Jan Fortune has just blogged on Why writers need to wait – indeed, not just writers but all artists. The virtue of waiting is not generally appreciated in our everyday worlds where anything that doesn’t arrive instantly runs the risk of being walked away from – or, more accurately, we run the risk of walking away from – and therefore losing – everything that does not come to us at the snap of the fingers.
This chimes so well with what I have said about therapeutic attitude that it might be considered an argument defining therapy as art but for the false dualism. Art and science are not a mutually exclusive dyad any more than body and mind. Each involves the other; And good scientific research also requires the capacity to wait.
I shall briefly recap on waiting in therapy as this is a blog on Therapeutic Attitude.
D. W. Winnicott, the ground-breaking paediatrician-turned-child-therapist probably best-known for the idea of the “good-enough mother” wrote of the “capacity in the therapist to contain the conflicts … and to wait for their resolution in the patient instead of anxiously looking around for a cure”. In doing so he was, whether he knew it or not, echoing the poet John Keats who wrote to his brother of his admiration for people who were “capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason”. (I suspect that Winnicott was perfectly aware of the connection because he also wrote elsewhere that, “if what I say has truth in it, this will already have been dealt with by the world’s poets”.)
This irritable reaching after cures and facts is something we see a great deal of at the moment. Perhaps it can come as some relief to know that it was also prevalent in Keats’ time.
Everything worth waiting for is worth the wait. Therapy and healing are creative processes, the instant therapy is a con and an addiction, your doctor is an artist as well as a scientist, and emergence is the key. We are living things, and development (of which healing is an example) is a living thing. We need to create the right conditions, be patient, and allow it to emerge.
- Winnicott, D. W. (1971). Therapeutic Consultations in Child Psychiatry (p2). London:
Hogarth & The Institute of Psycho-Analysis.
- Gittings, R. (1966). Selected Poems and Letters of John Keats (p40-41). Oxford: Heinemann Educational.
- Winnicott, D. W. (1986). Fear of breakdown. In: G. Kohon (Ed.). The British School of Psychoanalysis: The Independent Tradition (pp. 173–182). London: Free Association Books.
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.
cite as BMJ 2006;332:294