Role Enactment
More important than the morality of role acceptance is that of role enactment. In view of the fact that the medical role exists as a set of rights, duties, and values independently of who is acting in the role, the free action of doctors is to a great extent limited by the role.
We might put the point in other words by saying that the doctor is authorized by the collective values of the role to act only in certain ways. Or we might say that since doctors are representatives of their profession — they must act only in certain ways laid down by their collective. Their individual moral decisions will therefore be causally affected by the collective values of the medical tradition. More importantly, however, there is increasing insistence by professional bodies on treatment guidelines, protocols, and algorithms. These are thought to express the collective wisdom of the profession on the best management of patient care.Consider the following extract from a book concerned, among other matters, with the way in which we are increasingly organized into networks so that each person is only a small step in a huge network of algorithms, and it is the algorithm as a whole that makes the important decisions. The author takes the specific example of hospitals and writes:
Think about a modern hospital, for example. When you arrive the receptionist hands you a standard form, and asks you a predetermined set of questions. Your answers are forwarded to a nurse, who compares them with the hospital’s regulations in order to decide what preliminary tests to give you. She then measures, say, your blood pressure and heart rate, and takes a blood test. The doctor on duty examines the results, and follows a strict protocol to decide in which ward to hospitalize you. [...] Specialists analyze the results according to well-known statistical databases, deciding what medicines to give you or what further tests to run.
The algorithmic structure ensures that it doesn’t really matter who is the receptionist, nurse, or doctor on duty. Their personality, political opinions and momentary moods are irrelevant. As long as they follow the regulations and protocols they have a good chance of curing you. According to the algorithmic ideal, your fate is in the hands of “the system”, and not in the hands of the flesh and blood mortals who happen to man this or that post.(Harari 2015: 160-161)
There is clear justification for this, in that the most satisfactory result is likely to emerge from following the algorithm. For example, let us imagine that a general practitioner (GP) is interviewing a patient. She comes to the conclusion that the symptoms indicate a certain condition and treatment. Now, an experienced GP may have seen 50—100 similar cases. But the algorithm indicates that the symptoms should be fed into the computer, which contains information on 5 million cases. Hence, a more accurate diagnosis and treatment will emerge. But where is the responsibility here? The individual responsibility is that of the GP who followed the proper procedures, and presumably a computer programmer is responsible for correctly programming the data, but the data comes from innumerable sources (Susskind and Susskind 2015: 46—55). These sources amount to collective wisdom; they will express the best evidence base for the ailment in question. Even if a doctor thinks that this collective wisdom may not lead to the optimum treatment for a given patient, she may ignore her own judgment and go with the algorithm. There will always be a strong legal defense for the GP, to the effect that “I did what the protocol instructed.” In other words, strong pressure comes from the “system,” the collective. We might say that the treatment protocol acts as a kind of duress: even if the doctor thinks that in this case the protocol will not result in the optimum treatment for a patient, she puts her career at risk by ignoring it.
It might be said, of course, that there is certainly scope for discretion concerning ways of communicating and managing the patient. This is the “adverbial” side to treatment, mentioned earlier, concerning in what manner, when, and how much to communicate to a given patient. But even here, courses on “communication skills” have the effect, if not the aim, of stereotyping doctors’ responses to patients, conveying the idea that there is a universal, teachable, and learnable skill in communicating. Hence, the scope for individual initiative and therefore individual responsibility is increasingly limited, even in matters such as communication.
My argument so far has attempted to highlight the manner in which even apparently individual decisions in health care are strongly influenced by the shared collective values and attitudes of doctors and nurses and the whole continuing ethos of medicine. These collective values influence or even determine the actions of individual health professionals, from their entry to the professions to their conduct within them. Doctors, perhaps more than any other group, identify with their values and recognize themselves and other doctors as belonging to a group that shares the same values. There is therefore at least some collective causal responsibility, deriving from the ethos, for individual moral medical decisions.
Many writers on collective responsibility are concerned with collective guilt. They are interested in whether groups or even whole nations can be blamed for bad actions (French 1972). But collective values can also have good consequences. As far as medicine goes, both good and bad consequences spring from its collective values. The good consequences are obvious, but health care can be an unpleasant and stressful job. Doctors often must work long hours and deal with blood, sweat, tears, and worse, so the collective values and attitudes here can be a support and an inspiration in dealing with difficult cases. This is widely recognized and doctors have a high status in Western societies. Moreover, the collective wisdom of the algorithm is likely to lead to optimum treatment. There is an important downside to this, however, which I shall discuss later.
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