Ten years ago, in Being With and Saying Goodbye, I described the term Medically Unexplained Symptoms as “grandiose on the part of medicine because it implies that medicine should be able to explain everything, and anything it cannot explain falls somehow into a special category.” I went on to suggest that this is a stigmatised category which includes the idea of placebo, for similar reasons. Medicine is encouraged in its belief that it can explain everything, and it doesn’t very much like things that undermine this believe.
When, some decades ago, I trained in medicine and psychiatry, Miranda Fricker had not yet coined the term “epistemic injustice” and the concept – the process – was not thought about. As with racial blindness, I suppose, the perpetrators of the injustice do not notice what they are doing. The phrase is a commonly used one now, and I think it is a useful one, even if the choice of words is itself a little exclusive.
We were, though, exposed to some of the ideas of Karl Jaspers. He believed that the patient’s subjective experience was key to understanding and treating their condition. I don’t think that phenomenology limits us to an interest in subjective experience but the rise of phenomenology in psychiatry coincided, broadly speaking, with a rise in the importance of subjective experience. So far, so good. But then this idea that medicine can understand, know, and explain everything gets in the way.
Clinical empathy is a highly regarded concept in medicine and related disciplines. The concept is variously described and used. It might mean the ability to understand and communicate a patient’s experience, or the act of correctly acknowledging the emotional state of another.
Note the different language and its implications.
How does this sit alongside the idea of epistemic injustice? Between finding words to describe someone else’s experience and helping them to find their own words, there is a chasm masquerading as a thin line. The idea that I can know someone else’s experience is a form of arrogance, and a misunderstanding of subjectivity. Perhaps it is a small step for medicine which expects itself to know everything about the workings of a human, to believe that it can – and should – know their experience.
If we step away from the jargon and think of common language we will recognise how common it is for people – particularly when they are striving to help someone – to say, “I know how you feel.”
The truth of the matter is that I don’t know, but I am trying. I am listening with all my faculties, and as best I can. I hope I am getting the gist. I may be wrong, but… And is this helping?
And, broadening it out again to clinical humility, let us continue to have clinical supervision, even when we have reached exalted status in our professions. And not just in psychiatry. “Supervisor” is not a comfortable word. It smacks of bureaucracy, infantilising, lack of autonomy. But let’s emphasise the special nature of Clinical Supervision, overcome the desire to be the top monkey, and acknowledge that we don’t always know and that we, ourselves, may need help in our attempts to help someone else.
For the time being, at least, this is what I mean by clinical humility.
Therapeutic Attitude 
Julian Savulescu’s piece on conscientious objection demands, and will no doubt receive, critical discussion. My initial reaction was to respond ironically, presuming that he wrote the piece tongue-in-cheek. However, I am not practised at irony. Saying one thing and meaning another has always seemed too much like lying, and my conscience (sic) has tended to prevent me from being ironic with the conviction that is needed to bring it off. The other problem, which a colleague raised, was that Savulescu may have been writing with sincerity, and that to respond with irony might be disrespectful. I have therefore decided to respond as though he meant what he said.
He is right that individual values can get in the way of ethical health care. He is catastrophically wrong in jumping to the conclusion that doctors should eliminate their own values from their practice. He might just as well argue that, as there can sometimes be problems with policies, we should ignore them all. It was this startling lack of philosophical and ethical sophistication in his writing that caused me to presume that he was being ironic.
The paper opens with a quote from Shakespeare’s Richard III. Savulescu chooses to cite the values of a king who was known for his ruthless dishonesty (arguably almost devoid of conscience) , who put the Princes in the Tower, and whose subjects were ultimately too ashamed to fight for him at the Battle of Bosworth. In doing so, Savulescu has inadvertently put the case for the importance of conscience as an essential element of respectful and trusting relationships. He attributes the words to Shakespeare rather than his character, thus giving them greater weight. The Bard was probably himself writing ironically. Conscience, for Shakespeare’s Richard III was, after all, mostly guilt in the shape of the ghosts of his past victims. He could not go to war with a good conscience, so he had to ignore it. Finally, Savulescu, in what may be a Freudian slip, directs us in error to Scene iv, in which Richard, the “bloody dog” , gets the gruesome end that he deserves. This is an admonition and warning to those who would eschew the importance of conscience. Savulescu appears to take it as the opposite.
