwards and Glyn Elwyn. Evolving the multiple roles of `patients` in healthcare research: reflections after involvement in a trial of shared decision-making. Health Expectations, 2003; 6:3:189-197 Competing interests: I am a patient-researcher |
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Stevie M Gamble, retired HMIT EC2Y 8BL
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Stephen Bowler, Lay Member South Sheffield Research Ethics Committee, asserts in his Rapid Response of 8/3/05 that: ‘The sick regress – physiologically, personally, morally –‘ Perhaps he would care to share with us the evidence for his assertion. Stevie M Gamble Competing interests: None declared |
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Stephen Bowler, Lay Member South Sheffield Local Research Ethics Committee
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To say the sick regress is to say they fall below a standard otherwise upheld. The classic statement that ‘I’m not feeling myself today’, is ‘evidence’ enough – for those who choose to listen – of the drift of the sick away from the firm moorings of organic and existential inter-dependence we know as health. To be sick is to be un-free, to be unable to determine one’s own interests. A person who lacks such capacity is held less responsible for their actions. This is the standard view, for the simple reason that a market system rests upon the rational legal subject as the basis for contract. Upon such juridical foundations does the edifice of culture rest in modern, Western society. For sure, the sick individual is no less a person for so being. But such a person is less of an individual, because individualism is not a timeless category but a role within a moral and legal context. Which is why society sanctions – and doctors police – the sick role, as a special status with qualitatively different terms and conditions than those applicable in the general run of things. The extreme end of this logic, of course, can be seen in psychiatry. But it is no less true in any other sphere of medicine, where the boundaries between the normal and the pathological are in a process of continual negotiation. This is clearly the case in terms of clinical diagnoses, but is also true at the level of society as a whole. So-called somatising disorders, from ‘railway spine’ at the end of the nineteenth century, to ‘shell shock’ during the Great War, PTSD in the wake of Vietnam, and ME in more recent years, are comprehensible only in relation to a changing cultural script. One may deplore the script, but its influence in relation to sickness cannot be gainsaid: sickness is a regression from a socially constructed norm. The fact that the norm tends now to a more permissive view of incapacity – fuelling an explosion of claims for state benefits – serves to widen the conceptual net of sickness and undermine the very idea of the rational legal subject, free before the law and free also to determine his or her own destiny. This is a serious problem in our society today, and one that should not fall to medical practitioners to resolve. Nonetheless, the majority of people in society are not sick, and like not to think of themselves as such, for to do so is to admit of a diminution in their capacity as rights-bearing individuals. Indeed, one might extend this observation and suggest that some people feign sickness for precisely the same reason, in that it lowers the threshold of personal responsibility otherwise upheld. But just as we embrace and promote the potential for humanity to transcend its animal origins, we also extend our care and compassion to those who are, for whatever reason, incapacitated from so doing, with the expectation that they will, if at all possible and at the earliest opportunity, re-enter the world of free-willing responsible adulthood. The scope and purchase of the paradigm outlined here is suggested by the huge variety of ways in which we use the term health, as synonym for that which is fit, functional and good. To be sick is to go in the opposite direction, to regress, physiologically, personally and morally. Competing interests: None declared |
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