A Flourishing Practice?

Front matter

RC Royal College of GP General Practitioners

Practice?

Paterson

Contents

Forewords

This book is the third in a series of texts that began with Peter Toon’s Occasional Paper What is Good General Practice? back in 1994. Over two decades this series has documented Peter’s sustained intellectual contribution to the discipline of general practice, refracting his front-line experience of both seeing patients and teaching young doctors through the lens of his fascination with philosophy in general and ethics in particular. The inspiration for his continuing meditation has been After Virtue, a book by the Scottish philosopher Alasdair MacIntyre that was first published in 1981 and which is now in its third edition. All those who, like me, have found wisdom and encouragement in Peter Toon’s writing need perhaps to echo his own acknowledgement of Prof. Len Doyal, who first advised him to read MacIntyre. If only all such suggestions bore such abundant fruit.

The philosopher Richard Rorty described After Virtue as offering ‘a diagnosis of the present state of moral philosophy which expands into a diagnosis of the present state of modern society’. Peter Toon’s achievement has been to extend that diagnosis to the state of contemporary medical practice. He has expanded MacIntyre’s description of the fragmentation of morality as a consequence of the Enlightenment and has created the marvellously rich metaphor of a shipwreck with all of us clinging to different fragments of moral theory that contradict each other, leaving us all in a state of increasing moral confusion. He then extends this metaphor to claim that ‘people need sight of a lifeboat before they can abandon the philosophical flotsam to which they are clinging’. He offers a lifeboat kit founded on an ethics of virtue and applied to contemporary medical practice with an emphasis on the importance of internal goods for both patients and clinicians. Policy initiatives have been focused to a profoundly destructive extent on the external goods of money and power, and Peter Toon argues persuasively for a reassertion of the internal goods that constitute that sense of individual flourishing that is derived from the practice itself. He tests his arguments against the challenges of the Francis Report and offers us all as patients, clinicians and citizens a way of thinking and acting. He offers us a moral lifeboat.

Introduction

There is a constant stream of articles in the medical and the general press pointing out some moral problem or other with health care. Whilst preparing this paper I collected a thick file of these, a small proportion of which will be quoted in later chapters. I labelled the file half-seriously ‘O tempora, O mores!’ Common themes within the genre include threats to continuity of care, inappropriate care at the end of life, problems associated with commercialisation and privatisation of health care, defensiveness and risk aversion, and unrealistic expectations of care.

The cry ‘O tempora, O mores’ of course goes back more than 2000 years,’ and is part of the human condition. As they get older every generation believes the country is going to the dogs. Are the articles in my file just the standard response of an older generation to things not being what they used to be, or do they reflect genuine problems in health care?

In fact by no means were all these articles written by older people, nor were they just written by doctors and other health professionals — a wide variety of lay people seemed to have similar feelings. And perhaps in the end to make the case that health care faces a moral crisis only one reference is necessary — the Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust: January 2005—March 2009, the Francis Report.’

The view that health care is facing a moral crisis, in general or in specific ways, is often seen in terms of professionalism. A report on this subject from the Royal College of Physicians afew years ago suggested that in society in general ‘the ideals we equate with professionalism are in decline’. This report and other analyses of the state of medical care*® suggest a number of factors that are contributing to this decline. Some are specific to medicine, such as changes in working practices leading to loss of continuity of care, diminution of personal responsibility, loss of medical team structure and leadership by example, and an NHS ‘blame culture’. Factors affecting society more widely include rising consumerism, risk aversion and a decline in stability and continuity of relationships and the trust that this builds.

The influential virtue ethicist Alasdair MacIntyre however thinks that the problem lies deeper than this. In his influential book After Virtue’ he suggested that our society has experienced a fundamental breakdown in the framework of our moral understanding, and that this is the underlying cause of the moral problems and uncertainties we face and which he argues affect all areas of our life, not just health care. MacIntyre believes that to resolve this problem our society needs a shared narrative, a shared tradition, and a shared world view. He suggests that shared social activities with traditions, which he calls ‘practices’, are a central support for these. One of MacIntyre’s ‘practices’ is health care, or to be more precise medicine.’ (I will consider the relationship between medicine and health care from MacIntyre’s perspective in Chapter 2; for the present they can be seen as synonymous.)

