David Misselbrook

Retired

The medical profession is often presented with information on the value of treatment in terms of likely risk reduction. If this same information was presented to patients--so enabling them to give proper informed consent--would this affect their decision to be treated? To examine patients' choice about treatment in response to different forms of ri...

The commonest practical model used in contemporary medical ethics is Principlism. Yet, while Principlism is a widely accepted consensus statement for ethics, the moral theory that underpins it faces serious challenges in its attempt to provide a coherent and accepted system of moral analysis. This inevitably challenges the stability of such a conse...

While Principlism is a widely accepted consensus statement for ethics, the moral theory that underpins it faces serious challenges. This two-part paper proposes a version of virtue theory as a more grounded system of moral analysis. Part 2 examines the role of basic moral theory as the foundation to ethics and suggests how virtue theory can be used...

While medicine is now an immense global industry, clinicians often appear unclear as to its goals. This paper seeks to clarify proper goals for healthcare. This paper uses two philosophical steps to clarify our conceptualization of health and thus our goals for health care. Firstly, clinicians need to understand the significance of Hume's fact/valu...

A textbook on patient centred medicine.

A twin book review of "To kill a mockingbird" by Harper Lee and "Sacred Hunger" by Barry Unsworth, with reflections on institutional racism and white priviledge in my own upbringing.

What you need to know • In patients with new onset hyperglycaemia where the type of diabetes is ambiguous, diabetes specific autoantibodies are the diagnostic test of choice to distinguish between type 1 and type 2 diabetes • Patients with newly diagnosed diabetes who are over 40 and respond well to oral anti-hyperglycaemic therapy do not need to u...

BACKGROUND: Health Information disclosure is the cornerstone in respecting the patients’ autonomy and beneficence, particularly in the context of serious illness. Some Middle Eastern cultures prioritise beneficence over patient autonomy. This may be used as a justification when patient’s family takes over the decision-making process. Although guide...

What does it mean to be a virtuous professional? This chapter argues that healthcare workers’ communities of practice draw their culture both from moral theory and from the marketplace. The chapter explores how healthcare constructs itself as a professional (as opposed to solely technical or commercial) activity. It explores the role of moral theor...

Now in print. How do we understand the “self” that this book is searching for? By “self” I am meaning my body and my conscious mind, together. The body is easily open to scientific analysis – it is made of the same stuff as the rest of the universe. But what is consciousness made of – if it is “made of” anything? This question has puzzled us from...

Huge political, ideological and organisational changes are engulfing primary care, placing intense pressures on the sense of self for both patient and doctor within the consultation. A recent Health Foundation report urges us to develop care practices rooted in a philosophy of people as ‘ purposeful, thinking, feeling, emotional, reflective, relat...

Heart Of Darkness Joseph Conrad (First edition, 1899.) Penguin Classics deluxe edition, 2012, PB, 144pp, £7.99, 978-0143106586 What happens if one has all restraints removed? Do we at last flourish, to become our true selves? Do we become happy? Or would our flaws turn us away from both happiness and flourishing? Such a question is usually meaning...

You never know what will start a battle. However, you do not expect food fights between elderly aunts at the village teashop — one looks on in puzzled embarrassment. For doctors the relationship between medicine and the pharmaceutical industry seems hard to discuss in polite company and last summer saw a remarkable spat between two venerable journa...

The Soul Of The Marionette: A Short Enquiry Into Human Freedom John Gray Allen Lane, 2015, HB, 192 pp, £17.99, 978-1846144493 Are You An Illusion? Mary Midgley Routledge, 2014, PB, 176pp, £14.99, 978-1844657926 Every day we see patients whom we believe matter, because people matter. They often make real choices that we disagree with but we believ...

There is a scene in the 1970 World War II film Kelly’s Heroes when our platoon of heroes is seen ambling across a peaceful rural countryside. Suddenly the lead soldier steps on a mine. A routine stroll has changed into survival in the middle of a minefield. How will they navigate a safe path out? How will they cope as the inevitable enemy troop lor...

The Children Act McEwan Ian Vintage, 2015 PB, 224pp, £8.99 978-00995996 There are two reasons for a GP to read this novel. Firstly it’s by Ian McEwan. Read anything by Ian McEwan! As GPs we are the naturalists of the human jungle and McEwan offers us a way into other peoples’ lives and other peoples’ heads, which I take it is what fiction is for....

