Leadership in palliative medicine: moral, ethical and educational

Leadership in palliative medicine: moral, ethical and educational Background: Making particular use of Shale’s analysis, this paper discusses the notion of leadership in the context of palliative medicine. Whilst offering a critical perspective, I build on the philosophy of palliative care offered by Randall and Downie and suggest that the normative structure of this medical speciality has certain distinctive features, particularly when compared to that of medicine more generally. I discuss this in terms of palliative medicine’s distinctive morality or ethos, albeit one that should still be seen in terms of medical morality or the ethos of medicine. Main text: I argue that, in the context of multi-disciplinary teamwork, the particular ethos of palliative medicine means that healthcare professionals who work within this speciality are presented with distinct opportunities for leadership and the dissemination of the moral and ethical norms that guide their practice. I expand on the nature of this opportunity by further engaging with Shale’s work on leadership in medicine, and by more fully articulating the notion of moral ethos in medicine and its relation to the more formal notion of medical ethics. Finally, and with reference to the idea of medical education as both on going and as an apprenticeship, I suggest that moral and ethical leadership in palliative medicine may have an inherently educational quality and a distinctively pedagogical dimension. Conclusions: The nature of palliative medicine is such that it often involves caring for patients who are still receiving treatment from other specialists. Whilst this can create tension, it also provides an opportunity for palliative care professionals to disseminate the philosophy that underpins their practice, and to offer leadership with regard to the moral and ethical challenges that arise in the context of End of Life Care. Keywords: Palliative, Curative, End of life care, Leadership, Morality, Ethics, Education, Philosophy of medicine, Philosophy of palliative care, The Hippocratic tradition, The Asklepian tradition Background Fox and Swazey [2], discuss the idea of medical morality, In this paper I propose to discuss the conceptual partic- as distinct from medical or bio- ethics. They also sug- ulars of moral leadership and the way in which this gest that the morality of medicine varies in differing relates to palliative medicine as both a clinically and times and places, something that also applies to differ- morally distinctive form of medical practice. To my ing healthcare professions, such as nursing, as well as mind such ideas turn on a specific, broadly sociological, the divisions or sub-domains of practice: the medical conception of morality, understood as a – perhaps specialties. As is the case with these authors, I will be the – defining characteristic of a social field or cultural discussing the morality of medicine or, we might say, domain. This idea relates to the way in which a number of its moral order [3]. Such terms are used to refer to the anthropologists of medicine, notably Kleinman [1]and normative structure of medicine, and healthcare more generally. However, rather than use the term morality, I prefer to use a slightly different concept. Thus rather Correspondence: nathan.emmerich@anu.edu.au 1 than speak about ‘medical morality’ or the morality of Visiting Research Fellow, School of History, Anthropology, Politics and Philosophy, Queen’s University Belfast, Belfast, UK any sub-domain, such as palliative medicine and pallia- Endcare Research Fellow, Institute of Ethics, Dublin City University, Dublin, tive care, I tend to speak of the specific and morally or Ireland normatively defining ethos of a field. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Emmerich BMC Medical Ethics (2018) 19:55 Page 2 of 11 In what follows, then, I will be discussing the ethos of both palliative and curative medical practices. Thus, palliative care, and of medicine as a whole. More specif- whilst the difference between curative and palliative ically, I will be discussing the way in which the ethos of medicine may be considered marked and distinctive, palliative care apparently differs from that of medicine. there is no need to consider their differences to be as A similar contrast can be found in Randall and Downie’s profound as Randall and Downie’s work implies. Never- philosophy of palliative care [4]. In their work they set theless, their account remains informative, and reflecting up a contrast between two medical traditions: the on the differential influence of the Hippocratic and Hippocratic and the Asklepian. Their view seems to be Asklepian traditions on contemporary medical practice that the rise of modern, professional, scientific, specialist and its various sub-domains or fields illuminates the un- and, perhaps most importantly, curative medicine has derstanding of the ethos of both curative and palliative meant the Hippocratic tradition has come to dominate. medicine advanced in this paper. They consider the inception and development of pallia- Following a discussion of the notion of ethos, and tive care to represent a reinauguration of the Asklepian what it means for the way we should understand medi- tradition in modern medical practice. Whilst I think that cine in general and palliative medicine in particular, I many of their points are well made, there is a concern turn to some of Susan Shale’s ideas around moral leader- that this way of looking at things has the potential to set ship in medicine [7]. Whilst her work has focused on up a false dichotomy between the Hippocratic and the the management of healthcare organisations some of Asklepian, whilst also offering an insufficiently critical what she has to say about leadership in this domain ap- perspective on medical practice, its present and its his- plies to the clinical practice of medicine. I add to her torical traditions. Instead, I suggest that both curative analysis by, in particular, discussing the idea of, and need and palliative medicine represent a practical realisation for, a specific type of leadership: that of ethical leader- of the medical ethos. ship. Part of the reason medical anthropologists have In this view the differences between curative and pal- elected to focus on ‘medical morality’ has been to redir- liative medicine remain significant but are not without ect our attention away from ‘medical ethics’ and matters counterparts in other areas of medical practice. Con- that can be captured by principles, rules and codifica- sider, for example, the various ways in which the ethos tions. Nevertheless, principles, rules and codifications of medicine, its moral order, is realised in the context of are important facets of modern medical practice. Where, emergency medicine, general practice, and public health. and when, these matters arise it can be vital for someone Alternatively, consider the ethos of surgery, and its to take the lead, and to direct the attention of their col- differential specification within commercial and non- leagues to issues that have a specifically ethical, and not commercial plastic surgery. Whilst similar practices may just moral, dimension. occur within each of these fields they differ in terms of I also intend to further Shale’s analysis by relating no- their normative structure; their ethos and the underpin- tions moral and ethical leadership in medicine to an as- ning values, norms, and principles that, morally pect of both practice in general, and palliative care in speaking, define the field. There may, of course, be a sig- particular. This is the pedagogic or educational dimension nificant degree of shared values, norms and principles. of medicine. Whilst this dimension of medical practice Nevertheless, the ethos of commercial cosmetic surgery and leadership tends to go unremarked, it is nevertheless – which has a financial motivation and is guided by cer- commonplace to suggest that the process of medical edu- tain aesthetic principles – and cosmetic surgery that, cation is one of an extended apprenticeship (cf [8, 9]). As while not insensitive to comparable aesthetic principles, such it is not completed on graduation from medical places health and wellbeing at the heart of its practices, school, and nor should we presume it is complete when and is not motivated by profit, clearly differ. Such vari- one finishes foundational training. Furthermore, in an era ation is not specific to the notion of a moral ethos. Ra- of Continuing Professional Development (CPD), we need ther it is a matter of the way in which social fields are not presume that it has been completed at some point conceptualised (cf. [5, 6]). In understanding morality as prior to becoming a consultant or a partner in a GP sur- a matter of a field’s ethos, a certain degree of variability gery, say. Given the current culture of medicine, the im- must be accommodated. Indeed, one might say that the perative towards multidisciplinary team working in end of point of thinking about morality in this way is so as to life care, and in the context of the on-going nature of pro- accommodate the kind of variation that can be perceived fessional education, I wish to suggest that those who work both across and within particular societies or cultures. in palliative medicine and, one might add, palliative care Taking this approach means that the variation we find in more generally will often find that they encounter circum- the respective moral orientations of palliative and cura- stances that have a pedagogical component or value. tive medicine should not be seen as particularly novel. Somewhat simplistically, I think that they will find that, in Qualitatively comparable variations can be found within the course of normal practice, ‘teachable moments’ are not Emmerich BMC Medical Ethics (2018) 19:55 Page 3 of 11 uncommon. Some of these moments will be fairly explicit that seem misguided. There is an irreducible complexity in nature; they will involve the opportunity to question to social ontology both in terms of scale (considering the norms and suggest alternatives. Others will, I think, have a world at different levels) and in terms of the boundaries more implicit nature and will require palliative care pro- we consider to define the limits of particular social fields. fessionals to act as exemplars or role models, and, in so For example, consider whether or not the various Royal doing, to promote emulation amongst others, including Colleges of the UK’s healthcare professions are part of the non-palliative care specialists. It is in regards these latter NHS, and whether or not the ethos of the NHS can be pedagogical endeavours that the issue of professionalism considered as an important part of their moral character. will come to the fore. To my mind the answer the former question is no, whilst in relation to the latter question it would seem to be yes. Palliative care as/and the ethos of medicine In the light of these comments we can consider the con- Whilst I think that most of us would have an intuitive nection between palliative medicine, other medical special- grasp of what is meant when someone speaks of the ties and medicine as a whole. Whilst it is arguably the case ethos of medicine, the concept of ‘ethos’ itself has been that all specialities have their own distinctive moral orders, the subject of analytic neglect. With the exception of it is equally arguable that there is something specific about two essays by Wolff sustained analysis of the notion is, that of palliative medicine (and – and as a part of - pallia- for the most part, absent [10, 11]. This may well be due tive care) when we consider the relationship between these to the flexibility the term exhibits; something that ana- moral orders and that of medicine as a whole. Randal and lytic philosophy and applied ethics often takes as prima Downie’s philosophy of palliative care can be taken as sug- facie indication that a particular concept is of little intel- gesting that this is due to the fact that it is informed by an lectual use. However, in the first instance, my use of the alternative medical tradition [4]. Their view is that pallia- term can be situated within the context of a broadly tive care is Asklepian whereas other specialities, and medi- Bourdieuan social theory. In this context the fact that cine as a whole, are Hippocratic. However, their analysis the term can be applied to both social fields – the ethos seems to suggest that the relationship between these two of medicine - and individuals – as in the dispositions of traditions has a binary nature; that there stand in a dichot- (moral) character – is a strength. For Bourdieu, disposi- omous relationship. As such it would seem that the influ- tions of habitus and the social structures of fields are ence of the Asklepian tradition on palliative care precludes homologous or ontologically complicit [12]. Given this the relevance of the Hippocratic tradition, and vice versa. entanglement the fact that the term ethos can refer to Thus, the pre-eminence of the Hippocratic tradition in the characteristics of individuals (habitus) and social modernity entails the exclusion of Asklepian values. Such a fields should not be seen as being essentially problematic view would seem to suggest that the moral order of pallia- in nature. tive medicine – and palliative care more generally - not Nevertheless, I use the term as a field level concept only significantly differs from other areas of medical and to refer to the normative social structure, moral practice, but that they are incompatible with one an- shape or order, of particular fields. Unfortunately, this other. It would be better, I think, not to adopt such a raises another difficulty. Social fields do not have a sin- radical point of view and, instead, take note of Frist gular existence, but can be realised and attended to at a and Presley’s comment on the WHO definition of pal- variety of levels, depending on the focus of one’s atten- liative care: tion [5, 6]. Consider, for example, the ethos of a national "The World Health Organization defines palliative political party, and the potential differences between this care as: and the ethos of its local branches. The normative struc- ture of the larger body does not simply determine those “care that improves the quality of life of patients and of the smaller, subsidiary, bodies. Equally, the normative their families facing the problems associated with structure of the larger body is not simply an aggregation life-threatening illness, through the prevention and of the smaller, constitutive, bodies. Similar thinking can, relief of suffering by means of early identification and for example, be applied to the UK’s National Health impeccable assessment and treatment of pain and Service (NHS) and the institutions - hospitals, primary other problems, physical, psychosocial, and spiritual.” care trusts, GP surgeries, the National Research Ethics Service – that can be located within it. In this light it This should be how all medical care is