Monthly Archives: July 2013

Week 2: Morality

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Morality exists within the limits of reason.
But is there a universal moral code, a right or wrong answer to any moral question?

morality

Our experiences of the world and life are realised in the brain. Scientific research has found that the contributions of religion and society/culture affects neuroscience, therefore it affects how people, individually and in a group, view, process and act on context-specific information. Explicitly religious or societal/cultural beliefs and behaviors are at times in stark contrast with the “universal concept of morality”. Furthermore, religion and culture are often times the lens through which people view moral questions. Many view religion or societal/cultural beliefs/practices as a moral compass or guideline through the messy bits of life. Some may argue that a community, religious groups (often seen as dogmatism) or culture, needs to view itself as responsible for the moral growth of it’s members. But what about non-conformists, spiritual individuals or atheists…? Do they have no moral compass to guide them?  If two people are considered right from their cultural worldview and if moral variation exists, why not rather look at moral relativism instead of morality?

In health care, what my beliefs and opinions are with regards to my religious, spiritual, cultural or societal upbringing and experiences, has no place in the relationship with my patients nor, how I engage with them and what level and quality of care I provide. It comes down to universal human well-being, dignity and respect. If a parent of a patient of mine refuses to allow me to undress her child’s trunk to examine her spine, due to personal/religious or cultural beliefs, I need to respect that decision and value the difference of opinion. I need to educate and inform them of why that specific examination is crucial from a scientific/evidence-based point of view, but then explore and exhaust all other options to ensure they feel comfortable with their decision, that was not made under duress, within their religious or cultural context. Perhaps try radiography or palpation with marking of anatomical points… This has happened to me before in a clinical setting. Agree to disagree, and move on. This relates to our previous discussion on empathy with professional distance.

Yes, one can become frustrated with patients who have very idealistic and perhaps, from your perspective, limited or flawed views of the world and their health, but your job is to be neutral and see each patient as a human being. Your job is to provide excellent care and evidence-based health care education and support to all your patients within the universal code of morality guided by ethical laws, professional bodies and the legal framework of your country. An example is when a patient (of the Jehova’s Witness faith) refuses a blood transfusion, that could save his life. A compos-mentis person of legal age (age of consent or majority), as determined by law, can make his own informed decisions about his body and the way he chooses to live (including in health care). You cannot force treatment upon him, even if you are of the opinion, that what you are doing,  in terms of morality, is right, without exceptions. You are only relatively righteous in your opinion or behavior, as relative to your perverse contemporaries, not necessarily when observed out of context, or ”judged” by an absolute standard.

What about the Hippocratic Oath? Is this our moral high ground in health care? It requires a physician or health care provider to take an oath/pledge commitment, to uphold a number of professional ethical standards… So can this be seen as universal morality, a recognised standard of justice or goodness?

Other examples of moral questions are: A South African patient finds out that her child has an 80% chance of having Down Syndrome after going through the screening process as recommended by her Obstetrician/Gynaecologist (OB/GYN). With sensitivity and neutrality, she is educated about her options of termination/fetal abortion (legal in South Africa) or pregnancy progression and what the diagnosis entails regarding potential associated medical and functional problems, evidence-based medical and therapeutic interventions and quality of life. The OB/GYN cannot advocate termination because that is her opinion. Nor can she refuse to help the patient or inform her of termination because she is of opinion that she is making a terrible mistake. If the patient chooses to abort the fetus, is she a terrible human being who is killing a baby, a murderer? Or is she thinking about the well-being of her unborn, sparing the child of a life of disability, pain and suffering? Then, what if a woman was raped and carries the child of her rapist… Is abortion within the South African law, then OK? As a health care professional… My opinion on this doesn’t matter. And neither do yours. It is not your place to judge nor condemn the actions of others, as it is not your life and it does not affect you. That is the problem with morality, it is subjected to religious, personal and cultural beliefs/practices and if we believe in human connection, understanding and respect, we should practice what we preach. Leave all judgement at the door.

Ideally, we would want everyone to be guided by a universal moral code as some religious and societal/cultural sensibilities, attitudes, beliefs, dispositions and behaviors can lead to human suffering. That is why we have ethical guidelines and laws, to guide our clinical practice. What leads to universal morality, is the ability to reflect objectively about questions related to human dignity, respect, freedom and well-being. Just take yourself out of the picture for once.

I follow the Buddhist-philosophy (dharma), as a spiritual human being. It is a choice I made as an adult after many years of soul searching.  I grew up in a South African, Afrikaner-Christian home with my parents always telling us to educate and empower ourselves with information to make up our own minds about what kind of life we want to lead and person we want to be. I disagree with a lot of things that are fundamental to the Christian faith and the Afrikaner/Boer culture, but I value some aspects too. I believe in a lot of things, I have certain opinions and make certain decisions. But I believe that spirituality and my personal opinions and beliefs are private. I will not, nor should I force my opinions or beliefs on anyone else, or judge/condemn them for seeing the world differently. No one is perfectly ethical or moral, in every situation or context, but reflection, accepting your/other’s flaws and understanding why people do, say or act the way they do, will help this world become more tolerant, less judgmental and balanced where relative morality is focused on universal human well-being and “ubuntu” (human kindness).

A very inspirational speaker is Dan Ariely. I found his presentation  (especially the first few minutes) on “Our buggy moral code” very interesting and an eye opener to morality and health care.

