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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Agency Is Messy: Get Used to It a
Peter A. Ubel a
Duke University Published online: 15 Aug 2014.
Click for updates To cite this article: Peter A. Ubel (2014) Agency Is Messy: Get Used to It, The American Journal of Bioethics, 14:9, 37-38, DOI: 10.1080/15265161.2014.936246 To link to this article: http://dx.doi.org/10.1080/15265161.2014.936246
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 14(9): 37–53, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.936246
Open Peer Commentaries
Agency Is Messy: Get Used to It
Downloaded by [Michigan State University] at 02:57 20 February 2015
Peter A. Ubel, Duke University The truth often lies between extremes. Strawberry ice cream—best or worst flavor ever? Probably somewhere in the middle. Vladimir Putin—pure evil or complete angel? Again, the truth is somewhere in between (but not, IMHO, anywhere close to the middle). Physician duties—solely to individual patients in their care or only to society more broadly? Once again, I’d vote for somewhere between these two extremes. It is pretty apparent to me, in fact, that clinicians need to find the appropriate balance of these competing extremes, with the help of guiding principles, on a case-by-case basis. And yet Jon Tilburt (2014), in his thoughtful essay, struggles to find a more precise resolution to this conflict. He argues convincingly that both extremes are indefensible. We cannot “bunker” ourselves, and act as though societal costs are of no issue to physicians. We cannot “bail,” and assume that physicians are merely agents of society. But somehow he cannot accept the possibility that the third of his three B’s—the idea of “balancing” competing duties—is the right way to resolve this moral dilemma. Instead, he abandoned all hope of resolution: “Admittedly,” he writes, “this article does not satisfactorily solve the issue of dual agency.” It doesn’t solve the issue because the issue is unsolvable. That’s the way moral dilemmas often work. To take an example, consider war. Some pacifists argue that war is never just. But most serious thinkers disagree with this extreme view and hold that war is sometimes the appropriate way for a moral society to behave. Once they abandon this extreme, however, proponents of just war have a difficult time specifying exactly when war is just. They can point to unjust wars—taking over another country just to grab onto its resources. They might even, on occasion, agree on a just war—responding to the belligerence of another nation. But they can’t lay out all the conditions for when wars are just and unjust. That means that those people looking for hard and fast rules—”when these X criteria are met, a country can justly declare war on another”—will inevitably be disappointed.
The same disappointment holds for bioethicists looking for hard and fast rules telling physicians how to balance individual patient interests with societal interests. For example, they may decide that when principles conflict, they will give them a priority order. But Tilburt acknowledges the flaws in that view. If the priority order is absolute—always giving patient best interests priority over societal interests—that would essentially resolve dual-agency conflicts by eliminating them. Patient best interests would always win, and we would find ourselves back at the extreme position Tilburt had already abandoned. But if we don’t make such priorities absolute, then we are left with difficult judgment calls—just how small do patient interests have to be, and how large do societal interests have to be, for the latter to take precedence over the former? Dare I say, we are back at the kind of balancing act Tilburt wants to avoid? So why does Tilburt reject the idea of balancing these competing moral claims? His moral reasoning here is quite vague. He simply dismisses the notion of balancing because it “represents a serious departure from the historic norms of medicine because it abandons the idea that physicians’ special obligations to their individual patients are exclusive.” Tilburt seems to forget that, in this very article, he already abandoned that idea when he rejected bunkering. Given his lack of moral reasoning on this point, I think his rejection of balancing deserves a more psychological explanation. I think Tilburt does not want to balance the need for clinicians to perform this balancing act, because it forces them to admit the traditional moral teaching is wrong. Such admissions can be hard to make. Taking a stance that rejects long-established norms—not always easy to do. Making moral decisions is difficult. Drafting charters and codifying rules will not make this task easier. Rules can only do so much of our moral thinking for us. We will inevitably confront moral dilemmas, where no rule “tells” us the answer and where, no matter what we do, someone will be hurt.