In the west medical ethics are generally based on the secular moral theories of deontology, consequentialism, virtue, feminism and contractarianism. In many Islamic cultures morality derives from divine command theory. This has primary and secondary sources. Primary sources: • The Qur’an. This is seen as God’s word, thus is an ultimate and definiti...

The commonest practical model used in contemporary medical ethics is Principlism. Yet, while Principlism is a widely accepted consensus statement for ethics, the moral theory that underpins it faces serious challenges in its attempt to provide a coherent and accepted system of moral analysis. This inevitably challenges the stability of such a conse...

Our world contains moments of change. The assassination of John F Kennedy, the death of Princess Diana, the first broadcast of Monty Python. At a more modest level I remember listening to the Beatles’ first hit, Love Me Do , blasting out from my elder brother’s bedroom on a Sunday afternoon in 1962. Little did I realise that the brown austerity of...

A Flourishing Practice? Peter Toon RCGP, 2014, PB, 152pp, £18/£20 978-0-850843-53-8 Doctors don’t seem to be flourishing right now. GPs live in a world of multiple statutory, regulatory, and disciplinary perils, 5-yearly revalidation, deprofessionalisation, and who knows how many years to a pension. A world where doctors’ interests seem often to b...

Logically I have no way of proving that the universe contains any mind other than my own: I have no access to your mind. Each of us is in solitary confinement within our own consciousness. When I look at you I can only see and hear a body moving and sounding in a certain way. But, if we are functioning in a normal human way, we will experience the...

Soren Kierkegaard (1813–1855) reacted violently against the type of detached rationalistic philosophical method created by Hegel. His starting point was the unique nature of the consciousness of each individual. Kierkegaard states that ‘ In order to study the ethical, every human being is assigned to himself’. He sees ‘subjective truth’ as the ‘hig...

The Department of Health recently commissioned the Royal College of Surgeons (RCS) to review the medical profession’s statutory ‘duty of candour’. The RCS has now published its report, Building a Culture of Candour ( BCC ).1 The report seeks to explore the barriers for doctors, other healthcare workers, and healthcare organisations to their duty, a...

Although we are prepared to spend dizzying sums on health care no one seems quite sure what health is. The World Health Organization made a bold offer in 1948. Their definition of health is ‘ not merely the absence of disease or infirmity but a state of complete physical, mental and social well-being ’. But this utopian vision is an unattainable id...

Michael J Sandel Penguin, 2010 PB, 320pp, £9.99, 978-0141041339 According to Jiminy Cricket you should ‘always let your conscience be your guide’. But what about hard cases and new problems? Yes, we have the four principles. Maybe we need no more, just as I only need the brake, accelerator, clutch, and steering wheel to drive. Do I really have to...

Any properly conceived notion of health care will relate not only to facts (for example, I am breathing) but also to values (for example, it’s good to be alive). In our pluralistic world we have become scared of talking about our values and sought to retreat into facts, but this will not do. Medicine depends completely on judgements such as ‘state...

Nietzsche developed his own philosophical ideas after reading Schopenhauer’s The World as Will and Representation. Nietzsche rejected moral realism and saw morality as mere convention. In his books Beyond Good and Evil and The Genealogy of Morals Nietzsche rejects traditional morality as a restrictive enslavement to a Judeo–Christian petty bourgeoi...

Friedrich Nietzsche (1844–1900) is much celebrated but generally poorly understood. Nietzsche saw the human mind not as an instrument directed towards seeking truth but as a weapon in our struggle for an authentic existence and for power. Nietzsche initially studied classics and philology at Leipzig. His first published work The Birth of Tragedy a...

As medics we get perilously close to equating science with truth. But science and truth seemed to drift apart in the 20th century. We like to think that science proves things. This is a mistake. In the 1930s Karl Popper rejected arguments that ‘pass from single statements … such as the results of observations or experiments, to universal statements...

Can we really know what the world as it is in itself is like? The theory that our knowledge represents states of affairs in the world as it is in itself is called ‘realism’. The contrary position, that statements only tell us about the models in my mind rather than states of affairs in the world, is called ‘anti-realism’. Science tends to make qui...

GPs are used to QOFs and QUALYs, but qualia are far more vital! Qualia (singular ‘quale’) are the immediate individual conscious sensations that we experience, (such as ‘redness’, or pain) that we then put together and interpret as we mentally model the world. (Think of the old conundrum: how do I know that the redness I perceive when I look at a p...

