Friday, May 1, 2009

On ethics in bad scenarii.

ATTN: Mr. R.T.Quoll

Dear Reginal,

If the patient is twice as likely to have illness A as illness B, but treatment for A will kill him if he has treatment B, then we're watching House I'm not sure what should be done; moral certainty that the doctor should prescribe treatment A seems to require additional conditions.

Well, IANAD.

I think one of the fascinations of the "ticking time bomb" is related to the "fourty ninjas with uzis" fascination among so-called what-if monkeys.

It seems that the ticking-time-bomb interrogation *starts* with a (sensible!) desire to emphasize that some situations have no good immediate temporal outcome. IF the object of the scenarist is to exhort his pupils in the face of catastrophe not to despair nor to acquiesce to their vengeful or violent inclinations to "save thousands whatever the cost", then the scenario has perhaps been well-presented. On The Other Hand, if the scenario is presented as a harangue with the object of getting you to admit that sometimes this particular disgusting idea (torture, abortion, genocide) is the best answer, then sound the alarms and call your diocesan inquisitor.

The what-if monkeys seek to prove their schoolmasters fools by constructing scenarios in which the schoolmasters have no good thing to do: that is, they believe the best analysis is achieved by *complicating* the problem. Of course to me, this sounds like making our jobs more difficult than they need to be. If we've studied mathematical logic, we know there *is* a degree of complication that makes algorithmic decision impossible; the really mathematical approach to a Doctor's Diagnosis/Treatment Dilemma is to first simplify the problem.

So, let's try! (continuing the medical metaphor) Given the candidate diagnoses A and B, it's possible that neither condition (if untreated) is a life-threatening or debilitating condition. e.g. the conditions A might be common cold --- keep your energy up and don't stress-out? --- and B might be a deadly allergy to most of the food in the hospital that got a bit inflamed by walking in. "Treating" A would consist in moderate rest and eating, but if you insist on feeding the patient there and then, he'll die of ... something, anaphylaxis? However if you just send him home, he'll eat sensible foods and/or eventually get over his cold.

A worse, but still simplified possibility is where one candidate condition is harmless, but would complicate under treatment for the more-dire candidate. I expect one might look for a test to specifically *exclude* the milder condition, to conclude on the bad option by elimination. I don't imagine this is generically possible, but still emphasizing that there are still options

And I suppose we *can* imagine bad situations where both candidates have treatments we can't safely pursue in both circumstances, or together AND we can't diagnostically distinguish conditions A and B, but at some point we have to remember that you can't humanly fix every situation. That isn't failing as a human doctor, any more than it's a failure in a detective to not obtain plot-thwarting inteligence by abuse, nor of a self-defence expert to prove mortal when confronted by firearms.

At least, that's how it seems to me.

SGOTS the ethical dabbler

P.S., I think Tom will find this either interesting or hackish. If you can ask his opinion, that'd be nifty.


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