Q J Med 2004; 97: 553-554
QJM vol. 97 no. 8 © Association of Physicians 2004; all rights reserved.
Coda |
Impaled on the invisible
Driving into work recently, I was listening to the ‘Today’ programme on the radio. Someone was talking about global warming, and quoting a statement from the Confederation of British Industry. ‘Any measures taken to prevent global warming’, went the statement, ‘must not do any harm to British industry.’ My ears pricked up. I wondered if anyone would challenge this tosh, but of course no-one did. Yet an intelligent ten-year-old could tell you that you cannot reduce global warming without harming industry. Conversely, if you do not take some measures that will harm industry, there will almost certainly be more global warming. That indeed is the dilemma.Later the same day, I came across a similar argument. A friend asked me to look at an article he was writing about failed asylum seekers and the restrictions being placed on their use of the NHS in Britain. I read the article. It was passionate and polemical, but I doubted if it would convince anyone who was not already convinced. I asked my friend provocatively if he was proposing to open Britain and its health service to anyone in the world, regardless of their nationality or level of need. (He looked troubled for a moment. I don’t normally ask such illiberal questions.) I pointed out that his article was similar to the statement I had heard on the radio. It involved the denial of a dilemma.
Denied dilemmas are incredibly common. Once you start noticing them, you spot them everywhere. Politics is almost entirely based on them. Every speech, every manifesto, is either for something or against it. Certainly, very few politicians – at least in public – seem able to frame any issue as a painful dilemma and to confess that they are proposing what they hope, on the balance of probabilities, to be the ‘least worst’ option. (‘My fellow Americans, we are going to fight a war. Perhaps it will lead to peace in the Middle East, and perhaps it will make things worse. We may be saving more lives, or putting more at risk. I simply ask you to back my hunch that on balance this is the right thing to do ... ’)
In theory at least, doctors are in a very different position from politicians. We are not obliged by our calling to take up postures where we deny the existence of dilemmas. Nor do we have to conceal any private doubts we may have, in order to stay in our jobs. In spite of this, I believe that we may not be any better at spotting dilemmas, or naming them, than politicians are.
One particularly fashionable way for doctors to deny dilemmas these days is for them to quote scientific evidence in a way that implies that it abolishes any possibility of a dilemma (‘Studies show that these pills will lower your chances of a heart attack’). In fact, this habit is usually lazy, ignorant or disingenuous. The more we acquire evidence, the more we should actually become aware of alternative options, and therefore of the need to offer complex choices to patients. (‘If you do ‘x’, these are the likely consequences. If you do ‘y’, these are the different consequences. Or you could do nothing and this is what might follow’) Contrary to what many doctors seem to believe, evidence-based medicine should lead us away from certainty, and closer to decisions that are based on patients’ preferences, values and intuition—just as they always were.
I spend a fair amount of time doing clinical supervision and as I listen to the anxious narratives that doctors bring about cases that are upsetting them, I find denied dilemmas popping up all over the place. Often, the doctors who present cases have understood their problems in terms of conflict, but not as dilemmas. Asking people to reframe their problems as dilemmas can have a quite instant effect, sometimes with a visible jolt, as clarity replaces muddle. (‘If I declare this patient unfit for work I’m not being honest. But if I refuse, I may lose his co-operation’) Often, such a reframing will lead to a resolution to hand the dilemma back fairly and squarely to where it belongs: with the patient.
From observation of doctors appearing in the mass media, it seems that members of our profession find it hard to admit that every medical issue has its dilemmas, however obvious the facts or the science may seem. The most solid of medical truths are embedded in provisionality, and ultimately we can never free ourselves from the dilemma posed by our lack of foreknowledge: ‘This is what we doctors believe at the moment, but we have made asses of ourselves in the past, and we may be making asses of ourselves again ... ’
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||