The aim of this book is to try to see whether MacIntyre’s analysis of our situation and his suggested solutions can in fact be applied to health care, and whether they might help resolve these problems in professionalism and the pervading sense of moral crisis.

MacIntyre, virtue and ethics

After Virtue is part of a renaissance of virtue ethics within philosophy in the late twentieth century. From classical Greece to the Renaissance, moral philosophy centred on the question ‘What is the good life, and what do we need to do to live it?’ Plato and Aristotle, but also the Stoics and Epicureans, devoted much of their attention to this question, as did the writers of late antiquity and medieval philosophy. For most of them the answer was phrased in terms of virtue — the personal qualities that we need to live well. Thomas Aquinas considered virtue to be a habit or disposition to act rightly. Although virtues are guided by reason, they are not merely a matter of the intellect — they involve emotions and motivation as well.

Moral philosophy conceived in these terms centres on eudaemonia. Flourishing is my preferred translation of this Greek word used by Aristotle and other philosophers when pondering the purpose of life. Eudaemonia is a key concept in virtue ethics, which is teleological — it argues that life has a purpose, it is a narrative with a meaning, and the purpose of moral philosophy is to work out the best shape of that narrative for each one of us. It is sometimes translated almost literally as the good life (the most literal translation is ‘good spirited’) and also as happiness. I prefer flourishing because it implies a life story that not only has a purpose but also a shape — periods of growth and development, full maturity but also decay and ultimately death. The word is commonly used of plants — flourishing like the green bay tree.

This teleological view contrasts with the view taken by consequentialism, one of the dominant ethical approaches in health care today, that life is a meaningless succession of good and bad experiences; and morality consists of trying to maximise the good and minimise the bad. Eudaemonia doesn’t imply a life of uninterrupted fun, which would be neither realistic nor, probably in the long term, enjoyable — think of the soma-induced pleasures of Huxley’s Brave New World.’ A bland life of meaningless pleasure is not really a life worth living.

Aristotle and Aquinas, two of the greatest virtue ethicists, argued that we need virtues to achieve eudaemonia, to flourish. A virtue is a personal characteristic,

Introduction | 3 a habit or disposition of the personality, a personal strength. Urmson’ suggests that excellence is a better translation than virtue of the Greek word arete that Aristotle uses — not least because Aristotle discusses desirable intellectual as well as moral qualities. More recently Nussbaum and Sen” suggested that virtues are the qualities we need to overcome the challenges life throws at us.

But the virtues are also personal qualities worth having in themselves — the cultivation of the virtues is also part of the purpose of a good life. This is an important feature of virtue ethics, that being virtuous — having the habit of acting rightly, according to reason — not only enables us to do the right thing for others, but is also the best way for us to live too. It isa win-win approach; it’s good news for everybody. This contrasts with rights and duties based on or not on deontological morality, the other ethical approach commonly used in health care, which is a zero-sum game — the more rights the patient has, the more burdensome duties the clinician has.

Virtue ethics is also more holistic than deontology or consequentialism. Unlike the Kantian dutiful person or consequentialist who considers the right thing to do according to duty or consequences then grits his teeth and does it, the virtuous person does what is right because it is in her nature to do so; she cannot do otherwise. Her emotions and indeed her whole being — body and mind — are directed towards doing what is right, so that it is ‘second nature’ and can be done almost unconsciously, just as an athlete‘s body and mind are trained and totally directed towards running a race. That of course doesn’t mean the virtuous person doesn’t think about right and wrong; phronesis, practical wisdom, is one of the cardinal virtues. But virtue ethics recognises that we are not just thinking machines, weighing up consequences or deciding what duty requires, but people with emotions that colour our experiences and motivate our actions; and that our bodies affect our feelings and thinking, too. In his comic novel Three Men in a Boat " Jerome K. Jerome remarked that a full stomach made him feel beneficent and at peace with the world; the Scottish Jesuit Gerry Hughes reported rather more seriously how tiredness and sore feet affected his response to people he met on his walk to Rome.”