“A man does what he must.
In spite of personal consequences.
In spite of obstacles, pressures and dangers.
And that is the basis of all human morality”
Winston Churchill

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For PHT402 Professional Ethics Course

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Week 1: Reflection

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After reading all the blog posts and comments from my fellow course participants, I felt the need to reflect and consider the opinions expressed and respect the complexity of human connection and personal preference or perception. I would like to end the week’s topic of empathy off by reflecting on and summarising my thoughts, before moving onto the next chapter, morality.

 

Avatar - I see you

This week’s topic of empathy made me think of Avatar the movie,
with it’s central theme of connection and understanding.

“Oel Ngati Kameie” – I see you (I see into your soul, I understand you)

 

What surprised me most was the difference of opinion on empathy, perception of vulnerability and it’s role in the management of our patients as health care professionals and most importantly as human beings. Noam talked about the “scale of empathy” and stated that “empathy is balance”, which made me realise that empathetic engagement and human connection is a choice.  It made me reflect on the relationships I have my my little patients and their families.  I must be especially cautious of the interrelation of empathy and sympathy when working in the sensitive fields of physiotherapy, as there is a dividing line: your professional objectivity and role as therapist and health care provider.  Mary summarised this so beautifully by sharing her volunteer work experience in times of disability, pain, resentment, heartache, disappointment, loneliness and death.  Furthermore, I was inspired by and drawn to the well written blog posts by Jackie, Marna and Charde, discussing interpersonal communication and the importance of empathy in practice and life. Furthermore, I came to realise after reading Thomas‘ blog post how important it is to reflect and learn from past experiences in order to grow as a human being and become comfortable with “feeling” and connecting with others.

 

A few of the student’s blog posts and Wendy’s opinion on the usefulness and necessity of empathy in practice, really made me take a step back and understand that personality, therapeutic environment (context) and personal preference, all influence how therapists choose to connect, engage and communicate with patients.

 

I am still of the opinion that  empathetic engagement is context-specific and central to human connection.  It remains a choice of when, if, how and to what degree one displays empathy whilst maintaining professional objectivity and respecting patient-therapist roles and boundaries.  I believe that altruism is universal and natural, but using empathy as a communication skill to connect with others requires development and nurturing.  For me, it is an essential part of holistic patient management and care.

 

As a spiritual being, I have chosen the Buddhist-philosophy and follow the Dharmapada (“the path of Dharma”).
I found this quote from an ancient Sanskrit script inspiring:

“Resolve to be tender with the young; compassionate with the aged;
sympathetic with the striving; and tolerant with the weak and wrong.
Sometime in your life, you will have been all of these.”

Gautama Buddha

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For PHT402 Professional Ethics Course 

Week 1: Empathy

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“The great gift of human beings is that we have the power of empathy.”
Meryl Streep, actress
empathy

Is it even possible to find a more complex and misunderstood word? A word that bridges the gap between human experience, reactive emotion, compassionate thought and altruistic connection.

The idea of empathy was first described in the 1880’s by a German psychologist Theodore Lipps, who coined the term “einfuhlung” (literally, “in-feeling/touch”).  For me, this definition of empathy best encompasses the full meaning of the word in neutral context: The process of appreciating and understanding a person’s subjective experience while maintaining some degree of professional or personal distance.

As a physiotherapist or health care provider, having empathy is to be concerned with a much higher order of human relationship and understanding of your patients. For me, empathy has been a crucial and required altruistic communication skill as I am faced on a daily basis with overwhelmed and anxious new moms with their newborns, and scared, devastated and at times unrealistic expecting parents of babies and kids with special needs or medical respiratory problems. Our patients expect a lot from us and trust us with their vulnerability. We have to be careful of becoming too emotionally involved or invested in our patients’ lives and human experiences, as you can loose your professional objectivity and blur the patient-therapist boundaries. It can also lead to emotional burn-out by making you feel like you are responsible for your patients’ happiness and solving all their problems. I am of opinion that maintaining a healthy, altruistic but professional relationship with all your patients is key.  By being honest with sensitivity and compassion, listening and observing with all your senses and just taking the extra time to let your patients or their families speak or ask questions, really help to build a trusting patient-therapist relationship and human connection without sacrificing your professional objectivity.  Having mild empathy enhances every facet of holistic management and patient outcomes.

In this fast-paced world driven by quantity rather than quality, it often happens that we forget the importance of human compassion and understanding.  We have all heard or know of health care professionals with “poor bedside manners”. They often speak using medical jargon, talk down to patients or their loved ones, don’t make eye contact, rush through each consult or therapy session, brush off or interrupt patients asking questions, raising their concerns or discussing aspects of their lives.  Many health care professionals consciously choose not to interact with their patients on an emotional level, as they don’t see the point or are unsure of how to deal with it as vulnerability means uncertainty and they only want to focus on objectivity and what they can control. There is a fine line between empathy with professional distance, and sympathy with personal involvement.  I believe as human beings and more important as health care professionals, we have the ability and responsibility to expand our perceptions, lean into the discomfort of vulnerability and spend a little more time focusing on others in need by treating them with common decency and respect.  Remember, you cannot treat others with compassion if you are not kind to yourself first.

Now the controversy… Can empathy be taught? Some may argue that empathetic engagement in patient care or society can be taught… Some believe that it can be enhanced by various emotional intellect and communication skills training programmes and experiences. Others are of the opinion that empathy comes from altruistic human nature, that it is an inherent emotional communication skill that elicits compassion and sensitivity, as all humans long for connection… But it is still a choice, to engage or not to engage….  Where do you stand?

I’ll leave you with Alanis Morissette:

“…Thank you for seeing me, I feel so less lonely.

Thank you for getting me. I’m healed by your empathy…”

Blog Post: Week 1, themed “Empathy”, for PHT402 Online Professional Ethics Course