This piece was written in response to an article in the BMJ by the Oxford philosopher Julian Savulescu. I really didn’t like what he had to say at all. I thought his argument to be poorly constructed, and the position he reached (or perhaps started out from) to be repellent and dangerous. Here is a link to my rapid response to the BMJ, published on the 2nd of February 2006: Conscience is our Safeguard I don’t know why the formatting is so shoddy when you get there. It doesn’t make it any easier to read, so I have pasted it here for ease of reading. If it was due to my error in the original submission, then my apologies to the BMJ:
Tag: public services
Compass Bearings
A compass needle will point towards magnetic north, as long as there is not too much metal around, but typically when travelling we want to get to a geographic location, so it is geographic north that is the more useful reference in deciding our direction.
We often use the compass as a metaphor to evoke those bearings we use (or ignore) to varying degrees when deciding our values and actions. Individual politicians or business-people, for example, are occasionally criticised for their lack of “moral compass”.
Retiring from a post I have worked in for seventeen years has given me a new perspective on what I was doing and some of my strengths and weaknesses. This reflection is in its very early stages. I am two weeks retired and still disorientated by my sudden de-institutionalisation. I have decided to dig out that old compass.
And so it was, in conversation with a friend, that I found myself owning up to a relative lack of attention to what he and I came to call the “pragmatic compass”.
I have spent a fair bit of my time kicking against the pricks (a brilliant phrase that offers in its archaic imagery scope for serious irreverence). This has not achieved as much as I always hoped at the time. Early on, my optimism could have been put down to naivete but later, with greyer hair, one has to wonder at my lack of pragmatism. If I had a pragmatic compass I was not following it very closely.
Needless to say, I had some colleagues who were following theirs and, whilst they were doing so, I accumulated accolades for “standing up for people”. I am proud of that, of course, but I have wondered if I had the balance right and if I might have been able to achieve more if I had adjusted things a little.
My friend and I agreed that in the world – and perhaps especially in the workplace – we need to set our course somewhere between two bearings; those of the moral compass, on the one hand, and those of the pragmatic compass, on the other. If they coincide, then we are truly lucky. If on the other hand they point in opposite directions which, sometimes, they do – we have a particularly thorny problem to resolve. Sometimes, the pragmatic action is in the opposite direction to the moral one.
Anyway, this has got me musing on various situations in which “pragmatic north” and “moral north” diverge by differing angles and, in each case, which course I have chosen – or might in the future choose. I am not a great one for regret, but I think it is worth learning from experience.
The Sins of the Pathway
Systems change. A word that may be exactly right in one situation may not be appropriate in its new context. If this is not pointed out, then unhelpful associations may be imported and alter expectations or practice. This may not be in the interests of the proper running of the system.
The use of the word “pathway” is a good example. Some CAMH services have introduced “pathways” and these have replaced “teams” as the service unit in which treatment takes place. It should immediately be obvious that this might cause problems because the functions of a pathway and those of a team are very different. They are in different semantic categories, for a start.
During a Twitter discussion on outcomes in CAMHS a twitter-user asked a perfectly reasonable question. She wanted to gauge the level of agreement with the idea of specific “therapy pathways” for those who have suffered “childhood adversity”. I expanded on my disagreement in five tweets. The five-part argument, which focuses in turn on notions of Adversity, Therapy, Pathway, Control, and Development has a direct bearing on Therapeutic Attitude, so here it is.
Why do I argue AGAINST “specific ‘therapy’ pathways for those who have suffered childhood adversity”?
1) Adversity
Life traumatises, so all clinical services need to attend to trauma. All should be “therapeutic”.
Some adversities eclipse others and adversity is subjective, but no childhood is without adversity. I am not a Rebirther or a Primal Therapist, but I suspect that birth is itself profoundly traumatic. I have often thought that a number of things children experience around birth, and in the normal process of growing up, are likely to feel cruel and intrusive – nappy-changing, for example, or the denial of something important for what feels like an indefinite period of time. The context of these things can define them as abusive or not, abuse being socially defined. But the context can also undo (or compound) the inherent trauma. Negative experiences are explained, positively connoted and reframed, assuaged, and atoned for, through the miracle of “good enough” parenting. These parenting behaviours are the therapy that the fortunate child receives for their early childhood adversity. If the adversity is sufficiently ghastly, if the parents are not able to provide this normal level of lay therapy, or if the parents are themselves the source of the adversity, then professional intervention is likely to be necessary – possibly to remove the child from an ongoing trauma, or support the parents, educate or alter the environment, or, indeed, provide some form of circumscribed psychotherapy.