OK, every tribe likes to reserve some language for its own use and polish up a few long words to keep the barbarians at bay. Philosophers are no different, but not as bad as medics. ‘Ontology’ is the study of what types or categories of things might reasonably be thought to exist in the world itself as opposed to just our imagined ways of thinking...

Primary care ethics is a field of study that has recently found new life, with calls to establish the relevance of ethical discussion in general practice, to gather a body of literature and to carve out an intellectual space for primary care on the academic landscape of bioethics. In this report, we reflect on the key strands of the 4th primary car...

We cannot directly know the world as it is in itself, we only know our perception of it. This gap is one of the most important ideas of philosophy. Ludwig Wittgenstein famously opens his brief and enigmatic masterpiece the Tractatus Logico-Philosophicus with the statement ‘the world is the totality of facts, not of things’. He dismisses the very po...

Allocation of scarce healthcare resources is a hot issue. We all believe resources should be distributed justly, the trouble is no one seems quite sure what is just. Should resources be distributed according to need, according to a legal or regulatory entitlement or according to what a person has earned? And who should decide? John Rawls offered u...

We are exhorted to make our medicine rigorously evidence based and yet robustly patient centred. We find ourselves having to square a circle. Why is it that these two aspects of medicine seem so determined to pull apart? And why is it that the scientific picture of evidence-based medicine always gets to play front of stage? The US Philosopher Wilf...

Human rights certainly seem like a good idea but are they morally sound? Human rights do not figure in the major moral theories. Deontology holds that we have duties to one another, not rights. Virtue ethics holds that we should act well to one another. Utilitarianism does not go much for individual duties or rights at all but rather for what is be...

Surely gender has nothing to do with morality? Well, perhaps it just might. All approaches to ethics make assumptions about what constitutes human nature and the human good. A conventional description of a mature ethical person would value ideals such as autonomy, rationality, and justice. The feminist ethicist Carol Gilligan in her book In a Diffe...

The Euthyphro Dilemma;dilemma, even if God exists, not functioning as foundation of ethics;Plato's Euthyphro;“Euthyphro Dilemma” expressed in contemporary and monotheistic terms;Greek pantheon of gods;principled affirmation of divine impeccability;theistic ethicist and divine command theorist, not irrational

Kant, like Bentham, was an Enlightenment man. Morals must come not from authority or tradition, not from religious commands, but from reason. Kant also thought he had it sorted. The funny thing is that his answers were almost the opposite of Bentham’s. Kant started not with pain and pleasure but rather with the fact that mankind’s distinguishing f...

GPs are sometimes a bit smug about medical ethics. We are the ones trained in ethics, communication skills, and patient-centred medicine — we just are the good guys. Also we don't go around turning off life support machines, deciding who gets the transplant, or fiddling with stem cells, so if biomedicine makes mistakes it won't be our fault. Of co...

E thics has long been recognized as an integral element of primary health care 1. Despite the ubiquity of ethical challenges and dilem-mas in primary care, it remains a neglected domain in the world of bioethics. Accordingly, there have been calls to explore the ethical di-mensions of primary healthcare 2,3 On February 15 th 2011, the Royal Soci-et...

I am basing the critical evaluation of QoF in this chapter on archie Cochrane’s famous three questions, as restated by Haynes: ● Can it work? ● Does it work? ● is it worth it? In the words of Gillam and Siriwardena, ‘there appears [in the literature] to be general agree- ment that there is no evidence that health has improved [as a result of the Q...

Kmietowicz’s news report on the new pressure group Health Professionals for Change incorrectly includes the Royal Society of Medicine (RSM) among medical bodies that have “all adopted policies against changing the 1961 …

There are four main traditions that inform our current consensus statements on medical ethics. These are the virtue ethics of ancient Greece, the Judaeo-Christian tradition, deontology and utilitarianism. Feminist writers see all four of these traditions as stemming from a specifically masculine conception of human identity. Feminist writers offer...

We describe the planning and running of a seminar on medicine and literature for general practitioners. This was based on the educational principles of adult learning. We used academic papers, an extract from a novel, a short story, and a cartoon and asked participants to present a piece of literature of their choice. Although the general practitio...

The big idea of this paper is that medical histories, as presented on ward rounds, are part of a historic oral narrative tradition.1 The paper uses the oral-formulaic theory of two classical scholars (Parry and Lord) to compare the narrative of a typical case presentation to Homer's Iliad.An oral formula is “a group of words which is regularly empl...