Julie Lang reviews ‘Quality of Life: A Post-Pandemic Philosophy of Medicine’ (Imprint Academic, 2021) by Robin Downie.
Medicine, morality and ethics: a cultural context for health education
Robin Downie, Emeritus Professor of Moral Philosophy at the University of Glasgow, brings his distinctive philosophical perspective to the objectives and implementation of medical practice in the twenty-first century. He taught medical ethics to medical students for many years, and in his earlier texts he has witnessed and reflected on the scientific, clinical, cultural, and social changes that have taken place throughout his long lifetime. In Quality of Life, he argues for a reconsideration of the very ethos of medicine, perpetuated, in his view, by the ‘inward-looking nature of medical education’ (xi).In this review I will consider the strengths of Downie’s argument as well as some points of contention.
Describing his position as ‘revisionary’(1), Downie suggests that science-based treatments do not always provide the optimum remedies for humanity’s ills, and that a new approach is needed. Reaching back to medicine’s Greek origins, Downie identifies the rational, proof-driven doctrine of the Hippocratic School of medicine as the basis for Western thinking on disease and treatment. Downie challenges the primacy of this doctrine by turning to the beliefs of the followers of Asklepios, a Greek deity whose remit was medicine and healing. The School of Asklepios held that healing must come from within the patient. This change in emphasis, Downie suggests, could widen the scope of current evidence-led, quantitively-assessed remedies to incorporate the use of non-medical means. These might include community activities such as sport and fitness, accessible music, arts groups, or gardening. This enlarged model of health promotion, he suggests, would benefit not only individuals, but also communities and the environment. Quality of Life sets out the case for change in a four-part framework, by taking a philosophical view of medicine as it is related to science, to ethics, to its own ethos and to its involvement in the community in the wake of the Covid pandemic.
Downie considers the historical links of science with medicine, from the early beginnings of anatomy, through physiology, biochemistry, and pathology, to observational and qualitative studies. But he casts doubt on the objectivity criteria of the ‘gold standard’ (13) randomised controlled trial and its relevance to clinical practice. He also cautions against over-reliance on mathematical modelling. If algorithms are used in treatment planning, he contends, their application must not be to the detriment of the therapeutic interaction between the clinician and the patient. Good communication skills are enabled, not by teaching and learning stereotypical responses, but by attentive observation and listening. Downie proposes that such competences can be enhanced by the inclusion of the study of the arts and humanities in medical education, and he calls for a unifying strategy to blend evidence-based and patient-centred care.
Medical ethics and its teaching have been central to Downie’s work, so he takes pains to clarify terms. Ethics has different connotations in the spheres of morality, law and philosophy. Autonomy too has suffered from slippage in its meaning, from the Kantian principle of a moral decision that is reasonable and applies to oneself and everyone else alike, to the belief that patient autonomy means doing whatever the patient wants. Similarly, respect meant standing back from self-interest and acting reasonably, with consideration for all. Downie identifies however, that general principles are insufficient in making moral or ethical decisions. Instead, conflicting considerations must be balanced in coming to an ‘all-things-considered judgement’ (54), and he proposes that exposure to the arts and humanities can help doctors to cultivate a ‘holistic’ (55)understanding of patients and their problems. This new understanding is complementary to the knowledge provided by science and incorporates the idea that the patients’ own stories are relevant to their diagnosis and treatment.
Quality of Life addresses other important ethical topics. A key issue for this reviewer is Downie’s exploration of the ethics of assisted suicide. He posits ‘the right to die’ as ‘the right to be allowed to die’(77), and identifies that this right already exists, in that patients can lawfully refuse any life-sustaining treatment. He proposes that this entitlement should be more widely known. But Downie also contends that if a patient is in unbearable pain, something has gone wrong with the medical treatment, a claim not borne out by evidence on pain management in terminal care. A qualitative longitudinal study of patients in tertiary cancer care and hospice scenarios found that ‘there are challenges in securing pain relief in relation to different types of pain and their differential responsiveness to medications’ (Hackett et al 2016: 717).
Downie’s discussion of the movement to permit assisted dying is outmoded. He writes of the right to commitsuicide (78), a verb no longer used since death by suicide was decriminalised in 1961 in England and Wales and has never been an offence in Scotland. Downie suggests that information on how to end one’s own life provided by right-to-die organisations offers acceptable alternatives to medically assisted dying. In my view, his claim that such methods are effective in ending life ‘with minimum unpleasantness to self and others’(78) is staggering in its lack of insight and evidence. In a feat of ethical fence-sitting, Downie describes as ‘reasonable’(79) the desire of individuals to control the end of their lives of suffering, but he also proposes that dignity can be seen in those who accept and bear their fate with patience. Acceptance and patience are rare qualities for those enduring intractable pain or life-changing disability. To explore the BMA’s position on the topic, Downie looks back two decades to a 1999 BMA guideline. However, consider a 2020 survey of its members (BMA 2020), where the BMA found that 40% said the BMA should support a change in the law to permit assisted dying, and 21% said it should take a neutral position. In the same survey, 36% said they would be willing to actively participate in assisted dying. This twenty-first century statistic highlights the need for robust legislation to protect those clinicians who are conscientious objectors, while permitting those who are willing to offer the compassionate option of assisted death to patients who are eligible to seek it. This would require not only legislative change, but transformation of the character of medical practice.
