I have just watched someone die. Just one person. But a whole ecosystem has been destroyed. Everyone’s roots wind round everyone else’s. Rip up one person, and everyone else is compromised, whether they know it or not. This is true, too, for everything that is done to anyone. Death just points up, unavoidably, what is always the case.
This is trite. But it finds little place in bioethical or medico-legal talk. There, a human is a discrete bio-economic unit, and there’s a convention that one can speak meaningfully about its elimination without real reference to other units.
In some medico-legal contexts this is perhaps inevitable. There have to be some limits on doctors’ liability. Hence some notion of the doctor-patient relationship is probably inescapable, and the notion requires an artificially atomistic model of a patient.
But ethics can and should do better.
On 25 March 2013 the General Medical Council published the latest version of Good Medical Practice. The preamble states that doctors should ‘make the care of your patient your first concern.’ Note the singular: ‘patient’. I don’t like that. Yet clause 1 provides: ‘Good doctors make the care of their patients their first concern.’ Perhaps the plural, ‘patients’, here, simply reflects the plural ‘doctors’. But I’d like to think that it reflects, however dimly, a recognition of interconnectedness.
That recognition is occasionally explicit – most obviously in the realm of resource allocation. Funds spent on X are funds not spent on Y. But the resource allocation situation is but one example of the general principle of the reciprocity which is at the heart of being human.
Here’s my suggested redraft for the next edition of Good Medical Practice: ‘As a doctor you must make the welfare of all your patients your first concern. You must recognise that welfare connotes much more than mere physical well-being, and that it is impossible to treat one patient without affecting an entire community. A good doctor will regard the nexus in which a patient exists as the primary focus of her clinical attention.’
I’m sure that you didn’t just «watch» someone die, Charles.
You are of course right that doctors (and others involved, too, let us not forget) should not consider the patient atomistically.
But I’d like to make a couple of points, if I may:
1. I think you’re being a little hard on the GMC. Looking at sections 17-21 of their guidelines for End Of Life Care, I see good, sensible and caring ethical advice.
2. If we look at doctor-patient relationships outwith death, there are, I believe, dangers in advising doctors to always consider the community of their patient as their first concern. I’m sure we can both think of lots of examples where even though the doctor should of course consider this nexus, his or her duty is clearly towards the patient, regardless of the views of, or even the consequences on, their immediate circle.
Anthony: many thanks.
Re 1: Yes, good, sensible, caring ethical, patient-o-centric advice. But there is, or should be, more to it than that.
Re 2: A duty solely to the patient? I doubt it. A duty primarily to the patient? Sure.
I think we substantially agree, Charles.
But what prompted my reply was your statement that ” a good doctor will regard the nexus in which a patient exists as the PRIMARY FOCUS of her clinical attention” (my bold type).
And thank you using a philosophy blog to talk about death, which is (strangely?) an unfashionable topic in philosophy – outside trolleys and other “thought experiments”.
I share Anthony’s appreciation of this post as well as, to some extent, his concern about the idea that the nexus in which a patient exists should be the primary focus of a doctor’s clinical attention. I prefer Charles’ later comment that the doctor’s duty should be primarily, but not solely, to the individual patient.
What I’m wondering, though, is what this might mean in practice. One point I very strongly agree with is the idea that “welfare connotes much more than mere physical well-being”. While this idea is gaining ground,, I agree that there is still insufficient emphasis,, both among doctors and in the wider community, on psychological health, and importance of relationships in that context. Another issue that receives insufficient attention is the role of ageing as a cause of illness and death.
A friend of mine recently lost her mother, so that’s another ecosystem that’s been ripped up. What I’m not sure, though, is how achievable or desirable it is, in the context of the global (and by that I primarily mean human) ecosystem, to engineer negligible senescence. What is clear though, is that if we want people to stop dying, we need to stop them ageing. And perhaps it CAN be done, as Aubrey de Grey suggests, with regenerative medicine. (To be more precise, we will still age, but we will also be able to periodically reverse that ageing, so that there is no net ageing over the complete cycle. Where by ageing I of course mean the processes of physical decay, not the things we like about ageing, such as increased wisdom and experience.)
Peter and Anthony: many thanks.
To make this ‘nexus’ approach workable you have to use a ‘transactional’ approach to the assessment of the interests of the various people in the nexus: see http://jme.bmj.com/content/early/2012/08/13/medethics-2012-100763.abstract for an outline. The patient’s interests will of course be weighted particularly heavily – hence one can say, rather sloppily, as I did in my answer to Anthony, that the ‘primary’ duty will be to the patient. But there will be times when, at first blush, it looks as if the patient’s interests are trumped by those of others: R v Brown is a non-medical example of precisely that happening. In fact nothing of the sort has happened. When that happens the patient’s interests are still being respected: just not in the way that she’d necessarily like. The jurisprudential tools for analysing these problems are well establshed: see the host of authorities encrusted around Article 8 of the ECHR.
Re the desirability of eliminating senescence: I’m with Ryuichi Ida and the Easterns. Try to skip out of the reach of the relentlessly turning cycle of death and decay, and we skip straighht into the path of life-denying neurosis.
“But a whole ecosystem has been destroyed.”
No, it’s just moved on. Death isn’t an intrusion, it’s just part of the ordinary passage of time. A good doctor knows that everyone dies.
Comments are closed.