Address correspondence to Peter A. Ubel, Fuqua School of Business, Duke University, Box 90120, Durham, NC 27708, USA. E-mail: [email protected]
ajob 37
American Journal of Bioethics
That’s why the ethical practice of any profession is ultimately a balancing act. The job of bioethicists, then, is not to define away all dilemmas but, instead, to help practitioners recognize irresolvable conflicts and give them the tools to make wise judgments. &
REFERENCE Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36.
When Professional Obligations Collide: Context Matters Downloaded by [Michigan State University] at 02:57 20 February 2015
Kathryn M. Ross, American Board of Internal Medicine Elizabeth Bernabeo, American Board of Internal Medicine In “Addressing Dual Agency: Getting Specific About the Expectations of Professionalism,” Tilburt (2014) highlights how the ABIM Physician Charter may fail to guide physicians to arrive at informed decisions in the event of conflicting professional obligations. Upon reflecting on Tilburt’s suggestions for addressing dual agency through prioritization, specification, and role morality, we caution that our work supports the notion that professionalism is nearly always gray due to context. When we explored practicing internists’ reasoning in their perceived handling of typical challenges to professionalism, we discovered that physicians act upon a set of rules or guiding principles when encountering challenges to professionalism, but that these rules or principles are context dependent. We therefore argue that context has such a critical influence on individuals’ responses to professionalism challenges—potentially leading physicians to any one of several “right” decisions— that addressing dual agency by offering specific ways to handle conflicting obligations is not always feasible. First, we posit that professional codes are not designed to be all-encompassing, nor are they intended to suggest “the ideal way” for physicians collectively to handle the conundrum of dual agency. Frustration toward professional codes may exist because critics do not view them as guidelines to be applied on a case-by-case basis. There are varying stances on the subject: Veatch (2012) is against the acceptability of any professional code, while Levine (1993) and to some extent Tilburt (2014) argue the need for a “workable” code of professional ethics. Levine (1993) calls for a normative code that requires acceptance of two prerequisites: (1) emphasis on reality and (2) intelligence in order to comprehend the reality. These two prerequisites for a workable professional code may be helpful as we think critically about Tilburt’s conundrum of dual agency. To begin, we believe that codes such as the ABIM Physician Charter are intended as guidelines for living in reality
as professionals in the field of medicine. In reality, it would be difficult for any individual to fulfill the expectations of codes of professionalism, because we are human and susceptible to relativity and human error. There may also be gaps between the values or attributes physicians believe to be important for professional behavior, and how these values or attributes play out in professional behavior. Moreover, physicians and patients experience and share different personal narratives. Thus, to suggest that a professional code can offer guidance that is both universal and specific enough to address every challenge is a lofty, if not impossible, goal. The issue of context is also important here. Context has a critical influence on individuals’ behavior and is essential to understanding lapses in professionalism (Ginsburg et al., 2000). Campbell and colleagues (2007) have illustrated that gaps do exist between what physicians endorse as important to professionalism, and how they actually act in practice. In one study by DeRoches and colleagues (2010), the reasons physicians cited for not acting in accordance with their own self-endorsed values (e.g., reporting an impaired colleague) included a belief that someone else would take care of the issue, a belief that nothing would change, and fear of retribution. There may be other ways to think about why physicians may not act in accordance with their professional values and beliefs. Do they modify responsibilities outlined by the ABIM Physician Charter and other professional codes, and if so, how frequently or typically? What kinds of situations might prompt this behavior? How do physicians balance conflicting obligations across a spectrum of professional challenges? In one of our studies, we explored how and why practicing physicians respond to a set of professional challenges (Ginsburg et al. 2012). Our goal was to develop a better understanding of how physicians view these challenges, how they come to decisions about how to act, and what factors influence these decisions.
Ó American Board of Internal Medicine Address correspondence to Kathryn M. Ross, American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106, USA. E-mail: [email protected]
38 ajob
September, Volume 14, Number 9, 2014
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Agency Is Messy: Get Used to It a
Peter A. Ubel a
Duke University Published online: 15 Aug 2014.