defined." may be that the term ethos has been neglected because it seems unable to capture a singular moral order in William H. Frist and Martha K. Presley [13] “Training contexts that we assume one should exist. However, this the next Generation of Doctors in Palliative Care Is seems less of a problem for ethos and more of a fact the Key to the New Era of Value-Based Care.” about social reality. As such, it is out presuppositions Academic Medicine. Italics added. Emmerich BMC Medical Ethics (2018) 19:55 Page 4 of 11 In an era of high tech medicine the possibility of a for the establishment of the field of palliative care as well cure has, it seems, come to overshadow what was once a as palliative medicine as a distinct specialty, it is possible central part of all medical care. The success of scientific that such specialization is now becoming unhelpful. Fur- medicine during the late 19th and early 20th centuries, thermore, explaining this difference in terms of opposing the social consequences of the cognitive (re)structuring or contrasting medical traditions is an appealing strategy. of medicine into specialisms, and the emergence of As such the existing structural arrangements seem to be nursing as a distinct profession, are such that the im- given sense by Randall and Downie’sposition; it canap- portance of the kind of care highlighted in the WHO pear as if palliative care and curative care exhibit basic or definition of Palliative Care has been obscured when it fundamental differences. Nevertheless, an appeal to unity comes to medical practice in general. In cases where the has more to recommend it, even if that unity must accom- possibility of a cure begins to recede it once again pos- modate no small degree of diversity. sible to recognise and to realise (to re-cognise and to It is clear, then, that the notion of ethos offers a dis- real-ise or render real) that professionals need to be able tinctively pluralist perspective on the normative struc- to provide patients with this sort of care. Among the ture of social fields. Curative and palliative medicine sit first to do so was Cicely Saunders. The fact that her alongside one another and, in the final analysis, are part career was dedicated to caring for terminally ill oncology of the same cultural phenomena: modern medical prac- patients is, of course, highly relevant. This is a field tice. However, whilst neither denies the other, both cura- where days, weeks or months prior to the death of a pa- tive and palliative medicine have differing priorities tient, the curative treatments on offer can become when it come to the aims, objectives and goals that exhausted. It is also a field where curative treatment it- should be pursued in practice. From the perspective of self can be the cause of high levels of discomfit and dis- curative forms of practice it will likely be justified to sac- tress. It is also a context that not only lends itself to the rifice a patient’s quality of life in both the short and the involvement of the patient’s family in patient care, but medium term. In contrast, a palliative approach invites one that gives rise to a high degree of distress among all us to reconsider this pact. It may be that an increase in those involved with the patient and their care. Given the patient’s quality of life may justify forgoing treatment broader cultural changes in which religiosity is in de- that has the potential to increase life. At minimum, the cline, and both death and bereavement are increasingly ethos of palliative care is such that it promotes the re- medicalised, the factors mentioned can all be seen as consideration of the purpose of medical treatment, and contributing to a reassessment of how healthcare profes- promotes the provision of supportive care in such a way sionals could meet the needs of terminal – dying - pa- that the patient can pursue their own ends in – or with tients and what it might mean to provide care at the end - the time that they have left. This does not, of course, of life. Doing so did not involve abandoning the ethos of necessarily mean forgoing any and all forms of curative medicine but looking to it for resources appropriate to the or life-prolonging treatments; palliative care can be pro- needs dying patients and the families of such patients. vided in tandem with life-prolonging treatment and, at In my view the notion of ethos allows us to picture its best, can itself prolong life as well as aim at promot- these resources as well as to accommodate the ing its quality. Thus, some may wish to receive treat- Hippocratic and Asklepian medical traditions in a man- ments that will negatively impact their quality of life in ner that does not risk representing them as opposed or order to remain alive for an anniversary or other event dichotomous, or as in some way competing or conflict- to which they attach importance, significance or mean- ing, ideals. As suggested, an ethos can be realized (or ing, whilst others may wish to emphasize their quality of rendered real) in a variety of ways or, to put it another life over a shorter period. This can be seen as a facet of way, different aspects of the same ethos can come to the a broader difference. As Randall and Downie suggest: fore (or fall into the background) depending on the con- “[I]n conventional health care psychosocial and spirit- text, and the scale at which we elect to focus our atten- ual care is not primarily undertaken by health care pro- tion. Palliative care is not only part of modern medicine, fessionals – and indeed is not seen as part of healthcare but draws on and develops its historical and normative at all. But palliative care emphasizes that psychosocial traditions. As compared to other medical specialties, the and spiritual care are part of the remit of healthcare pro- demands of palliative care are such that different facets fessionals, possibly because they are thought to contrib- of the medical ethos are called forward, whilst other ute to quality of life, and to one ideal of a ‘good death’. aspects tend to be relegated. The fact of specialization – Here, again palliative care is different from conventional and the associated modes of social organization of prac- health care” [4]. tice, including training, and medical apprenticeships - has To my mind, it is better to take a slightly different per- meant that these differences have been concretized. spective; one that takes psychosocial and spiritual care Whilst this may once have been productive, and allowed to be part of medical practice in general, whilst also Emmerich BMC Medical Ethics (2018) 19:55 Page 5 of 11 acknowledging that different forms of medical practice are such that leadership need not be seen as a specific involve differing kinds or degrees of psychosocial and kind of activity but rather are about the way in which spiritual care. This view seems better able to accommo- some are able to conduct themselves. Consider, for date the activities of various healthcare professionals, in- example, the way Shale conceptualises moral leadership cluding general practitioners and those who work in in medicine, which she considers it to be “the process nursing homes, for example. Perhaps, then, the differ- of orchestrating organisational moral narratives” [7]. ence between palliative and conventional or curative Clearly, those who are not suitably situated within an medicine would be better characterized as follows: organisation cannot accomplish such orchestrations. As a result, the kind of leadership an individual can pursue is Curative medicine seeks to return patients to their closely linked to the location they occupy within particular own lives, so that they might independently pursue social fields. their own priorities and do so in the manner of their Given Shale is discussing the moral leadership of med- choosing. As part of palliative care, palliative medicine ical managers, whereas the present discussion is focused seeks to assist patients in leading their lives and to on moral leadership in the context of clinical practice, the support them in the pursuits they wish to prioritize in notion can be recast as the process of orchestrating moral the time that they have left. narratives that guide the treatment and care of patients. Such narratives certainly have an organisational dimension This is, then, an important facet of the ethos of pallia- but one that is less a matter of the institutional organisa- tive care. The focus is on the person as a whole, it is hol- tion that concerns Shale. The kind of organisational istic and encompasses - and seeks to support - the leadership exhibited by healthcare professionals who are patient’s own ends. In taking on this role the provision acting as such relates to the way in which clinical practice of palliative care often entails supporting the patient’s is structured. This might be a matter of organising care family in a manner that is of more immediate or direct for individual patients or might be more general and re- relevance than is the case in medical practice more gen- lated to the provision of care more generally. As such, we erally. Rather than seeking its elimination, as part of should not think of the difference between clinical prac- palliative care palliative medicine involves managing the tice and the organisational endeavours of management as patient’s medical condition(s) and associated symptoms. involving any kind of clear or absolute distinction. Never- This is clearest in end of life care. In general, the preven- theless, even as we build on the insights offered by Shale, tion of death can be taken as the raison d’être of medical we should not presume that her work can simply be ap- practice, and the notion that someone is dying is taken propriated to the task of conceptualising moral leadership to be a corporeal fire alarm, or as marking out the time- in clinical practice. As she suggests, the nature of moral frame in which doctors have to complete their work. In leadership may differ from one context to the next and contrast, palliative care accepts death and dying as part the kinds of moral leadership exhibited by managers of of life, and seeks to ensure that those who have reached healthcare organisations may differ from that offered by this point in their lives are as comfortable as is possible, professionals in the course of their clinical practice [7]. and, insofar as is possible, are able to pursue the actions In her work Shale suggests that leadership involves and ends they consider important. broad, general practices of responsibility and articulates a notion of propriety as a way to specify or identify more Moral leadership in palliative medicine concrete forms of such practices. In the context of Given the analysis presented in the previous section we medical management, she identifies five specific kinds of can conclude that those who specialise in palliative care propriety, these being: fiduciary; bureaucratic; collegial; are involved in the pursuit - or realisation - of a specific inquisitorial; and restorative. Whilst the practice of form of the medical ethos. Whilst there is, at the present palliative care may involve bureaucratic, inquisitorial moment, a general tendency to think that everyone and restorative propriety they do not directly relate to should be exhibiting some form of leadership at all moral leadership. times, it is important to recognise that healthcare profes- Fiduciary propriety involves the principle that a doc- sionals can pursue the realisation of the medical ethos tor’s first priority must be attending to the needs of their with out necessarily doing so as leaders, or whilst exhi- patients whilst collegial propriety is “a way of behaving biting something called leadership. That said, if the kind suited to an enterprise in which participants rely not of education discussed below can be considered a form upon hierarchy, but upon goodwill and cooperation, to of leadership, then it might be possible for palliative care meet their professional and moral responsibilities” [7]. professionals to act as leaders whilst doing little more Given the nature of palliative care the fiduciary propriety than fulfilling their normal, everyday roles and responsi- governing its practice not only significantly differs from bilities. In a similar vein, some definitions of leadership that of medicine more generally it may also come into Emmerich BMC Medical Ethics (2018) 19:55 Page 6 of 11 conflict with the fiduciary propriety of others. Whilst Ethical leadership and palliative medicine both have fiduciary responsibilities that require them to When Shale speaks of the morality of medicine or moral prioritise the needs of their patients, the general pre- leadership in medicine she has in mind a broad, struc- sumption that guides the care offered by medical profes- tural and relatively formal or, at least, explicit, concep- sionals is that what the patient needs is curative tion of the normative dimension of social life. Consistent treatment. Palliative care professionals need not reject with their use in both everyday and professional dis- this notion. Rather it is the case that they recognise the course Shale considers the terms morality and ethics to potential for curative treatment may be limited and that be “almost but not quite interchangeable” [7]. As noted what their patients need may not solely relate to bio- above, my conception of ethos is related the anthropo- medical matters, strictly defined, but to other areas of logical idea of medical morality. As such it is used to their life. In such cases, doctors from differing special- distinguish between the socio-cultural normativity em- ities must enter into dialogue with each other in an at- bedded in practice and a more formal notion of (med- tempt to produce a coherent moral narrative that might ical) ethics that is embedded in the discourse of applied guide the treatment and care of the particular patient at (bio)ethics and professional codifications. Nevertheless, hand. Given that palliative medicine can be considered a there is potential for a theoretical reconciliation of the relatively heterodox form of medical practice, and that more diffuse and tacit normativity that structures social medical professionals are no less susceptible to the de- fields and acts as the operative logic of practice – i.e. the nial of death than patients, when it comes to providing morality or ethos of medicine - and the notion of ethics care at the end of life, palliative care professionals must as the more formal, explicit and codified phenomena work the hardest to orchestrate the operative narrative, that can be articulated and reflected upon by social ac- the one that is actively guiding the care of the patient. tors. Such ethics, their formal articulation and cognitive Given the collective and team-based nature of medical or reflective role are not mere epiphenomena. Nor are practice in this area, such orchestration will be fundamen- they fundamentally distinct from practice. Rather, both tally dialogical and involve the mutual exchange of views reflection and the articulation of ethical values, norms, and