Doctors' Experiences of Work Related Moral Problems

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Doctors' Experiences of Work Related Moral Problems From the Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Stockholm, Sweden Doctors’ Experiences of Work Related Moral Problems: Responsibility without Clear Boundaries Reet Arnman Stockholm 2004 Author’s e-mail address: [email protected] Cover picture: Sigrid Naver. Cover design: Calle Thörn Published and printed by Karolinska University Press Box 200, SE-171 77 Stockholm, Sweden © Reet Arnman 2004 ISBN 91-7349-870-X 2 Abstract For as far back as the history of the medical profession can be traced, it has been assumed that doctors learn professional moral knowledge together with medical knowledge. From the sixties, internal professional morality has publicly changed to external morality, described with vocabulary and concepts, connected to philosophical branches. Although now incorporated in medical ethics teaching, it is not known how well they cover the problems of the clinical world. The main purpose of this thesis is to study doctors’ experiences of moral problems in their everyday working life. The most prominent schools of modern medical ethics with their assumptions regarding e.g. human nature and fact/value relations are also studied and their impact (by focusing on some issues and omitting others) on our public, shared ‘reality’ is described. According to a social constructionist approach (based on ideas from Alfred Schütz, Peter Berger and Thomas Luckmann) individuals perceive, interpret and act within a social life-world where things and events in every-day life have a self-evident meaning. Within a person’s life-world, moral life is a form of societal participation where experience is connected to moral concepts as loyalty, deception and (un-) fairness. To find a concept relevant one must have a standard (e.g. regarding social roles and other aspects of human life). Fourteen experienced doctors provide accounts of everyday work related moral problems. The interview analysis is carried out with a phenomenological method. A moral problem occurs in a situation when, according to the professional standard related to being a doctor, values – discussed in the thesis – are violated to such an extent that the doctors obtain an insight of an existing moral problem. What counts as relevant in each situation (what makes the context), depends on how the doctors experience features within social and institutional settings in relation to the assignment they have internalised as being theirs. For the interviewed doctors, morality is allied with the question: How shall I live my life as a responsible professional? The medical assignment with its inevitable risk of hurting fellow human beings, makes for the doctors, medicine and morality inseparably intertwined. Reflecting on the boundaries of the profession’s standard, is, for the doctors, different than working in concrete, practical situations where they often find themselves forced to take responsibility for political issues. Many of the doctors’ problems involve social and economic aspects and cannot be discussed merely from the framework of philosophically founded medical ethics’ theories. The doctors’ experienced problems are related to their comprehension of what kind of society, what kind of human relations, and what kind of health care we desire. In discussing these issues – negotiating about the contents of our value concepts – non- professionals’ experience as well as healthcare workers’ praxis-bound experience are necessary elements. Key words: Morality, doctors’ work related moral problems, responsibility, social constructionism, social life world, fact/values, standard, context 3 CONTENTS PREFACE 8 THE AIMS AND THE MAIN STRUCTURE OF THE BOOK 11 Aims 11 The main structure 11 CHAPTER ONE 14 THE BIRTH OF THE MEDICAL ETHICISTS 14 1.1 Outline of the chapter 14 1.2 Introduction 14 1.3 A glance back in time: philosophy and the printed word working together 15 1.4 How ethics became public and seemed to be simple 16 1.5 Should we all commit ourselves to an ethical theory? 17 1.6 Why ‘applied ethics’ of that kind at that time? Different explanations 18 1.7 What followed the first applied ethics period? 