The long-standing, self-contained ethos of the medical profession has had the dual aims of removing unwanted states of disease and infirmity and promoting wellbeing. However, this ethos can create resistance to suggestions that do not come from medicine itself. Downie observes that what constitutes disease and disability may vary across cultures, and he proposes that many of the conditions for which patients now seek treatment are not illness, but the result of aging, genetics, or lifestyle choices. Contemporary researchers take this concept of ‘medicalisation’ of symptoms a stage further. Clarke et al (2003) identify ours as an era of ‘biomedicalization’, where the focus is no longer on illness, disease, and disability as matters of an individual’s fate, but on health as a matter of moral self-transformation (Clarke et al 2003:172), a desirable state that that an individual can work toward. In Downie’s view, a broader conception of health care requires teamwork, not only across other health professions such as nursing or physiotherapy, but across a wide range of community services.
Downie concedes the complexity of problems linked to mental health and mental illness and he seeks to illuminate them by using a classification of his own devising. He implies that only patients with the most serious mental illnesses need treatment. There is extensive and recent literature on medicalisation of other symptoms (Moncrief 2014), but Downie does not refer to those sources. I ponder how contemporary psychiatrist colleagues would receive his use of the emotive word deviant (127), his reference to a 1947 monograph on anti-social behaviour, and his contention that counselling skills can neither be taught nor learned.
Downie draws together his previous arguments in the final section, proposing that many issues such as social isolation, boredom and anxiety about debt or obesity, rather than being medical problems, are caused by our ‘fractured society’(159). He applauds the advent of ‘social prescribing’(158) which enables the provision of non-medical options to support patients’ self-management and can include art, drama, music, or financial advice, according to need and availability. He returns to his theme that doctors can better cultivate the ability to make judgements about social prescribing through exposure to the arts and humanities. Downie takes his argument further in proposing a philosophical foundation of ‘communitarianism’(178), the view that communities, rather than individuals or the state, should be at the centre of our value system. Its principles are utility, maximising the benefit for the majority, and equity, setting criteria for justifiable differences in the way people are treated. By addressing the philosophical idea of the self-embedded in a culture, and the practical notion of a common good, communitarianism stresses informal social controls. Rather than an NHS which uses a science-based approach to target individuals, Downie argues for health as a social concept affected by social justice. This claim asserts that health is entwined with issues such as welfare and community involvement, and that the NHS requires radical changes in emphasis and in funding to address the societal problems of the UK. This change in emphasis could come, Downie suggests, by those in health care abandoning their professional isolation and working with the community. Quality of Life concludes with a plea for re-examination of what adds value and dignity to the lives of individuals and their societies. Downie argues that by incentivising people to pursue worthwhile or meaningful activities, they will also preserve their health. His call for an increase in community interventions is opportune; these measures will constitute an important part of our post-pandemic recovery.
Quality of Life sets out Downie’s expansive views on medical education, ethics, and philosophy. It is a readable, enigmatic mixture of opinion, history, theory, and literature. Its intended audience is unclear, but it is a thought-provoking text and it will be useful to those accessing and delivering education in a wide range of clinical professions.
BMA 2020. ‘Physician-assisted dying survey’, https://www.bma.org.uk/advice-and-support/ethics/end-of-life/physician-assisted-dying-survey [accessed 17 May 2021]
Clarke, A.E. et al. 2003. ‘Biomedicalization: Technoscientific Transformations of Health, Illness and US Biomedicine’, American Sociological Review, 68.2:161-194
Hackett, J., Godfrey M. and Bennett, M. 2016. ‘Patient and caregiver perspectives on managing pain in advanced cancer: a qualitative longitudinal study’, Palliative Medicine 30.8:711-719
Moncrief, J. 2014. ‘The medicalisation of “ups and downs”: The marketing of the new bipolar disorder’, Transcultural Psychiatry, 15.41:581-598
Julie Lang is a PhD researcher at the University of Glasgow. A physiotherapist in the NHS for forty years, the title of her thesis is ,’Representing death: how writers depict dying, death, choice and suicide.’ Julie is also a trustee of Friends at the End, a Scottish charity that supports those making end-of-life decisions, and campaigns for a change in legislation to allow medically assisted dying.