perspectives on the kind of care appropriate to the pa- and principles are specific forms of (cognitive) practice tient(s) at hand. In this context leadership does not mean and can be embedded in practical activities, such as clin- imposing one’s view but successfully presenting it to ical medicine, or in intellectual activities, such as the others in such a way that its validity can be recognised. kinds of ethical reflection we find in ethics committees, Such thinking naturally leads to a consideration of medical ethics classrooms and the activities of academic Shale’s notion of collegial propriety. Given the above com- ethicists, including those of philosophers. Regardless of ments there is significant potential for palliative care pro- the origin of such codifications - i.e. given the case at fessionals to find themselves in a position of challenging hand, medical ethics, whether or not they are the con- the dominant narrative of patient care. It is difficult to fabulations of applied ethicists and philosophers, the challenge the orthodox way of doing things, the prevailing product of socio-historical processes of professional or- ethos or, we might say, the established moral order. This ganisation, or, as is the case at the present moment, will be particularly relevant in places where palliative care some admixture of the both – any ethics is always has not yet been established. Whilst it can be frustrating, rooted in the practices, and therefore ethos, of one and whilst it can feel as if one is failing to discharge one’s (or more) field(s). duties to one’s patient, operating in a manner that respects Given the complexity of the notion of ethos, the rela- established norms of collegial propriety is a reflection of tionship between it, and the articulation of any substan- leadership. Whilst this should not be taken to mean that tive ethics, is not simple. The ethics of a particularly collegiality must be maintained at all times, or that leader- field of practice, medicine say, is not simply defined by ship can never involve imposing a point of view, leader- its ethos or determined by the normative social struc- ship is better understood as the ability to bring people tures associated with the field. Furthermore, an ethics along with you, to render others as fellow travellers. The may be influence and shaped by the ethos of an external ability to maintain collegial relationships with other pro- field. This can be perceived in the case of modern med- fessionals is, clearly, an important part of such leadership. ical ethics, something that has clearly been influenced by Furthermore, such collegiality is essential to the broader applied (bio)ethics. As this suggests, over time an ethics establishment of palliative care both alongside curative can contribute to the reformation of a field’s ethos and, care and, perhaps more importantly, during the transition thus, an ethos can be influenced by external fields and from the latter to the former. Such a transition involves practices. This often occurs through ethical discourses, moving from one ethos to another, and allowing certain exchanges and commentaries, but can also involve dee- values that inform medical practice to move into the back- per and subtler socio-cultural processes. For example, ground whilst other values come the fore. the hand of (bio)ethics can certainly be discerned in the Emmerich BMC Medical Ethics (2018) 19:55 Page 7 of 11 development of patient autonomy and, therefore, such notices. Amongst other things this has, it seems, medicine’s repudiation of paternalism. However this created the conditions where CPR is delivered to a large development might also be related to the advent of number of patients who are not only dying at that mo- consumerism in medicine. The fact that changes to the ment but who are a. in the final stages of terminal ill- doctor –patient relationship can be understood as ness, and b. unlikely to benefit from what is a fairly reflecting broader social norms indicates that there is invasive and violent intervention. In this context, there more too patient autonomy than the advent of biomed- is a clear potential for palliative care professionals to ical ethics. Nevertheless, given the issues at hand, such pursue a leadership role by raising the matter of whether broader considerations can be left to one side. If it is to or not procedures like CPR are futile and should there- be understood properly, the ethos of medicine can and fore be withheld. should be situated in and related to the broader moral This point can be applied more generally. Palliative context. However, for our present purposes it is enough care professionals are well placed to question the intro- to recognise that an ethos of social fields like medicine duction or maintenance of treatments that may no lon- and is sub-specialities can, more or less directly, be in- ger have the potential to benefit patients or, in the case fluenced and developed by more reflective discourses of interventions with significant side effects, which may like medical and bio- ethics. no longer meet the threshold of providing an overall We might say, then, that the relationship between med- benefit to the patient. In this context raising questions ical ethics and the ethos of medicine is, co-productive about whether or not it is appropriate to continue or [14]. The ethos of medicine provides a normative context discontinue treatment can be a form of ethical leader- for the articulation of medical ethics and, overtime, formal ship. This remains the case whether the treatment at medical ethics can contribute to the reformation of the hand is ANH or life support, if it is long-term medica- medical ethos. In this view, medical ethics education can tion for a pre-existing condition, or if it concerns the be seen as an influential conduit, effecting change and provision of, say, antibiotics in response to a recently ac- promoting medicine’s transition from what was an ethos quired infection. The impetus to raise these questions, of paternalism to one in which patient autonomy is given and the inclination not to consider them, is rooted in greater priority (cf. [15]). Finally, and more pertinently, the respective ethos of palliative and curative medicine. given that the ethos of an overarching field can take on However, raising them is one small part of the process. differing shapes in distinct sub-fields – albeit differing What is important in these case is to give due consider- shapes that share a certain family resemblance - then we ation to the matters at hand from both a clinical as well might expect to find that differing ethical imperatives are as an ethical perspective. Johnston, Cruess and Cruess accorded differing priorities, or understood in a slightly suggest “[e]thical leadership entails leading others in set- different manner, within different sub-fields. To my mind ting standards or, and therefore defining, moral or ac- this is what we find in the case of palliative medicine as ceptable behaviour” [16]. The ability to provoke, compared to other medical specialties as well as medicine structure and lead such conversations is a matter of eth- as a whole. Indeed, although the contrast is, perhaps, not ical leadership and whilst such conversations should not as great, similar thinking can be applied to palliative care result in the imposition of a ethical narrative by pallia- with regard to healthcare as a whole. In this context we tive care professionals, it is legitimate to think of such might, then, consider the notion of ethical leadership in discussions as, pace Shale, involving a process through the context of practicing palliative medicine. which the narrative of patient care is being orchestrated. The nature of palliative medicine is such that those The effect of palliative care professionals pursuing working in this field commonly encounter ethical issues such leadership activities as the ones I have discussed in that are relatively uncommon in other areas of medical this section clearly has the potential to promote ethical practice. This includes, for example, the increased use of practice as well as to impact positively on patient care at pain relief, possibly to the point of ‘terminal’ or ‘continu- the end of life. However, more than this, ethical leader- ous’ sedation. It may also include the withdrawing or ship has the potential to effect broader reforms on the withholding of life saving or life prolonging treatment. ethos of medicine. As Brodwin suggests, ethics and This can include Cardio-Pulmonary Resuscitation (CPR), morality (ethos) stand in a relationship of mutual artificial ventilation, Artificial Nutrition and Hydration co-production and reproduction [14]. Furthermore, in (ANH) and using antibiotics to combat an infection such the above-cited quote, Frist and Presley suggest that the as pneumonia. To some extent there seems to be an substantive definition of palliative care offered by the acceptance of Do Not Attempt Resuscitation (DNAR) WHO should be understood as defining medical care notices and, therefore, with the idea of withholding more generally [13]. Given the comments offered by treatment. Nevertheless, there is a broad reluctance to Randal and Downie and my reinterpretation of the way withhold CPR from those who have not consented to they present the Hippocratic and Asklepian traditions, it Emmerich BMC Medical Ethics (2018) 19:55 Page 8 of 11 would seem that palliative care brings to the fore some- independent analysis. Whilst it directly conditions prac- thing that, in its singular pursuit of a cure, modern tice through its embodiment in the dispositions of hab- medicine has a tendency to neglect [4]. The view I have itus, as an aspect of a social field any ethos has a largely set out is that certain of medicine socio-cultural values implicit or tacit existence. Our sense of the moral order are central to the practice of palliative medicine. These of the field(s) in which we are located is acquired over values are not entirely absent from medical practice time, and a function of an individual’s exposure to prac- more generally; rather, it is the case that they are some- tice and associated process of habituation; it is produced what marginalised and relatively peripheral. Returning through interrelated processes of socialisation and encul- them to the fore, in a manner that can engage medical pro- turation [21]. Given that any analysis of the ethos one fessionals in a discussion of the ethical dimension of end of inhabits inevitably involves moral considerations, then life care, is an essential facet of leadership in the care of one cannot but bring to bear one’s moral point of view, dying patients. Understanding that such discussions are something that is fundamentally formed and informed, not a matter of reasoned exchanges alone, but involve an shaped and reshaped, by the ethos one inhabits. encounter between differing realisations of the medical Whilst this places limits on the way in which we ethos, is essential to good leadership in this domain. should understand the moral point of view, no ethos is entirely uniform. In the preceding discussion I have, for Education and the practice of palliative care example, held that the ethos of medicine is variously rea- In the previous sections I discussed ideas of moral and lised in different medical specialities. In this context, one ethical leadership in the context of palliative care. In this route through which palliative care professionals can section I suggest that such endeavours have an inher- educate other professionals from other specialties is by ently pedagogical dimension. This pedagogy is of a cer- simply pursuing their professional responsibilities and tain kind, it is a largely tacit phenomena and, rather discharging their duties in an exemplary manner. In so than involving the simple acquisition of explicit know- doing they can provide a powerful demonstration of pal- ledge, it suggests changes and developments in practice liative care’s ends and the value it has to offer patients, that occur as the result of frameworks of participation their families, and the healthcare system as a whole. If, [17]. Such perspectives are rooted in anthropological as they pursue their work, they can also externalise their conceptions of socio-cultural learning theory as well as evaluation of the case(s) at hand, then such demonstra- associated notions of situated learning and ‘apprentice- tions are likely to be more effective. Such externalisation ship’ [18–20]. I have previously made use of such theor- is not the relatively simply task of expressing one’s think- etical accounts to sketch a connection between the ing about the case at hand, but the broader task of ex- moral socialisation of medical students and what I call pressing one’s thinking whilst also giving others a sense their ethical enculturation [21]. Whilst such work in- of the underlying perspective; the orientation that in- forms the following discussion, for current purposes it is forms and underpins the clinical evaluations that one perhaps better to focus on the notion of emulation and has to offer. As such, both the reflective practices and role modelling [22]. In so doing one can promote the the clinical practice of palliative care professionals can idea that the kind of leadership discussed above involves transmit, or make available, the particular values of the palliative care professionals acting as exemplars of med- field of palliative care. To practice in this way is to ical morality, and that this can prompt others to emulate present oneself as a role model. One need not, of course, their actions. In this way one can perceive such actions, be explicit about this aim. Our social norms are such and such leadership, as offering an implicit pedagogy to that holding oneself up as an exemplar is rarely a pro- those who might follow such leadership. ductive strategy. Nevertheless, the pursuit of leadership Whilst it is clear that reflective debate and the rea- can legitimately entail a conscious attempt to act as a soned exchange of views is essential to good medical role model. practice and end of life care it is also the case that differ- Such thinking about the educational possibilities pre- ing ethical perspectives can be rooted in differing moral sented to palliative care professionals is a little different orientations or ethos. Similarly, whilst it is certain that to the idea that one might try to be aware of ‘teachable the underpinning moral order or normative social struc- moments.’ Whilst not denying that such moments may tures of medical specialities, and the embodiment of arise, they are somewhat limited. For better or for worse, them by individuals in practice, are not fixed they are, the normative structure of medicine is marked by a cer- without question, highly durable. Furthermore, given the tain degree of hierarchy. The notion of a truly teachable fact that the ethos of medicine influences the reflective moment is no less subject to this hierarchy that any practices of professionals – the particular ways in which other facet of medical practice. One can take this as an they think and reason – it is not entirely possible to indication that such moments may arise between think of healthcare professionals as subjecting it to palliative care professionals and medical students, those Emmerich BMC Medical Ethics (2018) 19:55 Page 9 of 11 completing foundation years and some doctors at an patients require. Furthermore, at its best, palliative care early stage in their careers. Nevertheless, they are likely can both improve patient’s quality of life and its quantity to be uncommon in other contexts. Furthermore, the or length. Whilst any number of editorials and op ed. palliative care literature contains some suggestions on pieces can state these claims, the best proof is to be specialist education. Such work often promotes the view found by demonstrating the benefits of palliative care; that encounters with dying patients can be sources for displaying the contribution palliative care can make to the development of the correct moral attitude [23]. Such patients is the best route to being involved in the or- encounters should, of course, be accompanied by the chestration of treatment more generally. Over the past kind of reflective practices that are now central to edu- few decades palliative care has established itself as a le- cation and practice in both medicine and healthcare gitimate medical speciality. The challenge it now faces is more generally [24, 25]. It seems, then, that medical stu- to maintain this status whilst also become embedded in, dents and healthcare professionals in general can draw or available to, medical practice more generally. One route on their experiences in the field of palliative care and, in to meeting this challenge is through providing the moral, particular, their encounters with dying patients to de- ethical and educational leadership considered above. velop as empathic and caring professionals [26–30]. Those working within palliative care would then be well Endnotes advised to encourage such encounters and to facilitate Sociological and anthropological studies that seek to the subsequent reflection of others. This may entail little understand the social and cultural reality of morality more than providing a sympathetic ear, allowing col- and ethics have, after a long period of absence from leagues the space – or, simply, offering permission – so these disciplines, proliferated over the past fifteen years that they might discuss their experiences to whatever or so. Whilst, using the term ethos, this paper sets out degree they find necessary or helpful. Whilst the pro- my own view of morality as a field level phenomena motion such activities do not directly meet Shale’s readers may find it informative to think of Abend’s no- criteria of leadership – the orchestration of moral tion of the moral background [31]. This comment is par- narratives – they can be though of as making an indirect ticularly aimed at readers of a philosophical disposition contribution to the way in which the healthcare profes- who may be reassured by the clear link between Abend’s sional concerned will shape such narratives in future. ideas and Searle’s work on the making of social worlds [32, 33] and, for that matter, with Charles Taylor’s views, Conclusion particular those presented in Sources of the Self [34]. Whilst palliative medicine – and palliative care more In this paper I speak of both palliative medicine and generally - differs from medical practice it is, neverthe- palliative care. The latter is, of course, a broad field, one less, part of this broader enterprise. As such we should that encompasses the former. Arguable, my comments understand its morality or ethos do be an instantiation are primarily applicable to palliative medicine, not least or realisation of the ethos of medicine. Adopting this due to the cultural exigencies of medicine and its rela- point of view we can appreciate that the values, norms tionship to healthcare more broadly. For example, it is and principles that come to the fore in both palliative often the case that medical professionals are placed in a medicine and palliative care are not absent from medical de facto position of leadership. Nevertheless, one would practice more generally. It is merely the case that each hope that my comments can be considered informative has a different emphasis. Some of the values, norms and for those working within palliative care more generally. principles that we find in the forefront of curative med- Therefore, whilst not considering them precisely syn- ical practices do not receive the same emphasis in pallia- onymous, I make use of both ‘palliative medicine’ and tive contexts. There is then, a certain degree of ‘palliative care’ as terms that are intertwined, often commonality between palliative and curative medicine, switching between them as a matter of inclination and as a result there should be room for an appreciation of style. One might also note that, whilst palliative care is the shared aspects of their respective ethos. Neverthe- primarily associated with end of life care, this does not less, one should acknowledge that palliative care is a constitute the whole of the field. Certainly palliative medi- subaltern medical culture. Whilst this may cause it to be cine and palliative care contribute to improving the qual- somewhat neglected, or to be relegated to ‘Cinderella’ ity of life in non-terminal patients. Nevertheless, field’s status, this does provide its practitioners with opportun- origins lie within end of life care and this continues to be ity for moral, ethical and educational leaderships. Par- its mainstay. Thus, it forms the focus of this article. ticularly in the context of an aging population, and The term ethos is, of course, closely related to that of increasing levels of chronic, and often terminal, illnesses character. However, as should be clear, my use of the term amongst that population, it is becoming increasingly is as a field level concept. As such it refers to the moral clear that what palliative care has to offer is what many character - order or normative social structure - of a field, Emmerich BMC Medical Ethics (2018) 19:55 Page 10 of 11 cultural domain or institution. As such whilst I occasion- leadership. Strictly speaking, the former refers to leader- ally speak of the moral ethos this is, technically speaking, ship that is done in accordance with the relevant ethics, a tautology; it should be understood as having the same whilst the latter refers to leadership in matters of ethics. meaning as ethos. I have made significant use of the term However, not only do I find constructions such as ‘ethics elsewhere in my work [12]. leadership’ aesthetically displeasing, I also think the no- In fairness to Randall and Downie at various points in tion that one risks conflating two different things and their various texts they do represent the Hippocratic and confusing the reader to be somewhat ungenerous. Al- Asklepian as compatible with one another. For example, though the following discussion of professionalism might they acknowledge that Cicely Saunders implies as be considered as representing an ethics of leadership, I much and proclaim they hold that Hippocratic - or do not explicitly comment on such ethics. Thus I prefer scientific - observation can be combined with Askle- to continue to use the term ethical leadership when pian attention – the hypnotic gaze of the healer or, speaking of leadership in ethical matters. roughly, empathy and the way in which it can provide At the time of writing the UK medical profession is comfort to those we empathise with [4]. However, at engaged in an informal discussion regarding the use of other points their comments can seem divisive. How- CPR on dying or terminally ill patients. Given the overall ever, consider their assertion that it is impossible to success rates for the procedure it would seem that it is simultaneously provide bothcurativeand palliative relatively futile to attempt resuscitation on someone care [4]. This is clearly not the case in the UK and who is frail from old age, or dying due to the advanced whilst there may be very little overlap in the US, this stage of their terminal illness. Part of the problem here is due to the way reimbursements provided by insurance is that healthcare professionals are not allowed to place companies structure clinical practice, something that is in- DNAR orders on patients without discussing it with creasingly seen as highly problematic (cf. [35]). them or their families, who often do not understand the Reviewing this article, Dr. Michael Connoly points intense physical nature of the procedure or the possibil- out that whilst Cicely Saunders founded the modern ities for success. Understandably, discussion of these hospice movement, this was foreshadowed by the work matters is not easy, and sometimes the conversation is of the Irish Religious Sisters of Charity in the late 1800s either avoided or truncated. As a result, despite UK and, in the early 1900s, by St Joseph’s Hospice in doctors having wide latitude in regards refusing to pro- London. Furthermore, Saunders spent sometime work- viding treatments that they consider to be unwarranted ing in the latter institution. My thanks to Dr. Connoly or of little to no benefit to the patient, CPR is often for drawing my attention to these facts. provided in instances where the possibility of success is It is, of course, not only the diversity of palliative and entirely minimal. curative medicine that the notion of ethos allows us to And, one might add, the nature of objectivity. On accommodate. We can also accommodate difference in this point see Daston and Galison’s history of objectivity, ethos between medicine and surgery, where no easy ap- [36] whose analysis of the scientific point of view has in- peal to differing millennia old medico-cultural traditions formed my approach to the issue of ethical expertise and can be made. the ‘medical ethical’ point of view [37]. This may not be quite right. Bureaucratic propriety Abbreviations seems an important part of clinical practice in general. ANH: Artificial Nutrition and Hydration; CPD: Continuing Professional Similarly, if one suspects wrong doing, but has insuffi- Development; CPR: Cardio-Pulmonary Resuscitation; DNAR: Do Not Attempt cient reason for making any formal report, one might Resuscitation; NHS: National Health Service undertake some form of inquisitorial propriety whilst the aftermath of wrongdoing might result in a need for Acknowledgements A draft of this paper was given at the Association for Palliative Medicine’s restorative propriety. However, the practices do not Supportive & Palliative Care Conference, Belfast, March 2017. My thanks to seem to take on any distinctive or novel features as a Dr. Guy Schofield for the invitation. Thanks also to Professor Bert Gordijn for result of being placed in the context of palliative care, his comments on an earlier draft. as opposed to any other form of clinical endeavor. Funding This is, arguable, not the case in regards fiduciary The writing of this paper has been supported by my appointment as and collegial propriety. Postdoctoral Research Fellow to the ENDCARE project (Harmonisation and Whilst I do not intend to make use of the term in this Dissemination of Best Practice - Educating and alleviating the concerns of Health Care Professionals on the proper practice of End of Life care) funded by EU essay I have, elsewhere, discussed these issues in terms ERASMUS+ programme Agreement No. 2015–1-MT01-KA203–003728. The of ethos and eidos [12]. funding body played no role in the conceptualisation or writing of this paper. A meticulous approach to grammatical correctness would demand that, rather than speaking of ethical lead- Author’s contributions ership in palliative medicine, we ought to discuss ethics Sole Authored. The author read and approved the final manuscript. Emmerich BMC Medical Ethics (2018) 19:55 Page 11 of 11 Ethics approval and consent to participate 25. Taylor BJ. Reflective Pract for healthcare professionals. 3rd ed. Maidenhead: N/A. Open University Press; 2010. 26. MacLeod RD. On reflection: : doctors learning to care for people who are dying. Soc Sci Med. 2001;52:1719–27. Competing interests 27. MacLeod RD, Parkin C, Pullon S, Robertson G. Early clinical exposure to The author declares that he has no competing interests. people who are dying: learning to care at the end of life. Med Educ. 2003;37:51–8. 28. Crawford GB, Zambrano SC. Junior doctors’ views of how their undergraduate Publisher’sNote clinical electives in palliative care influenced their current practice of medicine. Springer Nature remains neutral with regard to jurisdictional claims in Acad Med. 2015;90:338–44. published maps and institutional affiliations. 29. Woroniecka K. Palliative care: my first rotation and the other side of healing. Acad Med. 2015;90:364. Author details 1 30. Block S, Billings JA. Nurturing humanism through teaching palliative care. Visiting Research Fellow, School of History, Anthropology, Politics and 2 Acad Med. 1998;73:763–5. Philosophy, Queen’s University Belfast, Belfast, UK. Endcare Research Fellow, 3 31. Abend G. The moral background: an inquiry into the history of business Institute of Ethics, Dublin City University, Dublin, Ireland. The Medical ethics. Princeton: Princeton University Press; 2014. School, Australian National University, Canberra, Australia. 32. Searle JR. The construction of social reality. New Ed. In: Penguin; 1996. 33. Searle J. Making the social world: the structure of human civilization. Oxford: Received: 29 May 2017 Accepted: 24 May 2018 OUP; 2011. 34. Taylor C. Sources of the self: the making of the modern identity. New Ed: Cambridge: Cambridge University press; 1992. References 35. Schenker Y, Arnold R. Toward palliative care for all patients with advanced 1. Kleinman A. Anthropology of bioethics. Writing at the margin: discourse cancer. JAMA Oncol. 2017;3(11):1459–60. between anthropology and medicine. Berkley: University of California 36. Daston L, Galison P. Objectivity. New York: Zone Books; 2007. Press; 1995. 37. Emmerich N. A sociological analysis of ethical expertise: the case of medical 2. Fox RC, Swazey JP. Medical morality is not bioethics: medical ethics in China ethics. SAGE Open. 2015;5:1–14. and the United States. Perspectives in Biological Medicine. 1984;27:336–60. 3. Moral SC. Believing animals: human personhood and culture. New York; Oxford: Oxford University Press; 2009. 4. Randall F, Downie RS. The philosophy of palliative care: critique and reconstruction. Oxford: OUP; 2006. 5. Fligstein N, McAdam D. A theory of fields. New York: OUP USA; 2012. 6. Krause M. How fields vary. The British Journal of sociology. 2017;n/a – n/a. 7. Shale DS. Moral leadership in medicine: building ethical healthcare organizations. Cambridge: Cambridge University Press; 2011. 8. Sinclair S. Making doctors: an institutional apprenticeship. Oxford: Berg Publishers; 1997. 9. Luke H. Medical Education and Sociology of medical habitus: “It’s not about the stethoscope!”. The Netherlands: Kluwer Academic Publishers; 2003. 10. Wolff J. Fairness, respect, and the egalitarian ethos. Philos Public Aff. 1998;27:97–122. 11. Wolff J. Fairness, respect and the egalitarian ethos revisited. J Ethics. 2010;14:335–50. 12. Emmerich N. Ethos, Eidos, Habitus: A Social Theoretical Contribution to morality and ethics. In: Brand C, editor. Dual process theories in moral psychology. Dordrecht: Springer; 2016. 275–300. 13. Frist WH, Presley MK. Training the next generation of doctors in palliative care is the key to the new era of value-based care. Acad Med. 2015;90:268–71. 14. Brodwin P. The coproduction of moral discourse in U.S. community psychiatry. Med Anthropol Q. 2008;22:127–47. 15. Emmerich N. Medical ethics education: an interdisciplinary and social theoretical perspective. London: Springer; 2013. 16. Johnston SE, Cruess SR, Cruess RL. Ethical leadership in modern medicine. Canadian Journal of Administrative Sciences/Revue Canadienne des Sciences de l’Administration. 2001;18:291–7. 17. Sfard A. On two metaphors for learning and the dangers of choosing just one. Educ Researcher 1998;27(2):4–13. 18. Guile D, Young M. Apprenticeship as a conceptual basis for a social theory of learning. Journal of Vocational Education & Training. 1998;50:173–93. 19. Lave J, Gibson TP. Apprenticeship in critical ethnographic practice: Chicago: University of Chicago Press; 2011. 20. Lave J, Wenger E. Situated learning: legitimate peripheral participation. USA: Cambridge University Press; 1991. 21. Emmerich N. Bourdieu’s collective Enterprise of Inculcation: the moral socialisation and ethical enculturation of medical students. Br J Sociol Educ. 2015;36:1054–72. 22. Kristjánsson K. Emulation and the use of role models in moral education. J Moral Educ. 2006;35:37–49. 23. Olthuis G, Dekkers W. Medical education, palliative care and moral attitude: some objectives and future perspectives. Med Educ. 2003;37:928–33. 24. Ghaye T, Lillyman S. Reflection: principles and practice for healthcare professionals. 2nd ed. Great Britain: Quay Books; 2010. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Ethics Springer Journals

