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GB Shaw

GB Shaw. ..a profession is a group of people who band together to hide their own shortcomings. Preface to The Doctor’s Dilemma. Illness as metaphor. Illness is the night-side of life, a more onerous citizenship…everyone holds dual citizenship

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GB Shaw

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  1. GB Shaw ..a profession is a group of people who band together to hide their own shortcomings.. Preface to The Doctor’s Dilemma

  2. Illness as metaphor • Illness is the night-side of life, a more onerous citizenship…everyone holds dual citizenship • Impossible to take up residence unprejudiced by the lurid metaphors with which it has been landscaped

  3. Upstream ethics • Towards an ethics of care, communication and competence • Emphasis on personhood in old age and dementia

  4. Competence Care Communication Reflective practice Law Ethics Societal Contract

  5. Code of practice • Philosophy • Habit • Aesthetic

  6. Why? • Special position of trust • Not like repairing a car • Can do lasting harm • Huge fiscal implications of practice

  7. What underpins? • Judaeo-Christian • Prejudices • Human failings

  8. Major ethical issues • Inadequate resource • Inadequate dignity and communication

  9. Strangers at the bedside • Lawyers • Some non-clinician ethicists Barriers I Non-prioritization by profession Media obsession with end-of-life/ hard issues

  10. Vulnerable groups • Tuskegee • Prescribing habits for poorer patients

  11. And every human heart that breaks, In prison-cell or yard, Is as that broken box that gave Its treasure to the Lord, And filled the unclean leper’s house With the scent of costliest nard. The Ballad of Reading Gaol

  12. Cloverhill Remand Prison 456 beds Wheatfield Prison Design capacity 320 Bed capacity 368

  13. Prisoners and health • Worse than general population • Older prisoners even worse Novick, 1997 Collins, 2006

  14. Trebling of older prisoners in UK 1990-2000

  15. Personhood, prisoners as patients • Doctors, medical students and prisoners

  16. Role model

  17. Role model 2

  18. A student in prison

  19. Students in UK • 47% placed in a situation where they had to act unethically • 61% observed a teacher acting unethically • 3 main types • Conflict between medical education and clinical care • Responsibility exceeding student’s capabilities • Involvement in care perceived to be substandard Hicks, BMJ, 2001

  20. Intimate examinations • A survey of students in one medical school found that intimate examinations had been done by second and third year students in situations that they found disconcerting • It also found that a quarter of examinations in anaesthetised or sedated patients seem not to have adequate consent from patients Coldicott, BMJ, 2003

  21. What students see.. • Communicative violations • (to or about patients or other health care professionals) • Role resistance • (individuals chafing against constraints or expectations of their perceived roles) • Objectification of patients • (ignoring patients or treating patients as vehicles for learning) • Accountability • (to colleagues or patients, including avoiding patients, failing to disclose information, or failing to treat appropriately) • Physical harm • (to patients or others) • Crossfire • (being put in the middle of a struggle between superiors) Ginsburg, Academic Medicine, 2002

  22. How they incorporate it… • Sense of witnessing (n = 34) • Knowing about (n = 4) • As opposed to self-reported (n = 10)

  23. Clinical clerkships USA • 58% reported having done something they believed was unethical • 52% reported having misled a patient • 80% reported at least one of these two behaviors • 98% had heard physicians refer derogatorily to patients

  24. 98% had heard physicians refer derogatorily to patients • 61% had witnessed what they believed to be unethical behavior by other medical team members • Of these students, 54% felt like accomplices Feudtner, Acad Med, 1994

  25. More likely to experience erosion of own ethical principles or act improperly • Evaluation fear • Fear of not fitting in

  26. Since, for the most part, students believe that they behave ethically, they are less likely to see the need for medical ethics education. So, unlike philosophy programme education, the first hurdle for professional schools ethics education is the establishment of its importance and its relevance R Rhodes, 2002

  27. ….(medical students) showed a levelling process of their moral reasoning. This finding prompts us to ask whether a hidden curriculum exists in the structure of medical education that inhibits rather than facilitates the development of moral reasoning. Patenaude, CMAJ, 2003

  28. No easy rule-based solutions... “Well, actually, they are written in stone”

  29. No easy algorithms...

  30. MedLine Ethics

  31. Talleyrand • Loyalty is a matter of timing • Ethical probity a matter of timing?

  32. The one that got away

  33. Prisoners in A/E • 20/20 assessed chained to prison officers • Including 65 year-old, 5’ 2” , acutely dyspnoeic after MI

  34. Upstream ethics • If we don’t get the every day discourse right…. • Small abuses lead to larger abuses

  35. Prisoners in A/E • Risk assessment • Liaison between hospital and prison • Secure facilities • Urgency prioritization

  36. Capital Punishment Disallowedactions include: • Starting intravenous lines for lethal injection drug • Determining death during execution • Administering the lethal drug • Supervising personnel who give the lethal drug

  37. Capital Punishment Disallowedactions include: • Ordering lethal drugs for the prison pharmacy • Maintaining or inspecting lethal injection devices • Monitoring vital signs during execution • Selecting injection sites for lethal drugs

  38. Physician Attitudes about Capital Punishment • 80% indicated that at least 1 of the disallowed actions was acceptable • 53% indicated that 5 or more were acceptable • 34% approved all 8 disallowed actions

  39. AMNCH Survey • 76 consultants and 139 NCHDs • 184 responded: 60% of the consultants and 100% of the JHDs

  40. 98% had treated prisoner patients at some stage in their career and 90% had done so in the last 2 years. • 60% felt uncomfortable whilst examining patients who were prisoners • 181 (98%) were unaware of any guidelines in place for the treatment of prisoner patients in general hospitals

  41. Breaches of confidentiality • 7% always • 88% sometimes • 3% never

  42. Asking prison officer to leave • 4% always • 65% sometimes • 31% never

  43. Inquiring as to risk • 14% always • 57% sometimes • 29% never

  44. Examining patient while restrained • 16% always • 67% sometimes • 17% never

  45. Balanced score-card • Self-evaluation and awareness accepted in medical profession • Need to develop structures and guidelines appropriate to professional practice with prisoners

  46. I never saw a man who looked With such a wistful eye Upon that little tent of blue Which prisoners call the sky The Ballad of Reading Gaol

  47. Reason..must approach nature [science] in order to be taught by it: but not in the character of a pupil who agrees to everything the master likes, but as an appointed judge who compels the witnesses to answer the questions he himself proposes Kant, A Critique of Pure Reason

  48. Scientism • ..science’s belief in itself: that is, the conviction that we can no longer understand science as one form of form of knowledge, but rather must identify knowledge with science Habermas, Knowledge and Human Inquiry

  49. Profession • Develop articulacy • Make case for adequate resource • Deal with prejudice • Self-critical • Strive for evidence base • Avoid artificial dichotolies

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