Conference on Ethics in Mental Health, Toronto 26-27 May 2006

Patterns of Practice:Do they help in clinical ethics?

Dr Julian C HughesPsychiatry of Old Age Service,

North Tyneside General Hospital and Institute for Ageing and Health,

University of NewcastleUK

Aim

• Patterns of practice might be a useful way to think about ethical decision making

Objectives

• To suggest the various ways in which our lives, including our professional lives, are patterned

• To raise the possibility that, at root, our clinical decisions are justified by particular patterns of practice, either good or bad

• To consider how a particular pattern of practice may or may not be justified from the ethical perspective

For starters

• “The moral world has its being in, it rests upon, what we do and how we act. It is in our actions and the way we treat one another that values come into being and are preserved in being.”

(Luntley, M. 1995. Reason, Truth and Self:

the Postmodern Reconsidered. London and New York: Routledge, p. 218)

The place of patterns in our lives

• Patterns of behaviour (eating and sleeping)

• Social patterns (manners and driving)

• Cultural patterns (football and music)

• Patterns of worship

• Patterns of thought (adverts and politics)

• Linguistic patterns of expression

Professional patterns

• Learned patterns of practice – education

• Professional ethics – the Bolam principle

• A story: to hydrate or not to hydrate?

The discontinuity problem

Clinical practice

Ethical theory

PoP Solution

Clinical practice

Ethical theory

Patterns of Practice

Linguistic practice

• We understand the meaning when we understand the use (Wittgenstein)

• Meaning and normativity

• Normativity and practice

• Patterns of linguistic practice as the prerequisite for meaning

Justification and practice

• The justification for saying that I understand: I have grasped a use

• ‘To understand a language means to be master of a technique’ (Wittgenstein, PI §199)

• ‘If I have exhausted the justifications I have reached bedrock, and my spade is turned. Then I am inclined to say: “This is simply what I do”.’ (Wittgenstein, PI §217)

Hence:

• Is a pattern of practice a justification?

• A ridiculous suggestion (Dr Shipman)!

• But I know what a pint of beer is!• ‘What people accept as a justification – is

shewn by how they think and live’ (Wittgenstein, PI §325)

The justification of clinical decisions

• This is simply what I do (hydrate) – is this all that we can say as a justification?

• The shared nature of patterns of practice

• What makes a particular pattern of practice right or wrong?– what constitutes a particular pattern of practice?– how are patterns of practice acquired?

Acquisition

• Education and training

• Informed practice

• Open to correction

• Shared, public nature

Patterns of Practice

Education and training

Clinical factors

Experience

Religious or spiritual factors

Political factors

Legal factorsCultural factors

Social factors

Moral factors

Ethical decisions as ordinary

Clinical practice

Ethical theory

Patterns of Practice

Justification

• Coherence of patterns of practice– from within– from without

• E.g. Artificial nutrition and hydration

• Concrete circumstances

In sum, PoP:

• Ethical decisions as ordinary• Engagement with concrete circumstances• Reflect embedding culture• Fixity from essential public and shareable nature• Stem from education, training and experience• Reflect dispositions• Need to be genuinely informed and open to

correction• Require coherence

Summary

• I’ve suggested various ways in which our lives, including our professional lives, are patterned

• I’ve raised the possibility that, at root, our clinical decisions are justified by particular patterns of practice, either good or bad

• I’ve considered how a particular pattern of practice may or may not be justified from the ethical perspective

In conclusion

• “The moral world has its being in, it rests upon, what we do and how we act. It is in our actions and the way we treat one another that values come into being and are preserved in being.”

(Luntley, M. 1995. Reason, Truth and Self:

the Postmodern Reconsidered. London and New York: Routledge, p. 218)