Leadership in palliative medicine: moral, ethical and educational

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Abstract

Background: Making particular use of Shale’s analysis, this paper discusses the notion of leadership in the context of palliative medicine. Whilst offering a critical perspective, I build on the philosophy of palliative care offered by Randall and Downie and suggest that the normative structure of this medical speciality has certain distinctive features, particularly when compared to that of medicine more generally. I discuss this in terms of palliative medicine’s distinctive morality or ethos, albeit one that should still be seen in terms of medical morality or the ethos of medicine. Main text: I argue that, in the context of multi-disciplinary teamwork, the particular ethos of palliative medicine means that healthcare professionals who work within this speciality are presented with distinct opportunities for leadership and the dissemination of the moral and ethical norms that guide their practice. I expand on the nature of this opportunity by further engaging with Shale’s work on leadership in medicine, and by more fully articulating the notion of moral ethos in medicine and its relation to the more formal notion of medical ethics. Finally, and with reference to the idea of medical education as both on going and as an apprenticeship, I suggest that moral and ethical leadership in palliative medicine may have an inherently educational quality and a distinctively pedagogical dimension. Conclusions: The nature of palliative medicine is such that it often involves caring for patients who are still receiving treatment from other specialists. Whilst this can create tension, it also provides an opportunity for palliative care professionals to disseminate the philosophy that underpins their practice, and to offer leadership with regard to the moral and ethical challenges that arise in the context of End of Life Care. Keywords: Palliative, Curative, End of life care, Leadership, Morality, Ethics, Education, Philosophy of medicine, Philosophy of palliative care, The Hippocratic tradition, The Asklepian tradition Background Fox and Swazey [2], discuss the idea of medical morality, In this paper I propose to discuss the conceptual partic- as distinct from medical or bio- ethics. They also sug- ulars of moral leadership and the way in which this gest that the morality of medicine varies in differing relates to palliative medicine as both a clinically and times and places, something that also applies to differ- morally distinctive form of medical practice. To my ing healthcare professions, such as nursing, as well as mind such ideas turn on a specific, broadly sociological, the divisions or sub-domains of practice: the medical conception of morality, understood as a – perhaps specialties. As is the case with these authors, I will be the – defining characteristic of a social field or cultural discussing the morality of medicine or, we might say, domain. This idea relates to the way in which a number of its moral order [3]. Such terms are used to refer to the anthropologists of medicine, notably Kleinman [1]and normative structure of medicine, and healthcare more generally. However, rather than use the term morality, I prefer to use a slightly different concept. Thus rather Correspondence: nathan.emmerich@anu.edu.au 1 than speak about ‘medical morality’ or the morality of Visiting Research Fellow, School of History, Anthropology, Politics and Philosophy, Queen’s University Belfast, Belfast, UK any sub-domain, such as palliative medicine and pallia- Endcare Research Fellow, Institute of Ethics, Dublin City University, Dublin, tive care, I tend to speak of the specific and morally or Ireland normatively defining ethos of a field. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Emmerich BMC Medical Ethics (2018) 19:55 Page 2 of 11 In what follows, then, I will be discussing the ethos of both palliative and curative medical practices. Thus, palliative care, and of medicine as a whole. More specif- whilst the difference between curative and palliative ically, I will be discussing the way in which the ethos of medicine may be considered marked and distinctive, palliative care apparently differs from that of medicine. there is no need to consider their differences to be as A similar contrast can be found in Randall and Downie’s profound as Randall and Downie’s work implies. Never- philosophy of palliative care [4]. In their work they set theless, their account remains informative, and reflecting up a contrast between two medical traditions: the on the differential influence of the Hippocratic and Hippocratic and the Asklepian. Their view seems to be Asklepian traditions on contemporary medical practice that the rise of modern, professional, scientific, specialist and its various sub-domains or fields illuminates the un- and, perhaps most importantly, curative medicine has derstanding of the ethos of both curative and palliative meant the Hippocratic tradition has come to dominate. medicine advanced in this paper. They consider the inception and development of pallia- Following a discussion of the notion of ethos, and tive care to represent a reinauguration of the Asklepian what it means for the way we should understand medi- tradition in modern medical practice. Whilst I think that cine in general and palliative medicine in particular, I many of their points are well made, there is a concern turn to some of Susan Shale’s ideas around moral leader- that this way of looking at things has the potential to set ship in medicine [7]. Whilst her work has focused on up a false dichotomy between the Hippocratic and the the management of healthcare organisations some of Asklepian, whilst also offering an insufficiently critical what she has to say about leadership in this domain ap- perspective on medical practice, its present and its his- plies to the clinical practice of medicine. I add to her torical traditions. Instead, I suggest that both curative analysis by, in particular, discussing the idea of, and need and palliative medicine represent a practical realisation for, a specific type of leadership: that of ethical leader- of the medical ethos. ship. Part of the reason medical anthropologists have In this view the differences between curative and pal- elected to focus on ‘medical morality’ has been to redir- liative medicine remain significant but are not without ect our attention away from ‘medical ethics’ and matters counterparts in other areas of medical practice. Con- that can be captured by principles, rules and codifica- sider, for example, the various ways in which the ethos tions. Nevertheless, principles, rules and codifications of medicine, its moral order, is realised in the context of are important facets of modern medical practice. Where, emergency medicine, general practice, and public health. and when, these matters arise it can be vital for someone Alternatively, consider the ethos of surgery, and its to take the lead, and to direct the attention of their col- differential specification within commercial and non- leagues to issues that have a specifically ethical, and not commercial plastic surgery. Whilst similar practices may just moral, dimension. occur within each of these fields they differ in terms of I also intend to further Shale’s analysis by relating no- their normative structure; their ethos and the underpin- tions moral and ethical leadership in medicine to an as- ning values, norms, and principles that, morally pect of both practice in general, and palliative care in speaking, define the field. There may, of course, be a sig- particular. This is the pedagogic or educational dimension nificant degree of shared values, norms and principles. of medicine. Whilst this dimension of medical practice Nevertheless, the ethos of commercial cosmetic surgery and leadership tends to go unremarked, it is nevertheless – which has a financial motivation and is guided by cer- commonplace to suggest that the process of medical edu- tain aesthetic principles – and cosmetic surgery that, cation is one of an extended apprenticeship (cf [8, 9]). As while not insensitive to comparable aesthetic principles, such it is not completed on graduation from medical places health and wellbeing at the heart of its practices, school, and nor should we presume it is complete when and is not motivated by profit, clearly differ. Such vari- one finishes foundational training. Furthermore, in an era ation is not specific to the notion of a moral ethos. Ra- of Continuing Professional Development (CPD), we need ther it is a matter of the way in which social fields are not presume that it has been completed at some point conceptualised (cf. [5, 6]). In understanding morality as prior to becoming a consultant or a partner in a GP sur- a matter of a field’s ethos, a certain degree of variability gery, say. Given the current culture of medicine, the im- must be accommodated. Indeed, one might say that the perative towards multidisciplinary team working in end of point of thinking about morality in this way is so as to life care, and in the context of the on-going nature of pro- accommodate the kind of variation that can be perceived fessional education, I wish to suggest that those who work both across and within particular societies or cultures. in palliative medicine and, one might add, palliative care Taking this approach means that the variation we find in more generally will often find that they encounter circum- the respective moral orientations of palliative and cura- stances that have a pedagogical component or value. tive medicine should not be seen as particularly novel. Somewhat simplistically, I think that they will find that, in Qualitatively comparable variations can be found within the course of normal practice, ‘teachable moments’ are not Emmerich BMC Medical Ethics (2018) 19:55 Page 3 of 11 uncommon. Some of these moments will be fairly explicit that seem misguided. There is an irreducible complexity in nature; they will involve the opportunity to question to social ontology both in terms of scale (considering the norms and suggest alternatives. Others will, I think, have a world at different levels) and in terms of the boundaries more implicit nature and will require palliative care pro- we consider to define the limits of particular social fields. fessionals to act as exemplars or role models, and, in so For example, consider whether or not the various Royal doing, to promote emulation amongst others, including Colleges of the UK’s healthcare professions are part of the non-palliative care specialists. It is in regards these latter NHS, and whether or not the ethos of the NHS can be pedagogical endeavours that the issue of professionalism considered as an important part of their moral character. will come to the fore. To my mind the answer the former question is no, whilst in relation to the latter question it would seem to be yes. Palliative care as/and the ethos of medicine In the light of these comments we can consider the con- Whilst I think that most of us would have an intuitive nection between palliative medicine, other medical special- grasp of what is meant when someone speaks of the ties and medicine as a whole. Whilst it is arguably the case ethos of medicine, the concept of ‘ethos’ itself has been that all specialities have their own distinctive moral orders, the subject of analytic neglect. With the exception of it is equally arguable that there is something specific about two essays by Wolff sustained analysis of the notion is, that of palliative medicine (and – and as a part of - pallia- for the most part, absent [10, 11]. This may well be due tive care) when we consider the relationship between these to the flexibility the term exhibits; something that ana- moral orders and that of medicine as a whole. Randal and lytic philosophy and applied ethics often takes as prima Downie’s philosophy of palliative care can be taken as sug- facie indication that a particular concept is of little intel- gesting that this is due to the fact that it is informed by an lectual use. However, in the first instance, my use of the alternative medical tradition [4]. Their view is that pallia- term can be situated within the context of a broadly tive care is Asklepian whereas other specialities, and medi- Bourdieuan social theory. In this context the fact that cine as a whole, are Hippocratic. However, their analysis the term can be applied to both social fields – the ethos seems to suggest that the relationship between these two of medicine - and individuals – as in the dispositions of traditions has a binary nature; that there stand in a dichot- (moral) character – is a strength. For Bourdieu, disposi- omous relationship. As such it would seem that the influ- tions of habitus and the social structures of fields are ence of the Asklepian tradition on palliative care precludes homologous or ontologically complicit [12]. Given this the relevance of the Hippocratic tradition, and vice