Clinical services, represent a deviation from health and can themselves be traumatic. Take, for example, the extraction of teeth. All of these clinically imposed traumas should come with a pre-packaged antidote to trauma. All clinical interventions need to be handled therapeutically. This does not only mean through the use of skill and aseptic technique to minimise the physical harm done, and anaesthesia to remove pain and memory, but also by contextualising the event and giving it a positive narrative significance. In Being With and Saying Goodbye I refer to this sort of thing as “between the lines”. What we do explicitly (on the lines, as it were) is important, but what we do to and with the patient, between the lines, is also important and needs to be part of the therapeutic venture.
So “childhood adversity” is a tautology. The presence of adversity in childhood is a question of degree, not one of dichotomous presence/absence. We need to have an expectation that adult interactions with the child contextualise the adversity and either buffer or heal the trauma. The intensity and duration of this interaction, and the set of skills brought to bear, will depend on the child’s need, and the adult’s position and capacity. As trauma is ubiquitous, clinical services need to be therapeutic.
2) Therapy
Here is my off-the-cuff definition of therapy. Therapy is the bringing professional skill and experience to bear on the matter of relating to people in order to help them back to a healthy trajectory
If “therapeutic” means helping to restore health then all clinical services should be therapeutic, and many of the things parents do are likely to be so as well. Most of this would not be “therapy”, though. The parent has skills and experience and they relate to their child, but that is not their job or professional expertise. It comes as part and parcel of being a parent to that child. If the skills and expertise amount to professionalism, then this person is not acting as a parent or a member of the public, but in their professional capacity. If, furthermore, they explicitly use the relationship in some way to achieve their aim which is to facilitate the restoration of a healthy developmental trajectory, then this is therapy, and they are being a therapist. It is primarily the relationship that is the tool. It requires skill and experience, and they are doing it as their job.
However, the timing and nature of therapy need to be sensitive to the needs of the individual, their capacity to tolerate various tensions, and the capacity of parents to tolerate supporting their child in therapy. The last notably involves tolerating not-knowing what is going on in the therapy.
So therapy may be something that takes place during a young person’s path through life, or through clinical services, but there should be no expectation that they begin therapy on entering a pathway and leave the pathway the moment they stop or drop out of therapy.
In other words, therapy and pathway should not be contingent upon one another.
More needs to be said about “pathway”, and that comes next…
3) Pathways
Predetermined service-delivery “pathways”, like the glass slipper or procrustean bed, risk the mutilation of people in order to fit them in.
The idea of clinical pathways has become common in the last few years. Some say that that this was on an ill-founded (in CAMHS) expectation that payment-by-results would shortly be introduced. My own cynical belief is that the popularity of “pathways” in clinical service delivery is due to their providing what Menzies-Lyth would call an “institutional defense” against anxiety. The shift away from clinician-patient relationship as the primary clinical entity, to the pathway, depersonalises the process and therefore makes it easier to discharge a patient from, or deny them access to, services.
It would be perfectly reasonable to observe that an individual undergoes a journey through the service. They enter the service and, hopefully, leave it. In between, they will encounter a range of clinicians and staff. They will disclose information of various kinds, and endure or enjoy a number of questions, tests, and treatments. These things could be set out on a time-line, and calling this a journey would seem fair enough. The words “path” and “pathway”, though, introduce an ambiguity. Someone’s path can be traced after the event and may turn out to be quite different from the path laid out on the ground and paved or marked with signposts. The latter is an intended route, but the path that a patient takes through services may not be the intended one at all.
This language reveals at least two arrogances. It is arrogant to think of the path that the patient takes through the services as being the only important one. Far more important are the paths that they take through their lives. We all have hopes for these paths. We hope for an absence of severe or enduring pain. We hope for company. We might hope for children. None of us sets out on our journey hoping that it will include a period of psychiatric treatment. Concentrating on the aesthetic of a predetermined clinical pathway is to neglect, relatively speaking, the more important path of the patient’s lived experience.
