Archive for the ‘Medical Ethics’ Category

A New Philosophy of Disability





Do Not Shadow [DNS] provides patients a respectful environment

imageAs a university professor,  I actively promote effective teaching methodologies.   But a recent multi-month stroke recovery through various medical facilities, where physicians, nurses, and therapists would ask if I minded students “tagging along” during their rounds has given me pause. For the most part, I assented without hesitation. Hands-on teaching and training represent an efficient and effective transfer of medical knowledge between generations of medical practitioners. But . . . for the sake of patient privacy and personal respect, should persons with certain mental illnesses and brain injuries be placed on an automatic, paternalistic “Do not Shadow” [DNS] List as opposed to a default, informed consent alternative? For instance, maintaining personal hygiene is an integral component of medical practice, but repeated bathing and toileting for training purposes seems superfluous and can diminish an authoritative/professional relationship between observed and observer. This issue first surfaced when a former student of mine accompanied my OT shower. I did not mind her observing my other therapeutic activities, like playing chess or testing limits of my visual field, but the public bath left me later feeling vulnerable, exposed, and slightly embarrassed. I don’t blame the rehabilitation facility as they did request my general consent. What wasn’t caught was that I previously was a professor at the same school as this prospective intern. The specific academic connection would have been difficult for anyone to catch as the student no longer attended the same university.

Reasons against forming and conforming to a “Do Not Shadow” [DNS] list for training purposes are manifold:  Shouldn’t informed consent be sufficient for patient autonomy and enough to preserve privacy? What brain injuries would we leave on and off such a list? And is the latter unnecessarily burdensome and inefficient? Shall mentoring/teaching value or individualrights take priority? Or  respect ultimately a relatively trivial matter compared to excellent training and efficient care?

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The ‘Customer’-Physician Relationship

Medicine is subtly shifting from an emphasis on what is ideally best for the patient to an environment where hospitals are marketed from survey results and physicians are instructed on how to encourage customers to check the ‘Excellent’ box when rating their care. The danger in primarily viewing a patient as a consumer is that well known adages like ‘the customer knows best’ can gravitate toward motivations based primarily on the profit motive rather than the apparent benefits of collaboration, patient voice, and better service.

The philosopher Immanuel Kant reminds us to ask whether we are treating persons (customers) as a means to some end (profits) or as ends themselves (patients). When push comes to shove at medicine’s financial margins, decisions tend to lean toward monetary gain. Efficiency and profits are needed components of every venture (even Kant says not to use people as a means only but as a means as well as an end). Yet this move from taking care of patients to customers—while promoting friendlier hospital environments—may be damaging to the health care system in the long run.

The Hippocratic Oath has been condemned for promoting a ‘guild-like’ environment and its ancient author set aside in the hope of adopting the examples of other tightly managed industries (ironically, some business academics call for managers to take on the guild-like professionalism of the medical field). While some combination of treating patients as a means and as an end is probably acceptable, it seems that the customer/consumer metaphor is being adopted wholesale.

To Hippocrates, a physician’s first consideration was to use his/her art for the patient’s well-being—a re-emphasis that can benefit all stakeholders. Otherwise, this move to make the medical environment more patient-friendly has the potential to make it ultimately more vulnerable.

Written in conversation with Cory Wilson, M.D.