Aristotle suggested that often a virtue lies between two opposite vices — the golden mean —- thus for example courage is between cowardliness and foolhardiness.'* Although in general this is a bit simplistic, we will find that this idea of moderation recurs throughout our discussion.

MacIntyre begins After Virtue with an account of the moral confusion we currently face and how it has arisen. In Chapter 1 I will look at some of the current problems facing health care (the things discussed in those ‘O tempora, O mores’ articles) to see whether they can be understood in the light of this account. This analysis suggests that MacIntyre’s general critique of our moral framework does seem applicable to the problems health care currently faces.

In Chapter 2 I move on to attempt an account of health care as a MacIntyrean practice, particularly exploring the impact of this understanding of health care on the roles that patients and health professionals play in this practice. Here immediately we will find that MacIntyre’s thesis leads to an approach to partnership between clinicians and patients no less real but somewhat different from that currently being promoted on a consumerist model. This discussion also involves thinking about the difference between an ethic with rights and duties at its heart and an ethic of virtue.

In Chapter 3 I will consider the internal goods of the practice of medicine. In part this will build on the consideration of the three aspects of general practice that I discussed in my first RCGP Occasional Paper." It will also however involve consideration of the differences between a virtue ethic founded on developing a narrative of flourishing and a consequentialist ethic based on maximising the pleasure of a formless life. This has significant implications for the balance between the three elements of general practice. The interpretative function, often thought of as the ‘extra’ in medicine, in fact should be the centre of our practice. With this in mind, in Chapter 4 I will consider the boundaries of illness in relation to specific conditions. This reveals more ways in which health care is affected by a fragmented and confused moral discourse, and suggests some ways in which seeing the purpose of health care as developing a narrative of flourishing for individual patients may affect diagnosis and treatment.

In Chapter 5 I will explore the concept of professionalism and professional flourishing, and how this links to MacIntyrean concepts of internal goods and virtues. Chapter 6 deals with some of these virtues, particularly compassion, one of the key virtues that the professional in the practice of health care requires, and explores how they might contribute to flourishing. This understanding of professionalism is one of the key elements in considering the implications of a MacIntyrean position for the institutions that support the practice of medicine, including physical institutions providing health care, educational structures, continuing education and revalidation, which will be discussed in Chapter 7. Chapter 8 concludes the work with some brief suggestions on how we might start to move nearer to a vision of health care as a flourishing practice. This is more of an agenda than a prescription. This will include an analysis of the many limitations of the current work.

Few of the criticisms in this work of health care as it is currently practised or the visions of how things might be different are original; almost every week I find an article in the British Medical Journal, the British Journal of General Practice or the general media that makes one of the points found here. What I have tried to do in this work is to link these critiques and visions, fragments of the tradition of which MacIntyre speaks, within a coherent framework with a sound meta-ethical basis.

This is not a textbook of primary care ethics or a personal view of how health care should be organised; nor is it an evidence-based review of the current state of health care in the UK. Rather it is an attempt to use the philosophical approach

Introduction! 5 of rational argument and the exploration of concepts and their implications to see whether MacIntyre’s ideas might prove useful in addressing some of the problems facing health care today. It primarily deals with values rather than with facts, although these are so intertwined in health care that it is impossible not to take some view of what the facts are.

It takes important concepts one by one and explores them to see whether MacIntyre’s perspective makes sense, and attempts to understand the implications of looking at the world of health care in that way. Also, like many philosophical works, it uses ‘thought experiments’ (‘devices of the imagination used to investigate the nature of things’) to try to imagine what health care would look like if MacIntyre’s hypotheses were correct.

MacIntyre was pessimistic about the chances of piecing together a shared moral tradition from the fragments; he limits his claim for After Virtue to being a ‘partial solution’ to the problems we face.'® Although this work too is at best a partial solution to the problems health care faces, I am less pessimistic than he is about the state of practices, certainly about the practice of health care. Much in health care in the UK today accords with his vision of a flourishing practice, although it is definitely threatened by the moral fragmentation he describes. Because it seems to me that a MacIntyrean approach can bring together many of the concerns commonly voiced about the way health care has been heading, it is worth giving some attention to how his ideas might work out in practice.

l.

Cicero MT. First Cataline Oration. 63 Bc. www.thelatinlibrary.com/cicero/catl.shtml [accessed 16 January 2014].

