A gratifying mental exercise

Issue: BCMJ, vol. 50 , No. 6 , July August 2008 , Pages 298 Editorials

A few years ago I wrote an editorial about my experiences at the annual ethics conference hosted by the BC College of Physicians and Surgeons here in Vancouver. As I recall, I had attended at least one previous conference prior  to deciding to write the editorial and did so because of what I felt was an extremely rewarding professional experience. 

However, I suspect I may have been a trifle over-expansive in my praise, as I was recently asked to act as a moderator for two sessions  at the most recent conference on medical bioethics. 

Having absolutely no ability to pleasantly demur, and after several discussions with my breakfast partner focused on who was going to do the spring garden work while I was acting smart, for the umpteenth time I failed to ademur. In fact, I delighted in the invitation to participate in a conference that advertised an ethical/moral focus on the new age of genetics and evidence-based medicine.

Now that the conference is over, a few things have become clear. First,  I am impressed that when articulate people present the epistemological grounding required to sort out ethically uncertain clinical situations, it is actually understandable. 

Second, I was reminded of how enjoyable discussions around ethical decision-making can be, particularly when they are framed by well-spoken, thoughtful, passionate speakers. The almost equal mix of nonclinical and clinical ethicists at this conference was an excellent decision by the course planners. 

I don’t think I was alone in appreciating the more academic perspectives that the pure bioethicists brought to the main conference topics of The New Age of Genetics and Evidence-Based Medicine. However, I must admit that the clinician’s perspective on both of these hot-button topics proved to be more useful for me in my role as a decision-making clinician. 

Dr Ross Upshur, a family doctor/ bioethicist from Toronto, Dr Katherine Paton, ophthalmologist and special assistant to the dean of the UBC Medical School, and Dr Barbara Mc­Gil­livray from UBC Medical Genetics provided 2 days of intriguing, thought-provoking, dialogical discourse on clinically important ethical questions from their respective areas. Additionally, the fact that most of what the speakers had to say actually threatens to stay with me is a somewhat disturbing realization from someone who often can’t remember where he put his car keys 5 minutes ago. 

On Saturday, evidence-based medicine (EBM) was discussed by a panel of four experts, and I was intrigued to find that they seemed to share the same iconoclastic sense that EBM was a long way from ever becoming what the original proponents envisioned. Everyone, in fact, seemed to share my long (secretly) shared sense that EBM has many faults, not the least of which is the assumption of its primacy in clinical decision-making. 

There were many illuminating discussions around how EBM forms only part of the clinical-decision equation and that clinical experience, patient preferences, and the ethnic, socioeconomic, and political milieu the patient lives in  are all equally important. 

There were intriguing discussions and questions around the hierarchy of evidence, and no one was surprised by the revelation that meta-analyses of randomized clinical trials or systemized reviews by MEDLINE, the Cochrane Library, and so on can be individualized or cherry-picked by groups funded by insurers or other third-party payers based on their own economic drivers rather than a universal recognition or widely accepted ascription of hierarchical primacy. 

My last editorial on this topic made the recommendation that more of us need to attend this excellent conference, and this year’s message is a clone of the previous one. Health care workers, as a unique, privileged group in our society, need to recognize and regularly speak out about these philosophically important topics. Most people expect that their doctor is trained in and very aware of the ethical constructs that surround clinical decision-making. 

Semi-regular attendance at accredited conferences such as this one makes good sense on a number of professional and personal levels. 

It has been my experience that the ethics conference is an intriguing, educational, and professionally gratifying mental exercise to go through every few years. And as in my case, if you can find a way to write a gratuitously pandering editorial, you just might land yourself a job as the 2009 conference moderator.
—JAW

James A. Wilson, MD. A gratifying mental exercise. BCMJ, Vol. 50, No. 6, July, August, 2008, Page(s) 298 - Editorials.



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