19 1.8 Ethics in the health care sector, different discourses 20 1.8.1 The one-theory period 20 1.8.1.1 A way to write about abortion/the rights of the unborn: 21 1.8.1.2 A way to try to discuss euthanasia (or doctors seem to be responsible for every death) 22 1.8.2 Around ‘Four Principles’ 22 1.8.3 The ethics of traditions 23 1.8.3.1 Ideas from Aristotle and from Continental philosophers into medical praxis 24 1.8.4 The situation-based ethics (The ethics in the personal meeting) 25 1.8.5 Ethics bound to gender (and perhaps, profession) 25 1.9 Clinical ethics (Three stories) 26 1.10 A reminder about the society outside health care 27 1.11 Two ways of writing about moral matters 27 4 1.12 My personal interpretation 29 1.12.1 About philosophies and philosophers or Four (of many) reasons to be humble 30 1.12.1.1 Time for thinking does not necessarily lead every philosopher to the same conclusion 30 1.12.1.2 Philosophers historically formed preunderstanding of morality 31 1.12.1.3 Readers historically formed preunderstanding of philosophers’ texts 31 1.12.1.4 Everything may not be understandable 32 1.12.2 Turning this writing back to medical ethics 32 1.12.2.1 Looking to the past in order to see the present more clearly 32 1.12.2.2 Philosophers teaching doctors, how do patients’ and other individuals’ values count (= a hint of chapter two)? 34 1.12.3 Coming next 35 1.13 Summary 36 CHAPTER TWO 37 FACTS AND VALUES 37 2.1 Outline of the chapter 37 2.2 Introduction 37 2.3 Different philosophical views regarding how facts relate to values 39 2.3.1 A value-loaded world 41 2.3.2 About ethical theories 42 2.3.2.1 Universal acclaim 42 2.3.2.2 Non-universal acclaim (?) 46 2.3.3 About medical ethical principles 49 2.3.3.1 The Four School-Ethical Principles 50 2.3.4 How do we decide what is moral? 52 2.3.5 The Open-Texture of Moral Concepts 52 2.3.5.1 What counts as creating a moral problem (a social constructionist approach) 54 2.3.5.2 The social construction of patients’ and doctors’ premedical moral world 57 2.4 Laypeople 57 2.4.1 From ordinary life (before becoming a Patient) 58 2.4.1.1 Today the public moral debate is too narrow for laymen 61 2.5 Law influences both patients and doctors (and is sometimes seen as far away from morality) 62 2.5.1 Family with veto rights, but hardly any others 63 2.5.2 Law and moral 64 2.6 Other Cultures and religion (Neither the law, nor principles take problems away) 64 2.7 Getting outside the fight regarding the right to define the world 65 2.7.1 In real life, things count far back and social context counts 66 2.8 Summary 67 5 CHAPTER THREE 68 METHODOLOGICAL CONSIDERATIONS AND STUDY DESIGN 68 3.1. Outline of the chapter 68 3.2. Introduction 68 3.2.1 Life-world 69 3.3 About different research approaches 71 3.3.1 More in detail about the phenomenological approach/method 75 3.3.1.1 Giorgi’s variant of the phenomenological method 75 3.4 Obtaining empirical material in the study 78 3.5 Reflections on the study and my position 80 3.6 Summary 83 CHAPTER FOUR 84 MORAL PROBLEMS AS PERCEIVED BY EXPERIENCED DOCTORS 84 4.1 Outline of the chapter 84 4.2 Introduction 84 4.3 The structure of the phenomenon moral problems for doctors 85 4.3.1 Values governing the perception of moral problems 88 4.3.1.1 Working with the inevitable risk of hurting instead of helping 91 4.3.1.2 Moral problems emerging from being a responsible professional 92 4.3.1.3 Moral problems concerning co-creatorship of a unwanted future 93 4.3.1.4 Violating democratic values 93 4.3.1.5 Treating fellow human beings poorly 95 4.3.2 The doctors’ Standard 95 4.3.2.1 Influence from contemporary society 96 4.3.2.2 Personal value ground 96 4.3.2.3 Internal, internalised standards (from the doctors’ life-world) 97 4.3.2.4 The doctors’ lack of help from rules 99 4.3.3 Circumstances, which appear to be morally significant: Context 101 4.3.3.1 Problems around the medical assignment 102 4.3.3.2 The family, fellow human beings in crisis and parts of problems 105 4.3.3.3 Following the law does not banish moral problems 106 4.3.3.4 Problems around professional co-operation 107 4.3.3.5 Comments on context 107 4.4 How do the doctors deal with their problems? 108 4.5 Summary 109 6 CHAPTER FIVE 110 CONTEXTUALISED PROBLEMS, TRANSFORMED TO MORAL PROBLEMS BY INTERNALISED VALUES AND DOCTORS’ STANDARDS 110 5.1 Outline of the chapter 110 5.2. A value-loaded assignment 110 5.2.1 The purpose of the study is to high light a few doctors’ experience 112 5.3 Clinical morality in the light of medical ethics 113 5.3.1 Loss of knowledge 114 5.3.1.1 Not discovering social problems 114 5.3.1.2 Not counting on clinical uncertainty 115 5.3.1.3 Lack of focus on everyday medical problems 115 5.3.2 Production of knowledge 115 5.3.2.1 The Patient as a whole person with the right to autonomy 116 5.3.2.2 Back to the sixties 118 5.3.2.3 The Natural Scientific physician 119 5.4 Other research, coming from outside, discovering the praxis-bound moral world 121 5.5 How to move forwards practically 122 5.5.1 The role and the boundaries for school medicine and doctors’ assignments 122 5.5.2 A broader discussion with more participants 124 5.5.3 The possibility of bringing up more issues in democratic discussions 126 5.5.4 Back to the sixties once more, and the fifties and the forties… 127 5.6 Conclusion 127 GLOSSARY 129 LIST OF PERSONS 132 FIGURES 134 ACKNOWLEDGEMENTS 137 REFERENCES 138 7 PREFACE Towards the end of the sixties I had my first summer job as a doctor in a Swedish rural district.
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