Francis R. Independent Inquiry into Care Provided by Mid Staffordshire NHS Foundation Trust: January 2005-March 2009. Volume I. London: The Stationery Office, 2013, http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/ dh_113447.pdf [accessed 16 January 2014].

Royal College of Physicians. Doctors in Society: medical professionalism in a changing world. Report of a working party. London: RCP, 2005, www.rcplondon.ac.uk/sites/default/files/ documents/doctors_in_society_reportweb.pdf [accessed 16 January 2014].

Rosen R, Dewar S. On Being a Doctor: redefining medical professionalism for better patient care. London: King’s Fund, 2004, www.kingsfund.org.uk/publications/on_being_a.html accessed [accessed 16 January 2014].

Levenson R, Dewar S, Shepherd S. Understanding Doctors: harnessing professionalism. London: King’s Fund, 2008, www.kingsfund.org.uk/sites/files/kf£/ Understanding- Doctors-Harnessing-professionalism-Ros-Levenson-Steve-Dewar-Susan-Shepherd- Kings-Fund-May-2008_0.pdf [accessed 16 January 2014].

MacIntyre A. After Virtue (2nd edn). London: Duckworth, 1985. MacIntyre. After Virtue, p. 194.

Huxley A. Brave New World. London: Chatto & Windus, 1950. Urmson JO. Aristotle’s Ethics. Oxford: Blackwell, 1988.

Nussbaum M, Sen A. The Quality of Life. Oxford: Clarendon, 1993.

. Jerome JK. Three Men in a Boat. 1889. www.gutenberg.org/ebooks/308 [accessed

16 January 2014].

Aristotle. The Ethics of Aristotle: the Nicomachean ethics (trans. JAK Thomson). Harmsworth: Penguin, 1955, Book II.

Toon PD. What is Good General Practice? (Occasional Paper 65). London: RCGP, 1994.

Brown JR, Fehige Y. Thought experiments. In EN Zalta (ed.), The Stanford Encyclopedia of Philosophy (fall 2011 edn). http://plato.stanford.edu/archives/fall2011/entries/thoughtexperiment [accessed 16 January 2014].

MacIntyre. After Virtue, p. 201.

Chapter 1 MacIntyre’s fragmented moral universe and its impact on health care

Conceptual fragmentation

In the first chapter of After Virtue! Alasdair MacIntyre imagines an Orwellian future in which there is a Luddite reaction against natural science; laboratories are smashed and the culture of scientific discourse is destroyed. Some time later people try to recreate scientific knowledge, but all they possess are fragments, without any real understanding of the nature and purpose of science. So:

adults argue with each other about the respective merits of relativity theory, evolutionary theory and phlogiston theory, although they possess only a very partial knowledge of each. Children learn by heart the surviving portions of the periodic table and recite as incantations some of the theorems of Euclid. *

He goes on to suggest that our understanding of morality and the language we use about it is in a similar state of disorder to that of science in his imaginary world. The destruction of tradition that he argues was a consequence of the Enlightenment has broken up the moral framework in which we live, as the wreck of a ship breaks up its hull. We are left with fragments, pieces of theory and their implications, which hold together in themselves but that are not connected to each other. We are clinging to this wreckage, but without the underlying consensus of a shared tradition there is nothing to hold the fragments together. This, he argues, is why many of our ethical discussions cannot be resolved; they are conducted between people clinging to separate bits of the moral wreckage, shouting at one another across a sea of chaos.

The debate on abortion illustrates this. Some believe that the fetus is a person just as much as any adult is. Like an adult it has a ‘right to life’, and any action that interferes with that right counts as murder.’ Others argue that a woman has a ‘right to choose” whether or not to go on with a pregnancy she does not want and has tried hard to prevent.’ Yet others believe that a decision on an unwanted pregnancy should depend on the likely outcomes of going on with the pregnancy or terminating it; sometimes abortion offers the best chance of happiness for the pregnant woman and/or her existing children, and so is best; at other times it does not. Each conclusion follows logically from its premises, but we lack a way to reconcile the differences between premises with conflicting outcomes; in philosophical jargon they are ‘incommensurable’.