versa. entanglement the fact that the term ethos can refer to Thus, the pre-eminence of the Hippocratic tradition in the characteristics of individuals (habitus) and social modernity entails the exclusion of Asklepian values. Such a fields should not be seen as being essentially problematic view would seem to suggest that the moral order of pallia- in nature. tive medicine – and palliative care more generally - not Nevertheless, I use the term as a field level concept only significantly differs from other areas of medical and to refer to the normative social structure, moral practice, but that they are incompatible with one an- shape or order, of particular fields. Unfortunately, this other. It would be better, I think, not to adopt such a raises another difficulty. Social fields do not have a sin- radical point of view and, instead, take note of Frist gular existence, but can be realised and attended to at a and Presley’s comment on the WHO definition of pal- variety of levels, depending on the focus of one’s atten- liative care: tion [5, 6]. Consider, for example, the ethos of a national "The World Health Organization defines palliative political party, and the potential differences between this care as: and the ethos of its local branches. The normative struc- ture of the larger body does not simply determine those “care that improves the quality of life of patients and of the smaller, subsidiary, bodies. Equally, the normative their families facing the problems associated with structure of the larger body is not simply an aggregation life-threatening illness, through the prevention and of the smaller, constitutive, bodies. Similar thinking can, relief of suffering by means of early identification and for example, be applied to the UK’s National Health impeccable assessment and treatment of pain and Service (NHS) and the institutions - hospitals, primary other problems, physical, psychosocial, and spiritual.” care trusts, GP surgeries, the National Research Ethics Service – that can be located within it. In this light it This should be how all medical care is defined." may be that the term ethos has been neglected because it seems unable to capture a singular moral order in William H. Frist and Martha K. Presley [13] “Training contexts that we assume one should exist. However, this the next Generation of Doctors in Palliative Care Is seems less of a problem for ethos and more of a fact the Key to the New Era of Value-Based Care.” about social reality. As such, it is out presuppositions Academic Medicine. Italics added. Emmerich BMC Medical Ethics (2018) 19:55 Page 4 of 11 In an era of high tech medicine the possibility of a for the establishment of the field of palliative care as well cure has, it seems, come to overshadow what was once a as palliative medicine as a distinct specialty, it is possible central part of all medical care. The success of scientific that such specialization is now becoming unhelpful. Fur- medicine during the late 19th and early 20th centuries, thermore, explaining this difference in terms of opposing the social consequences of the cognitive (re)structuring or contrasting medical traditions is an appealing strategy. of medicine into specialisms, and the emergence of As such the existing structural arrangements seem to be nursing as a distinct profession, are such that the im- given sense by Randall and Downie’sposition; it canap- portance of the kind of care highlighted in the WHO pear as if palliative care and curative care exhibit basic or definition of Palliative Care has been obscured when it fundamental differences. Nevertheless, an appeal to unity comes to medical practice in general. In cases where the has more to recommend it, even if that unity must accom- possibility of a cure begins to recede it once again pos- modate no small degree of diversity. sible to recognise and to realise (to re-cognise and to It is clear, then, that the notion of ethos offers a dis- real-ise or render real) that professionals need to be able tinctively pluralist perspective on the normative struc- to provide patients with this sort of care. Among the ture of social fields. Curative and palliative medicine sit first to do so was Cicely Saunders. The fact that her alongside one another and, in the final analysis, are part career was dedicated to caring for terminally ill oncology of the same cultural phenomena: modern medical prac- patients is, of course, highly relevant. This is a field tice. However, whilst neither denies the other, both cura- where days, weeks or months prior to the death of a pa- tive and palliative medicine have differing priorities tient, the curative treatments on offer can become when it come to the aims, objectives and goals that exhausted. It is also a field where curative treatment it- should be pursued in practice. From the perspective of self can be the cause of high levels of discomfit and dis- curative forms of practice it will likely be justified to sac- tress. It is also a context that not only lends itself to the rifice a patient’s quality of life in both the short and the involvement of the patient’s family in patient care, but medium term. In contrast, a palliative approach invites one that gives rise to a high degree of distress among all us to reconsider this pact. It may be that an increase in those involved with the patient and their care. Given the patient’s quality of life may justify forgoing treatment broader cultural changes in which religiosity is in de- that has the potential to increase life. At minimum, the cline, and both death and bereavement are increasingly ethos of palliative care is such that it promotes the re- medicalised, the factors mentioned can all be seen as consideration of the purpose of medical treatment, and contributing to a reassessment of how healthcare profes- promotes the provision of supportive care in such a way sionals could meet the needs of terminal – dying - pa- that the patient can pursue their own ends in – or with tients and what it might mean to provide care at the end - the time that they have left. This does not, of course, of life. Doing so did not involve abandoning the ethos of necessarily mean forgoing any and all forms of curative medicine but looking to it for resources appropriate to the or life-prolonging treatments; palliative care can be pro- needs dying patients and the families of such patients. vided in tandem with life-prolonging treatment and, at In my view the notion of ethos allows us to picture its best, can itself prolong life as well as aim at promot- these resources as well as to accommodate the ing its quality. Thus, some may wish to receive treat- Hippocratic and Asklepian medical traditions in a man- ments that will negatively impact their quality of life in ner that does not risk representing them as opposed or order to remain alive for an anniversary or other event dichotomous, or as in some way competing or conflict- to which they attach importance, significance or mean- ing, ideals. As suggested, an ethos can be realized (or ing, whilst others may wish to emphasize their quality of rendered real) in a variety of ways or, to put it another life over a shorter period. This can be seen as a facet of way, different aspects of the same ethos can come to the a broader difference. As Randall and Downie suggest: fore (or fall into the background) depending on the con- “[I]n conventional health care psychosocial and spirit- text, and the scale at which we elect to focus our atten- ual care is not primarily undertaken by health care pro- tion. Palliative care is not only part of modern medicine, fessionals – and indeed is not seen as part of healthcare but draws on and develops its historical and normative at all. But palliative care emphasizes that psychosocial traditions. As compared to other medical specialties, the and spiritual care are part of the remit of healthcare pro- demands of palliative care are such that different facets fessionals, possibly because they are thought to contrib- of the medical ethos are called forward, whilst other ute to quality of life, and to one ideal of a ‘good death’. aspects tend to be relegated. The fact of specialization – Here, again palliative care is different from conventional and the associated modes of social organization of prac- health care” [4]. tice, including training, and medical apprenticeships - has To my mind, it is better to take a slightly different per- meant that these differences have been concretized. spective; one that takes psychosocial and spiritual care Whilst this may once have been productive, and allowed to be part of medical practice in general, whilst also Emmerich BMC Medical Ethics (2018) 19:55 Page 5 of 11 acknowledging that different forms of medical practice are such that leadership need not be seen as a specific involve differing kinds or degrees of psychosocial and kind of activity but rather are about the way in which spiritual care. This view seems better able to accommo- some are able to conduct themselves. Consider, for date the activities of various healthcare professionals, in- example, the way Shale conceptualises moral leadership cluding general practitioners and those who work in in medicine, which she considers it to be “the process nursing homes, for example. Perhaps, then, the differ- of orchestrating organisational moral narratives” [7]. ence between palliative and conventional or curative Clearly, those who are not suitably situated within an medicine would be better characterized as follows: organisation cannot accomplish such orchestrations. As a result, the kind of leadership an individual can pursue is Curative medicine seeks to return patients to their closely linked to the location they occupy within particular own lives, so that they might independently pursue social fields. their own priorities and do so in the manner of their Given Shale is discussing the moral leadership of med- choosing. As part of palliative care, palliative medicine ical managers, whereas the present discussion is focused seeks to assist patients in leading their lives and to on moral leadership in the context of clinical practice, the support them in the pursuits they wish to prioritize in notion can be recast as the process of orchestrating moral the time that they have left. narratives that guide the treatment and care of patients. Such narratives certainly have an organisational dimension This is, then, an important facet of the ethos of pallia- but one that is less a matter of the institutional organisa- tive care. The focus is on the person as a whole, it is hol- tion that concerns Shale. The kind of organisational istic and encompasses - and seeks to support - the leadership exhibited by healthcare professionals who are patient’s own ends. In taking on this role the provision acting as such relates to the way in which clinical practice of palliative care often entails supporting the patient’s is structured. This might be a matter of organising care family in a manner that is of more immediate or direct for individual patients or might be more general and re- relevance than is the case in medical practice more gen- lated to the provision of care more generally. As such, we erally. Rather than seeking its elimination, as part of should not think of the difference between clinical prac- palliative care palliative medicine involves managing the tice and the organisational endeavours of management as patient’s medical condition(s) and associated symptoms. involving any kind of clear or absolute distinction. Never- This is clearest in end of life care. In general, the preven- theless, even as we build on the insights offered by Shale, tion of death can be taken as the raison d’être of medical we should not presume that her work can simply be ap- practice, and the notion that someone is dying is taken propriated to the task of conceptualising moral leadership to be a corporeal fire alarm, or as marking out the time- in clinical practice. As she suggests, the nature of moral frame in which doctors have to complete their work. In leadership may differ from one context to the next and contrast, palliative care accepts death and dying as part the kinds of moral leadership exhibited by managers of of life, and seeks to ensure that those who have reached healthcare organisations may differ from that offered by this point in their lives are as comfortable as is possible, professionals in the course of their clinical practice [7]. and, insofar as is possible, are able to pursue the actions In her work Shale suggests that leadership involves and ends they consider important. broad, general practices of responsibility and articulates a notion of propriety as a way to specify or identify more Moral leadership in palliative medicine concrete forms of such practices. In the context of Given the analysis presented in the previous section we medical management, she identifies five specific kinds of can conclude that those who specialise in palliative care propriety, these being: fiduciary; bureaucratic; collegial; are involved in the pursuit - or realisation - of a specific inquisitorial; and restorative. Whilst the practice of form of the medical ethos. Whilst there is, at the present palliative care may involve bureaucratic, inquisitorial moment, a general tendency to think that everyone and restorative propriety they do not directly relate to should be exhibiting some form of leadership at all moral leadership. times, it is important to recognise that healthcare profes- Fiduciary propriety involves the principle that a doc- sionals can pursue the realisation of the medical ethos tor’s first priority must be attending to the needs of their with out necessarily doing so as leaders, or whilst exhi- patients whilst collegial propriety is “a way of behaving biting something called leadership. That said, if the kind suited to an enterprise in which participants rely not of education discussed below can be considered a form upon hierarchy, but upon goodwill and cooperation, to of leadership, then it might be possible for palliative care meet their professional and moral responsibilities” [7]. professionals to act as leaders whilst doing little more Given the nature of palliative care the fiduciary propriety than fulfilling their normal, everyday roles and responsi- governing its practice not only significantly differs from bilities. In a similar vein, some definitions of leadership that of medicine more generally it may also come into Emmerich BMC Medical Ethics (2018) 19:55 Page 6 of 11 conflict with the fiduciary propriety of others. Whilst Ethical leadership and palliative medicine both have fiduciary responsibilities that require them to When Shale speaks of the morality of medicine or moral prioritise the needs of their patients, the general pre- leadership in medicine she has in mind a broad, struc- sumption that guides the care offered by medical profes- tural and relatively formal or, at least, explicit, concep- sionals is that what the patient needs is curative tion of the normative dimension of social life. Consistent treatment. Palliative care professionals need not reject