The Journal of the American Medical Association published an essay on the intricacies of evidence-based medicine and the need for practical reasoning last month. For some of us, the findings come as no surprise: best practices in patient-centered care should include attention to each patient’s particulars, including their lifestyles and preferences. That is, even so-called routine care can fail if it is too loosely tied to the patients themselves.
One example might be the need for kidney dialysis. Early in my work in bioethics, I met a patient who was then eighty-eight years old with age-related kidney decline and who lived half an hour from the dialysis site in a rural location. She was contrasted with a twenty-five year old patient with kidney disease who lived in a large city. In each case, the patient’s doctor strongly recommended dialysis as treatment. Both were financially stable.The doctor was disappointed (almost coercively so) that the 88 year old determined not to undergo dialysis, after considering that the half hour drive alone, done twice a day, three days a week, would sap energy in her final years, to say nothing of the treatment itself. She lived another fourteen years without undergoing dialysis. The twenty-five year old, by contrast, had fewer mitigating circumstances made use of dialysis and ultimately ended up with a successful kidney transplant.
As many physicians and bioethicists have long known, doing good medicine is more an art than a science. That’s not to say that science isn’t part of medicine, but test results and prescriptions do not do the kind of work that it takes to practice medicine well. It takes skill and, from an ethicist’s standpoint, the virtue of practical wisdom, to treat patients well.
Indeed, I was surprised to see the words “practical reason” in the article, because “practical reason” has been largely a technical term used by ethicists, especially those working with virtue. Practical reason is the virtue a person cultivates in learning to do the right thing in the right way at the right time. I think it’s perhaps the toughest of the cardinal virtues to practice and inhabit because, well – it takes courage to do the right thing, and a thirst for justice, as well as some experience with moderation (just to round out the cardinal virtues). But it also takes knowledge, concern, kindness, and perhaps even love of patients and others involved – to name a few other virtues that don’t tend to get discussed either in shorthand Aristotelian ethics courses, or in medical ethics in general.
Don’t get me wrong: I think JAMA is spot on to name practical reason as important. Just – I’m not sure we’re ready for it, and by we, I don’t mean only the patients.
As a case in point, a differently-focused news story at NPR on the current (and rather public) debate about blood pressure guidelines comes to a similar point. A national committee of doctors selected for their expertise in researching and/or treating blood pressure made a determination, based on evidence, that the guidelines for what counts as high blood pressure requiring the use of prescription drugs could be changed – raised – to a higher level. People who had been at a formerly high level (140/90) who had been treated for drugs would now come below the high risk threshold (150/90) and could be taken off their drugs, where before, those drugs might have been seen as “good medicine” and vital for people at that threshold.
Harlan Krumholz, the NPR story’s author, notes that many people in the public might be uncomfortable with the idea that
Most medical decisions aren’t cut and dried. Instead they’re usually made with uncertainty about what is best for each person.
It’s the uncertainty that is risky here, for MDs and patients alike. Treatments could always be wrong, diagnoses can always be wrong, drugs can always not work – yet most of the time, in contemporary standard discussions of medicine among lay people and doctors alike, we tend to ignore that possibility. Instead, we opt for “guidelines” which in practice become hard and fast rules about what a doctor should do (and not incidentally, it’s the guidelines that provide one of the backbones for malpractice threats).
Here’s the hard thing about practical reason, though. If you’re at the beginning stages of developing practical reason – say, a 4th year medical student – the guidelines are helpful and actually guide good practice for those with inexperience. But part of the point of developing practical reasoning is precisely that people who have become experts know when to let go of the guidelines because they know those guidelines won’t help this particular patient. And yet that’s also scary – because even experts can make mistakes in judgement and even knowing that some particular guideline is probably wrong doesn’t necessarily point the way toward what will be “right” for a particular person.
“Everyone makes mistakes.” Hopefully everyone’s mother has said that to them at some point – and as I said above, mistakes happen even when people practice all the guidelines. Yet for all that our mothers might have preached otherwise, we are not a culture that forgives mistakes very well because we’re fearful of what’s at stake – our physical well being and our very lives. And yet paradoxically, JAMA notes that the best medical care comes when we take those risks.
I think our real need is to figure out how to be a culture that cultivates mistakes in pursuit of excellence and how to be comfortable with the kind of uncertainty that making mistakes requires. It’s certainly not going to come in the form of more guidelines. That’s actually where the JAMA article’s conclusion goes wrong: at the end, it calls for “guideline panels” for developing procedures and best practices. Despite the fact that the authors call for “frontline patients and clinicians” and suggest that the panels “should avoid making a strong recommendation when the best course of action heavily depends on the patient’s context, goals, values, and preferences”, the presence of these panels is likely (especially in current atmosphere) simply to reiterate guidelines as set-in-stone rules. Those guidelines may possibly be good “rules” for beginners, but they won’t really lead to practical wisdom or excellence in medical practice.