To test whether this idea is helpful in understanding the moral problems that health care faces we must examine the conceptual frameworks within which we currently organise our values. If MacIntyre is right then we will find separate ‘fragments’ of the moral shipwreck that do not fit together. This does seem to be the case. Much of the discussion of values in health care today can be seen as taking place within the framework of ‘fragments’ of moral discourse, each of which makes sense separately but which are not coherently related. An outline of one possible analysis of value ‘fragments’ and how they are used in health care, with some examples of how these seem to be used incommensurably to address some aspects of medical practice, forms the rest of this chapter.

The deontological fragment

Since the Enlightenment, approaches to ethics based on rights and duties (deontological) or on the results of actions (consequentialist) have dominated moral philosophy, and so it is not surprising that they are major influences in thinking about values in medical practice. Ethicists see the two as alternatives and there is much discussion of the rival merits of each, but health care appears to use them both, but for different purposes.

Deontological ethical systems are based on rights and reciprocal duties. Thus the right to life imposes on others a duty not to kill. This is a ‘negative duty’ (a duty not to do something) and it is linked to a ‘liberty right’® — the freedom not to have harmful things done. There are also ‘claim’ rights, linked to ‘positive duties’. Thus, for the right of children to education’ to be meaningful, someone (parents, the local community or the state) must have a duty to provide that education; without someone with a positive duty to meet a claim, rights are just a rhetorical device, or as Bentham suggested ‘nonsense on stilts’.®

The language of rights has become increasingly popular in recent years, particularly in the UK since the inclusion of the European Convention on Human Rights in our law by the Human Rights Act 1998.’ The NHS constitution” is framed largely in terms of rights, most of which impose duties on health professionals or institutions that provide health care. Evans" suggested that health care might be more collaborative if there were more emphasis on patients’ duties; interestingly, the NHS constitution uses the weaker term ‘responsibilities’ when discussing what is expected of patients. (This may reflect the influence of consumerism, another ‘fragment’ discussed below.)

Discussions of professional standards in health care are usually conducted in terms of duties. In the UK for medical practitioners the General Medical Council’s (GMC) ‘Duties of a doctor’! is central. Other professional codes are

MaclIntyre’s fragmented moral universe | 9 similarly phrased.” Although the Nursing and Midwifery Council Code™ does not explicitly speak of duty, it mentions patient rights and uses a repeated ‘you must’ stem that is typical of deontological imperatives.

The language used in these statements has been criticised for lack of realism.” For some, duty is a gloomy word, the ‘Stern daughter of the voice of God’'® bringing to mind obligatory Sunday afternoon visits to boring aunts, sharing your chocolates with hated cousins and finishing your greens. We do our duty because we have to rather than because we want to. Indeed, some dour deontologists have suggested that an act only counts as good if you don’t really want to do it. Visiting a friend in hospital because you care for him and enjoy his company isn’t morally praiseworthy; it is acting according to duty but not from duty. This view is often attributed to Kant, although not all commentators accept this interpretation of his views.”

Certainly “Duties of a doctor’ can feel depressing. With so many demanding duties one may be excused for asking ‘Why bother?’ Someone with the natural gifts and educational achievements needed to practise medicine could surely have more fun and earn three times as much by being an accountant or a lawyer without taking on such onerous burdens?

Another criticism of deontological ethics is that the theory cannot resolve conflicts between the rights of different people, for example those of the mother and of the fetus in the rights-based approach to abortion discussed above. Duties may also conflict; for example, the duty of confidentiality may conflict with a duty of care for others, as with an epileptic who drives or a patient infected with human immunodeficiency virus (HIV) who will not tell his wife of his condition. There is the conflict between the duty of GPs in commissioning groups to obtain the best possible health care for the local population and the interpretation of the GMC’s duty of the doctor to ‘make the care of your patients your first concern’ as meaning the patient in the consulting room. This is one example that is currently often discussed of how deontological thinking can be problematic in health care.