with their use in both everyday and professional dis- this notion. Rather it is the case that they recognise the course Shale considers the terms morality and ethics to potential for curative treatment may be limited and that be “almost but not quite interchangeable” [7]. As noted what their patients need may not solely relate to bio- above, my conception of ethos is related the anthropo- medical matters, strictly defined, but to other areas of logical idea of medical morality. As such it is used to their life. In such cases, doctors from differing special- distinguish between the socio-cultural normativity em- ities must enter into dialogue with each other in an at- bedded in practice and a more formal notion of (med- tempt to produce a coherent moral narrative that might ical) ethics that is embedded in the discourse of applied guide the treatment and care of the particular patient at (bio)ethics and professional codifications. Nevertheless, hand. Given that palliative medicine can be considered a there is potential for a theoretical reconciliation of the relatively heterodox form of medical practice, and that more diffuse and tacit normativity that structures social medical professionals are no less susceptible to the de- fields and acts as the operative logic of practice – i.e. the nial of death than patients, when it comes to providing morality or ethos of medicine - and the notion of ethics care at the end of life, palliative care professionals must as the more formal, explicit and codified phenomena work the hardest to orchestrate the operative narrative, that can be articulated and reflected upon by social ac- the one that is actively guiding the care of the patient. tors. Such ethics, their formal articulation and cognitive Given the collective and team-based nature of medical or reflective role are not mere epiphenomena. Nor are practice in this area, such orchestration will be fundamen- they fundamentally distinct from practice. Rather, both tally dialogical and involve the mutual exchange of views reflection and the articulation of ethical values, norms, and perspectives on the kind of care appropriate to the pa- and principles are specific forms of (cognitive) practice tient(s) at hand. In this context leadership does not mean and can be embedded in practical activities, such as clin- imposing one’s view but successfully presenting it to ical medicine, or in intellectual activities, such as the others in such a way that its validity can be recognised. kinds of ethical reflection we find in ethics committees, Such thinking naturally leads to a consideration of medical ethics classrooms and the activities of academic Shale’s notion of collegial propriety. Given the above com- ethicists, including those of philosophers. Regardless of ments there is significant potential for palliative care pro- the origin of such codifications - i.e. given the case at fessionals to find themselves in a position of challenging hand, medical ethics, whether or not they are the con- the dominant narrative of patient care. It is difficult to fabulations of applied ethicists and philosophers, the challenge the orthodox way of doing things, the prevailing product of socio-historical processes of professional or- ethos or, we might say, the established moral order. This ganisation, or, as is the case at the present moment, will be particularly relevant in places where palliative care some admixture of the both – any ethics is always has not yet been established. Whilst it can be frustrating, rooted in the practices, and therefore ethos, of one and whilst it can feel as if one is failing to discharge one’s (or more) field(s). duties to one’s patient, operating in a manner that respects Given the complexity of the notion of ethos, the rela- established norms of collegial propriety is a reflection of tionship between it, and the articulation of any substan- leadership. Whilst this should not be taken to mean that tive ethics, is not simple. The ethics of a particularly collegiality must be maintained at all times, or that leader- field of practice, medicine say, is not simply defined by ship can never involve imposing a point of view, leader- its ethos or determined by the normative social struc- ship is better understood as the ability to bring people tures associated with the field. Furthermore, an ethics along with you, to render others as fellow travellers. The may be influence and shaped by the ethos of an external ability to maintain collegial relationships with other pro- field. This can be perceived in the case of modern med- fessionals is, clearly, an important part of such leadership. ical ethics, something that has clearly been influenced by Furthermore, such collegiality is essential to the broader applied (bio)ethics. As this suggests, over time an ethics establishment of palliative care both alongside curative can contribute to the reformation of a field’s ethos and, care and, perhaps more importantly, during the transition thus, an ethos can be influenced by external fields and from the latter to the former. Such a transition involves practices. This often occurs through ethical discourses, moving from one ethos to another, and allowing certain exchanges and commentaries, but can also involve dee- values that inform medical practice to move into the back- per and subtler socio-cultural processes. For example, ground whilst other values come the fore. the hand of (bio)ethics can certainly be discerned in the Emmerich BMC Medical Ethics (2018) 19:55 Page 7 of 11 development of patient autonomy and, therefore, such notices. Amongst other things this has, it seems, medicine’s repudiation of paternalism. However this created the conditions where CPR is delivered to a large development might also be related to the advent of number of patients who are not only dying at that mo- consumerism in medicine. The fact that changes to the ment but who are a. in the final stages of terminal ill- doctor –patient relationship can be understood as ness, and b. unlikely to benefit from what is a fairly reflecting broader social norms indicates that there is invasive and violent intervention. In this context, there more too patient autonomy than the advent of biomed- is a clear potential for palliative care professionals to ical ethics. Nevertheless, given the issues at hand, such pursue a leadership role by raising the matter of whether broader considerations can be left to one side. If it is to or not procedures like CPR are futile and should there- be understood properly, the ethos of medicine can and fore be withheld. should be situated in and related to the broader moral This point can be applied more generally. Palliative context. However, for our present purposes it is enough care professionals are well placed to question the intro- to recognise that an ethos of social fields like medicine duction or maintenance of treatments that may no lon- and is sub-specialities can, more or less directly, be in- ger have the potential to benefit patients or, in the case fluenced and developed by more reflective discourses of interventions with significant side effects, which may like medical and bio- ethics. no longer meet the threshold of providing an overall We might say, then, that the relationship between med- benefit to the patient. In this context raising questions ical ethics and the ethos of medicine is, co-productive about whether or not it is appropriate to continue or [14]. The ethos of medicine provides a normative context discontinue treatment can be a form of ethical leader- for the articulation of medical ethics and, overtime, formal ship. This remains the case whether the treatment at medical ethics can contribute to the reformation of the hand is ANH or life support, if it is long-term medica- medical ethos. In this view, medical ethics education can tion for a pre-existing condition, or if it concerns the be seen as an influential conduit, effecting change and provision of, say, antibiotics in response to a recently ac- promoting medicine’s transition from what was an ethos quired infection. The impetus to raise these questions, of paternalism to one in which patient autonomy is given and the inclination not to consider them, is rooted in greater priority (cf. [15]). Finally, and more pertinently, the respective ethos of palliative and curative medicine. given that the ethos of an overarching field can take on However, raising them is one small part of the process. differing shapes in distinct sub-fields – albeit differing What is important in these case is to give due consider- shapes that share a certain family resemblance - then we ation to the matters at hand from both a clinical as well might expect to find that differing ethical imperatives are as an ethical perspective. Johnston, Cruess and Cruess accorded differing priorities, or understood in a slightly suggest “[e]thical leadership entails leading others in set- different manner, within different sub-fields. To my mind ting standards or, and therefore defining, moral or ac- this is what we find in the case of palliative medicine as ceptable behaviour” [16]. The ability to provoke, compared to other medical specialties as well as medicine structure and lead such conversations is a matter of eth- as a whole. Indeed, although the contrast is, perhaps, not ical leadership and whilst such conversations should not as great, similar thinking can be applied to palliative care result in the imposition of a ethical narrative by pallia- with regard to healthcare as a whole. In this context we tive care professionals, it is legitimate to think of such might, then, consider the notion of ethical leadership in discussions as, pace Shale, involving a process through the context of practicing palliative medicine. which the narrative of patient care is being orchestrated. The nature of palliative medicine is such that those The effect of palliative care professionals pursuing working in this field commonly encounter ethical issues such leadership activities as the ones I have discussed in that are relatively uncommon in other areas of medical this section clearly has the potential to promote ethical practice. This includes, for example, the increased use of practice as well as to impact positively on patient care at pain relief, possibly to the point of ‘terminal’ or ‘continu- the end of life. However, more than this, ethical leader- ous’ sedation. It may also include the withdrawing or ship has the potential to effect broader reforms on the withholding of life saving or life prolonging treatment. ethos of medicine. As Brodwin suggests, ethics and This can include Cardio-Pulmonary Resuscitation (CPR), morality (ethos) stand in a relationship of mutual artificial ventilation, Artificial Nutrition and Hydration co-production and reproduction [14]. Furthermore, in (ANH) and using antibiotics to combat an infection such the above-cited quote, Frist and Presley suggest that the as pneumonia. To some extent there seems to be an substantive definition of palliative care offered by the acceptance of Do Not Attempt Resuscitation (DNAR) WHO should be understood as defining medical care notices and, therefore, with the idea of withholding more generally [13]. Given the comments offered by treatment. Nevertheless, there is a broad reluctance to Randal and Downie and my reinterpretation of the way withhold CPR from those who have not consented to they present the Hippocratic and Asklepian traditions, it Emmerich BMC Medical Ethics (2018) 19:55 Page 8 of 11 would seem that palliative care brings to the fore some- independent analysis. Whilst it directly conditions prac- thing that, in its singular pursuit of a cure, modern tice through its embodiment in the dispositions of hab- medicine has a tendency to neglect [4]. The view I have itus, as an aspect of a social field any ethos has a largely set out is that certain of medicine socio-cultural values implicit or tacit existence. Our sense of the moral order are central to the practice of palliative medicine. These of the field(s) in which we are located is acquired over values are not entirely absent from medical practice time, and a function of an individual’s exposure to prac- more generally; rather, it is the case that they are some- tice and associated process of habituation; it is produced what marginalised and relatively peripheral. Returning through interrelated processes of socialisation and encul- them to the fore, in a manner that can engage medical pro- turation [21]. Given that any analysis of the ethos one fessionals in a discussion of the ethical dimension of end of inhabits inevitably involves moral considerations, then life care, is an essential facet of leadership in the care of one cannot but bring to bear one’s moral point of view, dying patients. Understanding that such discussions are something that is fundamentally formed and informed, not a matter of reasoned exchanges alone, but involve an shaped and reshaped, by the ethos one inhabits. encounter between differing realisations of the medical Whilst this places limits on the way in which we ethos, is essential to good leadership in this domain. should understand the moral point of view, no ethos is entirely uniform. In the preceding discussion I have, for Education and the practice of palliative care example, held that the ethos of medicine is variously rea- In the previous sections I discussed ideas of moral and lised in different medical specialities. In this context, one ethical leadership in the context of palliative care. In this route through which palliative care professionals can section I suggest that such endeavours have an inher- educate other professionals from other specialties is by ently pedagogical dimension. This pedagogy is of a cer- simply pursuing their professional responsibilities and tain kind, it is a largely tacit phenomena and, rather discharging their duties in an exemplary manner. In so than involving the simple acquisition of explicit know- doing they can provide a powerful demonstration of pal- ledge, it suggests changes and developments in practice liative care’s ends and the value it has to offer patients, that occur as the result of frameworks of participation their families, and the healthcare system as a whole. If, [17]. Such perspectives are rooted in anthropological as they pursue their work, they can also externalise their conceptions of socio-cultural learning theory as well as evaluation of the case(s) at hand, then such demonstra- associated notions of situated learning and ‘apprentice- tions are likely to be more effective. Such externalisation ship’ [18–20]. I have previously made use of such theor- is not the relatively simply task of expressing one’s think- etical accounts to sketch a connection between the ing about the case at hand, but the broader task of ex- moral socialisation of medical students and what I call pressing one’s thinking whilst also giving others a sense their ethical enculturation [21]. Whilst such work in- of the underlying perspective; the orientation that in- forms the following discussion, for current purposes it is forms and underpins the clinical evaluations that one perhaps better to focus on the notion of emulation and has to offer. As such, both the reflective practices and role modelling [22]. In so doing one can promote the the clinical practice of palliative care professionals can idea that the kind of leadership discussed above involves transmit, or make available, the particular values of the palliative care professionals acting as exemplars of med- field of palliative care. To practice in this way is to ical morality, and that this can prompt others to emulate present oneself as a role model. One need not, of course, their actions. In this way one can perceive such actions, be explicit about this aim. Our social norms are such and such leadership, as offering an implicit pedagogy to that holding oneself up as an exemplar is rarely a pro- those who might follow such leadership. ductive strategy. Nevertheless, the pursuit of leadership Whilst it is clear that reflective debate and the rea- can legitimately entail a conscious attempt to act as a soned exchange of views is essential to good medical role model. practice and end of life care it is also the case that differ- Such thinking about the educational possibilities pre- ing ethical perspectives can be rooted in differing moral sented to palliative care professionals is a little different orientations or ethos. Similarly, whilst it is certain that to the idea that one might try to be aware of ‘teachable the underpinning moral order or normative social struc- moments.’ Whilst not denying that such moments may tures of medical specialities, and the embodiment of arise, they are somewhat limited. For better or for worse, them by individuals in practice, are not fixed they are, the normative structure of medicine is marked by a cer- without question, highly durable. Furthermore, given the tain degree of hierarchy. The notion of a truly teachable fact that the ethos of medicine influences the reflective moment is no less subject to this hierarchy that any practices of professionals – the particular ways in which other facet of medical practice. One can take this as an they think and reason – it is not entirely possible to indication that such moments may arise between think of healthcare professionals as subjecting it to palliative care professionals and medical students, those Emmerich BMC Medical Ethics (2018) 19:55 Page 9 of 11 completing foundation years and some doctors at an patients require. Furthermore, at its best, palliative care early stage in their careers. Nevertheless, they are likely can both improve patient’s quality of life and its quantity to be uncommon in other contexts. Furthermore, the or length. Whilst any number of editorials and op ed. palliative care literature contains some suggestions on pieces can state these claims, the best proof is to be specialist education. Such work often promotes the view found by demonstrating the benefits of palliative care; that encounters with dying patients can be sources for displaying the contribution palliative care can make to the development of the correct moral attitude [23]. Such patients is the best route to being involved in the or- encounters should, of course, be accompanied by the chestration of treatment more generally. Over the past kind of reflective practices that are now central to edu- few decades palliative care has established itself as a le- cation and practice in both medicine and healthcare gitimate medical speciality. The challenge it now faces is more generally [24, 25]. It seems, then, that medical stu- to maintain this status whilst also become embedded in, dents and healthcare professionals in general can draw or available to, medical practice more generally. One route on their experiences in the field of palliative care and, in to meeting this challenge is through providing the moral, particular, their encounters with dying patients to de- ethical and educational leadership considered above. velop as empathic and caring professionals [26–30]. Those working within palliative care would then be well Endnotes advised to encourage such encounters and to facilitate Sociological and anthropological studies that seek to the subsequent reflection of others. This may entail little understand the social and cultural reality of morality more than providing a sympathetic ear, allowing col- and ethics have, after a long period of absence from leagues the space – or, simply, offering permission – so these disciplines, proliferated over the past fifteen years that they might discuss their experiences to whatever or so. Whilst, using the term ethos, this paper sets out degree they find necessary or helpful. Whilst the pro- my own view of morality as a field level phenomena motion such activities do not directly meet Shale’s readers may find it informative to think of Abend’s no- criteria of leadership – the orchestration of moral tion of the moral background [31]. This comment is par- narratives – they can be though of as making an indirect ticularly aimed at readers of a philosophical disposition contribution to the way in which the healthcare profes- who may be reassured by the clear link between Abend’s sional concerned will shape such narratives in future. ideas and Searle’s work on the making of social worlds [32, 33] and, for that matter, with Charles Taylor’s views, Conclusion particular those presented in Sources of the Self [34]. Whilst palliative medicine – and palliative care more In this paper I speak of both palliative medicine and generally - differs from medical practice it is, neverthe- palliative care. The latter is, of course, a broad field, one less, part of this broader enterprise. As such we should that encompasses the former. Arguable, my comments understand its morality or ethos do be an instantiation are primarily applicable to palliative medicine, not least or realisation of the ethos of medicine. Adopting this due to the cultural exigencies of medicine and its rela- point of view we can appreciate that the values, norms tionship to healthcare more broadly. For example, it is and principles that come to the fore in both palliative often the case that medical professionals are placed in a medicine and palliative care are not absent from medical de facto position of leadership. Nevertheless, one would practice more generally. It is merely the case that each hope that my comments can be considered informative has a different emphasis. Some of the values, norms and for those working within palliative care more generally. principles that we find in the forefront of curative med- Therefore, whilst not considering them precisely syn- ical practices do not receive the same emphasis in pallia- onymous, I make use of both ‘palliative medicine’ and tive contexts. There is then, a certain degree of ‘palliative care’ as terms that are intertwined, often commonality between palliative and curative medicine, switching between them as a matter of inclination and as a result there should be room for an appreciation of style. One might also note that, whilst palliative care is the shared aspects of their respective ethos. Neverthe- primarily associated with end of life care, this does not less, one should acknowledge that palliative care is a constitute the whole of the field. Certainly palliative medi- subaltern medical culture. Whilst this may cause it to be cine and palliative care contribute to improving the qual- somewhat neglected, or to be relegated to ‘Cinderella’ ity of life in non-terminal patients. Nevertheless, field’s status, this does provide its practitioners with opportun- origins lie within end of life care and this continues to be ity for moral, ethical and educational leaderships. Par- its mainstay. Thus, it forms the focus of this article. ticularly in the context of an aging population, and The term ethos is, of course, closely related to that of increasing levels of chronic, and often terminal, illnesses character. However, as should be clear, my use of the term amongst that population, it is becoming increasingly is as a field level concept. As such it refers to the moral clear that what palliative care has to offer is what many character - order or normative social structure - of a field, Emmerich BMC Medical Ethics (2018) 19:55 Page 10 of 11 cultural domain or institution. As such whilst I occasion- leadership. Strictly speaking, the former refers to leader- ally speak of the moral ethos this is, technically speaking, ship that is done in accordance with the relevant ethics, a tautology; it should be understood as having the same whilst the latter refers to leadership in matters of ethics. meaning as ethos. I have made significant use of the term However, not only do I find constructions such as ‘ethics elsewhere in my work [12]. leadership’ aesthetically displeasing, I also think the no- In fairness to Randall and Downie at various points in tion that one risks conflating two different things and their various texts they do represent the Hippocratic and confusing the reader to be somewhat ungenerous. Al- Asklepian as compatible with one another. For example, though the following discussion of professionalism might they acknowledge that Cicely Saunders implies as be considered as representing an ethics of leadership, I much and proclaim they hold that Hippocratic - or do not explicitly comment on such ethics. Thus I prefer scientific - observation can be combined with Askle- to continue to use the term ethical leadership when pian attention – the hypnotic gaze of the healer or, speaking of leadership in ethical matters. roughly, empathy and the way in which it can provide At the time of writing the UK medical profession is comfort to those we empathise with [4]. However, at engaged in an informal discussion regarding the use of other points their comments can seem divisive. How- CPR on dying or terminally ill patients. Given the overall ever, consider their assertion that it is impossible to success rates for the procedure it would seem that it is simultaneously provide bothcurativeand palliative relatively futile to attempt resuscitation on someone care [4]. This is clearly not the case in the UK and who is frail from old age, or dying due to the advanced whilst there may be very little overlap in the US, this stage of their terminal illness. Part of the problem here is due to the way reimbursements provided by insurance is that healthcare professionals are not allowed to place companies structure clinical practice, something that is in- DNAR orders on patients without discussing it with creasingly seen as highly problematic (cf. [35]). them or their families, who often do not understand the Reviewing this article, Dr. Michael Connoly points intense physical nature of the procedure or the possibil- out that whilst Cicely Saunders founded the modern ities for success. Understandably, discussion of these hospice movement, this was foreshadowed by the work matters is not easy, and sometimes the conversation is of the Irish Religious Sisters of Charity in the late 1800s either avoided or truncated. As a result, despite UK and, in the early 1900s, by St Joseph’s Hospice in doctors having wide latitude in regards refusing to pro- London. Furthermore, Saunders spent sometime work- viding treatments that they consider to be unwarranted ing in the latter institution. My thanks to Dr. Connoly or of little to no benefit to the patient, CPR is often for drawing my attention to these facts. provided in instances where the possibility of success is It is, of course, not only the diversity of palliative and entirely minimal. curative medicine that the notion of ethos allows us to And, one might add, the nature of objectivity. On accommodate. We can also accommodate difference in this point see Daston and Galison’s history of objectivity, ethos between medicine and surgery, where no easy ap- [36] whose analysis of the scientific point of view has in- peal to differing millennia old medico-cultural traditions formed my approach to the issue of ethical expertise and can be made. the ‘medical ethical’ point of view [37]. This may not be quite right. Bureaucratic propriety Abbreviations seems an important part of clinical practice in general. ANH: Artificial Nutrition and Hydration; CPD: Continuing Professional Similarly, if one suspects wrong doing, but has insuffi- Development; CPR: Cardio-Pulmonary Resuscitation; DNAR: Do Not Attempt cient reason for making any formal report, one might Resuscitation; NHS: National Health Service undertake some form of inquisitorial propriety whilst the aftermath of wrongdoing might result in a need for Acknowledgements A draft of this paper was given at the Association for Palliative Medicine’s restorative propriety. However, the practices do not Supportive & Palliative Care Conference, Belfast, March 2017. My thanks to seem to take on any distinctive or novel features as a Dr. Guy Schofield for the invitation. Thanks also to Professor Bert Gordijn for result of being placed in the context of palliative care, his comments on an earlier draft. as opposed to any other form of clinical endeavor. Funding This is, arguable, not the case in regards fiduciary The writing of this paper has been supported by my appointment as and collegial propriety. Postdoctoral Research Fellow to the ENDCARE project (Harmonisation and Whilst I do not intend to make use of the term in this Dissemination of Best Practice - Educating and alleviating the concerns of Health Care Professionals on the proper practice of End of Life care) funded by EU essay I have, elsewhere, discussed these issues in terms ERASMUS+ programme Agreement No. 2015–1-MT01-KA203–003728. The of ethos and eidos [12]. funding body played no role in the conceptualisation or writing of this paper. A meticulous approach to grammatical correctness would demand that, rather than speaking of ethical lead- Author’s contributions ership in palliative medicine, we ought to discuss ethics Sole Authored. The author read and approved the final manuscript. Emmerich BMC Medical Ethics (2018) 19:55 Page 11 of 11 Ethics approval and consent to participate 25. Taylor BJ. Reflective Pract for healthcare professionals. 3rd ed. Maidenhead: N/A. Open University Press; 2010. 26. MacLeod RD. On reflection: : doctors learning to care for people who are dying. Soc Sci Med. 2001;52:1719–27. Competing interests 27. MacLeod RD, Parkin C, Pullon S, Robertson G. Early clinical exposure to The author declares that he has no competing interests. people who are dying: learning to care at the end of life. Med Educ. 2003;37:51–8. 28. Crawford GB, Zambrano SC. Junior doctors’ views of how their undergraduate Publisher’sNote clinical electives in palliative care influenced their current practice of medicine. Springer Nature remains neutral with regard to jurisdictional claims in Acad Med. 2015;90:338–44. published maps and institutional affiliations. 29. Woroniecka K. Palliative care: my first rotation and the other side of healing. Acad Med. 2015;90:364. 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BMC Medical EthicsSpringer Journals

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