Next we are introduced to the concept of conscience invoked to avoid duty. I would call this idea oxymoronic: One cannot knowingly, by definition, use conscience for an ulterior end, although one could pretend to, in which case avoidance of duty is the value to which one’s conscience is urging adherence. I hope that Savulescu is not suggesting that avoidance of duty is an important value for doctors.
It is impossible to be impressed with the moral or philosophical weight of Savulescu’s argument when he uses absolutes ( “always” appears in two consecutive sentences) and value-laden phrases ( “Their values crept in…”, and “..has been squarely overturned…”) with reckless abandon. He refers to duty without saying to whom the duty is owed, and introduces “true” and “grave” duties without definition. He speaks of action in the public interest without alluding to the inevitable conflict between individual and public interest that pervades any debate about state provision of health services. Even his use of the word “paternalism” implies that it is a negative, when in ethical discourse it is a value of
central importance to be weighed against autonomy – each having their role to play in differing proportions. He reduces complexity to a series of right / wrong dichotomies, and claims that a position that is morally defensible when adopted by a few becomes indefensible when adopted by a larger number. He conflates distinct concepts (for example conscience with values with religious belief with adherence to a school of religious thought). He seems to believe that acting according to one’s conscience is the same as “making moral decisions on behalf of patients”. This is not a good example of reasoned argument!
By his exclusive use of the termination of pregnancy as the medical paradigm, he exposes his starting point, but he doesn’t begin to discuss even this narrow area with balance. I would agree that a doctor who objects to abortion might choose to work in another area of medicine, but he fails to acknowledge that a woman who has a conscientious objection to abortion may have a right to treatment by a gynaecologist who does not perform the operation. He totally ignores other branches of medicine, such as general practice, geriatrics, psychiatry.
Savulescu suggests that doctors should simply carry out instructions and that the full range of a doctor’s duties can be set out at medical school for the student to take or leave. I can only infer that he left clinical medicine at a relatively junior stage. Medicine must, by its nature, be an evolving profession, responding to an evolving world The doctor’s commitment must therefore be constantly renewed.
It seems that, in Savulescu’s utopian vision of the world, medicine is neither an art, nor has it anything to do with a relationship between individuals; our scientific and moral knowledge is comprehensive and incontrovertible; last year’s scientific theories were held in good faith but were wrong, whilst this year’s are correct, and so faith doesn’t come into the equation. He seems to be advocating blind adherence to the current dominant values and he does not consider the risk of institutionalised abuse of medicine. He implies that though this happened in Hitler’s Germany and in the USSR, we have learned that lesson once and for all. He seems to have forgotten that the values of individual clinicians may be the only real safeguard against that horror.
There is a place for the maverick and the iconoclast in ethical discourse and I welcome the provocation of this debate, but Savulescu has given us no clue, other than the outrageous nature of his argument, that he may be acting as “devil’s advocate”. He appears. therefore, to bring the weight of philosophy, Oxford University, and medical ethics with him. What worries me more than Savulescu’s views, therefore, is the fact that the BMJ has published them without qualification, disclaimer, or balancing argument. The danger of publishing this extreme view on its own and provoking uncontrolled debate is that the (hopefully) inevitable howl of protest may be read by some as the squealing of doctors as we are brought further to heel.
I must conclude, therefore, by readily accepting that individual values can result in unethical practice. The risk, though, is best minimised by teamwork, continuous professional development, appraisal, and supervision. Personal integrity underpins the doctor-patient relationship. The values of the individual doctor are our safeguard against the institutionalised abuse of medicine.
Competing interests:
None declared
cite as BMJ 2006;332:294