The consequentialist fragment

Moral theories that focus on trying to maximise the good, rather than on rights and duties, are known as consequentialist because they judge the rightness of actions by their consequences. If deontology is the fragment of moral discourse to which the GMC and professional bodies are clinging, then public health and its input into health policy and resource allocation seem to be attached to consquentialism. Because this theory considers the total sum of good that an action produces, irrespective of who benefits from it, it seems the ideal way to look at the health of populations. In the UK, health policies," decisions by the National Institute for Health and Care Excellence (NICE) and the inclusion of activities in the GP Quality and Outcomes Framework (QOF) are often justified on grounds of ‘health gain’ — a consequentialist concept often measured in terms of QALYs — quality-adjusted life years.’

Although taken as axiomatic in these areas, consequentialism and QALYs are also widely criticised. It is suggested that QALYs further disadvantage the disadvantaged, because a life-extending intervention will add fewer QALYs to someone whose quality of life is already poor for some other reason than to someone otherwise in good health.” QALY-based analysis finds it hard to take account of individuality and different perceptions of the good. It has to assume that everyone shares the same consequentialist vision of the good. It also risks treating people as means rather than ends. If everyone with a high cholesterol takes a statin, we know how many heart attacks will be prevented in a population (assuming that the research data are valid and reliable) — but we have no means of knowing which individuals will avoid a heart attack, so a policy of promoting statin treatment for all at risk (such as the QOF) focuses on the good of the population as a whole rather than the choice of the individual.

Consequentialism cannot take account of the structure of an individual human narrative. In this view life is a series of episodes linked in an arbitrary manner; all that matters is the overall good of the episodes. When I was a child we used to play a game called ‘Consequences’ at Christmas. Pieces of paper were passed round, and each person added a line to a story, not knowing what went before or after. The resulting ‘narrative’ of who met whom, where, what they said and the consequence, was nonsensical, though often amusing. The consequentialist view of life is like this. The only sense that can be made of this meaningless tale is to maximise pleasurable episodes — to eat, drink and be merry.”

Because consequentialists emphasise the quantity of good in a life, rather than seeing it as a narrative with a purpose and shape, they have problems with its inevitable end in death. A philosophy that sees good as a longer and less painful life will naturally see death as something to be avoided for as long as possible. The postponement of death is of course doomed to failure (and often an expensive failure, as more and more resources are poured into resisting the inevitable) and society pays a high cost to support a long, slow decline by dementia and increased disability.*? Conversely, however, when the pain of life outweighs its pleasure and will always do so, death is to be welcomed and indeed assisted. Thus consequentialist arguments are often used to support making elective death more easily available when the balance of good and suffering in a life becomes irreversibly negative.”

Other value-laden fragments

The two fragments I have discussed so far are traditional approaches to ethics. The incommensurable criticism each makes of the weaknesses of the other, which I have tried to summarise above, are well rehearsed in the moral philosophy literature. The other four fragments in our moral universe that I want to suggest are helpful in understanding the current state of confused moral discourse in medicine — legalism, managerialism, capitalism and consumerism — are less obviously ethical. Indeed they are often thought of as value free, but each of them in fact contains implicit values. As so often in health care because the values in these fragments are rarely explicit they are easily overlooked, and seen either as self-evident truths or statements of fact rather than evaluations.

These fragments are not totally separate; there are strong links between them and perhaps some of them might be better considered as one fragment rather than two — for example, are capitalism and consumerism different fragments, or two aspects of one conceptual framework that emphasise different aspects of it? This may be an interesting question but from the point of view of the purpose of this chapter, which is to establish whether MacIntyre’s view that we live in a fragmented moral universe applies to health care, we only need to establish that such fragments exist and are incommensurable. It is not necessary to establish a definitive analysis of those fragments or the boundaries between them.

The legal fragment

If duty is the stern daughter of the voice of God, then the law is her even sterner granddaughter: a codification of rights and duties. The law takes suspicion as axiomatic, in a similar way that Descartes started from the premise that the only thing he could confidently believe was ‘I think’.* In the law nothing is taken on trust, nothing believed without evidence. The Anglo-Saxon legal system in the UK has at its heart an adversarial relationship, since both civil and legal cases are tried by the two opposing parties each presenting their case. Although legalism derives its values from the law taken to extremes, its effect on health care cannot be blamed on lawyers. Lawyers may be free from legalism whilst non-lawyers may be extremely legalistic.