Click for updates To cite this article: Peter A. Ubel (2014) Agency Is Messy: Get Used to It, The American Journal of Bioethics, 14:9, 37-38, DOI: 10.1080/15265161.2014.936246 To link to this article: http://dx.doi.org/10.1080/15265161.2014.936246
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 14(9): 37–53, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.936246
Open Peer Commentaries
Agency Is Messy: Get Used to It
Downloaded by [Michigan State University] at 02:57 20 February 2015
Peter A. Ubel, Duke University The truth often lies between extremes. Strawberry ice cream—best or worst flavor ever? Probably somewhere in the middle. Vladimir Putin—pure evil or complete angel? Again, the truth is somewhere in between (but not, IMHO, anywhere close to the middle). Physician duties—solely to individual patients in their care or only to society more broadly? Once again, I’d vote for somewhere between these two extremes. It is pretty apparent to me, in fact, that clinicians need to find the appropriate balance of these competing extremes, with the help of guiding principles, on a case-by-case basis. And yet Jon Tilburt (2014), in his thoughtful essay, struggles to find a more precise resolution to this conflict. He argues convincingly that both extremes are indefensible. We cannot “bunker” ourselves, and act as though societal costs are of no issue to physicians. We cannot “bail,” and assume that physicians are merely agents of society. But somehow he cannot accept the possibility that the third of his three B’s—the idea of “balancing” competing duties—is the right way to resolve this moral dilemma. Instead, he abandoned all hope of resolution: “Admittedly,” he writes, “this article does not satisfactorily solve the issue of dual agency.” It doesn’t solve the issue because the issue is unsolvable. That’s the way moral dilemmas often work. To take an example, consider war. Some pacifists argue that war is never just. But most serious thinkers disagree with this extreme view and hold that war is sometimes the appropriate way for a moral society to behave. Once they abandon this extreme, however, proponents of just war have a difficult time specifying exactly when war is just. They can point to unjust wars—taking over another country just to grab onto its resources. They might even, on occasion, agree on a just war—responding to the belligerence of another nation. But they can’t lay out all the conditions for when wars are just and unjust. That means that those people looking for hard and fast rules—”when these X criteria are met, a country can justly declare war on another”—will inevitably be disappointed.
The same disappointment holds for bioethicists looking for hard and fast rules telling physicians how to balance individual patient interests with societal interests. For example, they may decide that when principles conflict, they will give them a priority order. But Tilburt acknowledges the flaws in that view. If the priority order is absolute—always giving patient best interests priority over societal interests—that would essentially resolve dual-agency conflicts by eliminating them. Patient best interests would always win, and we would find ourselves back at the extreme position Tilburt had already abandoned. But if we don’t make such priorities absolute, then we are left with difficult judgment calls—just how small do patient interests have to be, and how large do societal interests have to be, for the latter to take precedence over the former? Dare I say, we are back at the kind of balancing act Tilburt wants to avoid? So why does Tilburt reject the idea of balancing these competing moral claims? His moral reasoning here is quite vague. He simply dismisses the notion of balancing because it “represents a serious departure from the historic norms of medicine because it abandons the idea that physicians’ special obligations to their individual patients are exclusive.” Tilburt seems to forget that, in this very article, he already abandoned that idea when he rejected bunkering. Given his lack of moral reasoning on this point, I think his rejection of balancing deserves a more psychological explanation. I think Tilburt does not want to balance the need for clinicians to perform this balancing act, because it forces them to admit the traditional moral teaching is wrong. Such admissions can be hard to make. Taking a stance that rejects long-established norms—not always easy to do. Making moral decisions is difficult. Drafting charters and codifying rules will not make this task easier. Rules can only do so much of our moral thinking for us. We will inevitably confront moral dilemmas, where no rule “tells” us the answer and where, no matter what we do, someone will be hurt.