The second arrogance is to believe that the service can decide the pathway beforehand. Service design needs to have sufficient flexibility to adapt to each individual patient’s needs, values, and circumstances. You cannot constructively start therapy when it suits the service if the patient is not ready or if therapy is not what they want. The nature and timing of treatment in mental health services is co-constructed – or should be. If it isn’t, then it is not likely to be very therapeutic. Forcing someone into a pre-determined path, like forcing minced meat and breadcrumbs into a sausage machine, is anti-therapeutic, even if the path is called a “therapeutic path”.
4) Control
Life knocks us off our healthy developmental path. Services should give back to patients the agency to determine their path, using borrowed resources
Anything that knocks people off their healthy developmental arc (anything that is traumatic, for example) should be responded to with the aim of restoring agency, if not total autonomy, as soon as possible. Some people may manage to negotiate this without assistance, but many will require skilled support of some kind. This dependency should be temporary and partial. That is to say that the person should retain a significant degree of, if not full, control of decisions, and if they do hand over responsibility, this should be returned by the end and incrementally throughout, if possible. So the aim of clinical services, where someone has lost or suffered a set-back in their control, should be to restore to them, to the extent that is possible, the agency or access to agency that they have lost. This should be done actually, but also symbolically. We should not, therefore, even appear to predict or dictate their direction through services. We can make suggestions and recommendations. We can offer alternatives. In retrospect we can ask them about their pathway through the services and, in particular, if there was anything that we might have done to improve or detract from it. We cannot, and should not attempt or claim to, set it out in advance.
5) Development
Life = development and does not stop at 18. Therefore developmental ethos should continue through adult and elderly services
It may be true that childhood and adolescence are times of particularly acute developmental change, but the whole of life is developmental, and autonomy should lie with the individual as much as possible throughout.
Coda
This is not an argument against therapeutic expertise, but an argument for it. Nor is it an argument against the consolidation within a team of expertise in specific therapies. All teams and practices should be “therapeutic” but therapy teams within services are justified by the expertise that they preserve and concentrate. They can be used for specialised treatment, but they also inform the culture of services as a whole.
The retrospective study of patients’ paths through the services is justified if it leads to smoother transitions and greater responsiveness to needs and values of the patient. Pre-ordained pathways, on the other hand are not justifiable, whatever they are called, but calling them “therapy pathways” commits a whole bundle of sins.
Being With And Saying Goodbye – the book
It would be foolish for me to advertise, with shoddy writing, something that according to the generous endorsement it has received is written well. I could hardly do better than to quote from these endorsements:
‘Informed by a lifetime of experience in the author’s own field of child and adolescent psychiatry, the “therapeutic attitude” for which he argues has much to offer caring clinicians in every area of medicine.’
– Professor Bill Fulford, St Catherine’s College, Oxford
‘Anyone working in the field of child and adolescent health, education or social services will come away inspired and refreshed by Andrew’s candour, his ironic humour and superb writing.’
– Dr Sebastian Kraemer, Honorary Consultant, Tavistock Clinic
‘ This is a timely, important book because the attitude so beautifully described and illustrated is in danger of being squeezed out of us. Reading it will help you survive through difficult times whilst rekindling the hope that things could and should be done better.’
– Penelope Campling, medical psychotherapist and co-author of Intelligent Kindness: Reforming the Culture of Healthcare
‘This book inspires hope that we can recover a kind of professionalism that has been undermined by our current target-driven culture. Andrew West’s vision is compelling. A book that should be read by all those involved in commissioning services as well as by practitioners.’
– Sue Gerhardt, author of Why Love Matters
I can direct you to Karnac Books where you can get a better idea of this title and order it:
Click here to go to Karnac United States
Of course I would love it if you ordered it from your local “High Street” bookshop. Blackwell’s in Oxford have it in stock, for example, and at the time of updating (Sept 2018) Blackwell’s Online have it at a reduced price! Alternatively, you may want to by it online, using one of Ethical Consumer Magazine’s high-scoring sites.
Please take a look, read, comment, recommend…..
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