Address correspondence to Peter A. Ubel, Fuqua School of Business, Duke University, Box 90120, Durham, NC 27708, USA. E-mail: [email protected]
ajob 37
American Journal of Bioethics
That’s why the ethical practice of any profession is ultimately a balancing act. The job of bioethicists, then, is not to define away all dilemmas but, instead, to help practitioners recognize irresolvable conflicts and give them the tools to make wise judgments. &
REFERENCE Tilburt, J. C. 2014. Addressing dual agency: Getting specific about the expectations of professionalism. American Journal of Bioethics 14 (9): 29–36.
When Professional Obligations Collide: Context Matters Downloaded by [Michigan State University] at 02:57 20 February 2015
Kathryn M. Ross, American Board of Internal Medicine Elizabeth Bernabeo, American Board of Internal Medicine In “Addressing Dual Agency: Getting Specific About the Expectations of Professionalism,” Tilburt (2014) highlights how the ABIM Physician Charter may fail to guide physicians to arrive at informed decisions in the event of conflicting professional obligations. Upon reflecting on Tilburt’s suggestions for addressing dual agency through prioritization, specification, and role morality, we caution that our work supports the notion that professionalism is nearly always gray due to context. When we explored practicing internists’ reasoning in their perceived handling of typical challenges to professionalism, we discovered that physicians act upon a set of rules or guiding principles when encountering challenges to professionalism, but that these rules or principles are context dependent. We therefore argue that context has such a critical influence on individuals’ responses to professionalism challenges—potentially leading physicians to any one of several “right” decisions— that addressing dual agency by offering specific ways to handle conflicting obligations is not always feasible. First, we posit that professional codes are not designed to be all-encompassing, nor are they intended to suggest “the ideal way” for physicians collectively to handle the conundrum of dual agency. Frustration toward professional codes may exist because critics do not view them as guidelines to be applied on a case-by-case basis. There are varying stances on the subject: Veatch (2012) is against the acceptability of any professional code, while Levine (1993) and to some extent Tilburt (2014) argue the need for a “workable” code of professional ethics. Levine (1993) calls for a normative code that requires acceptance of two prerequisites: (1) emphasis on reality and (2) intelligence in order to comprehend the reality. These two prerequisites for a workable professional code may be helpful as we think critically about Tilburt’s conundrum of dual agency. To begin, we believe that codes such as the ABIM Physician Charter are intended as guidelines for living in reality
as professionals in the field of medicine. In reality, it would be difficult for any individual to fulfill the expectations of codes of professionalism, because we are human and susceptible to relativity and human error. There may also be gaps between the values or attributes physicians believe to be important for professional behavior, and how these values or attributes play out in professional behavior. Moreover, physicians and patients experience and share different personal narratives. Thus, to suggest that a professional code can offer guidance that is both universal and specific enough to address every challenge is a lofty, if not impossible, goal. The issue of context is also important here. Context has a critical influence on individuals’ behavior and is essential to understanding lapses in professionalism (Ginsburg et al., 2000). Campbell and colleagues (2007) have illustrated that gaps do exist between what physicians endorse as important to professionalism, and how they actually act in practice. In one study by DeRoches and colleagues (2010), the reasons physicians cited for not acting in accordance with their own self-endorsed values (e.g., reporting an impaired colleague) included a belief that someone else would take care of the issue, a belief that nothing would change, and fear of retribution. There may be other ways to think about why physicians may not act in accordance with their professional values and beliefs. Do they modify responsibilities outlined by the ABIM Physician Charter and other professional codes, and if so, how frequently or typically? What kinds of situations might prompt this behavior? How do physicians balance conflicting obligations across a spectrum of professional challenges? In one of our studies, we explored how and why practicing physicians respond to a set of professional challenges (Ginsburg et al. 2012). Our goal was to develop a better understanding of how physicians view these challenges, how they come to decisions about how to act, and what factors influence these decisions.
Ó American Board of Internal Medicine Address correspondence to Kathryn M. Ross, American Board of Internal Medicine, 510 Walnut Street, Suite 1700, Philadelphia, PA 19106, USA. E-mail: [email protected]
38 ajob
September, Volume 14, Number 9, 2014
