Covid-19 and the moral case for personal judgement
- November 25, 2020
- David Seedhouse
The tension between independence and compliance is everywhere in society – but in medicine, reason must come before rules.
The tension between independence and compliance is omnipresent. It begins at a birth, as the baby asserts its interests over its mother’s, and she responds with benign control. From nursery to school to the workplace to end-of-life care, we are pulled in opposite directions. We accept systems managed by other people so long as they deliver results, but at the same time we want to make our own decisions.
We live on a shifting spectrum – obedience to rules at one end, faith in ourselves at the other.
At the extremes of obedience, consistency is the gold standard. To achieve it we must have rules for best practice. If the rules are followed the outcomes will be the same whichever professional is helping whichever client; for the sake of reliability and to minimise risk, we should observe standards and protocols.
The opposite view, which prioritises individual difference over conformity, is that however much humans impose rules, sooner or later they lose their relevance. Human life is too rich to be governed by technical solutions. Life is not standardised. Intelligent healthcare, for example, requires personal reflection and intuition. Where there are rules it is necessary to decide which, if any, to apply. There is no alternative but to trust ourselves.
Algorithms versus heuristics
Different perspectives on this tension abound in psychology and the social sciences. The most general distinction is between algorithms and heuristics, in which an algorithm is a set of well-defined instructions for carrying out a particular task and a heuristic is a short-cut technique that helps you look for an answer without going through every step.
A very simple illustration of the difference is in searching for lost car keys you know are in your kitchen: an algorithmic approach would systematically search every inch of the room until the keys are found, guaranteeing success. A heuristic approach would use experiences of similar situations to look first in the most obvious places. There is no guarantee of success, but it is likely to be a quicker search.
Nobel prize winner Daniel Kahneman states that decisions based on algorithms are more reliable than human judgements. He claims that countless psychological experiments show that we overrate our decision-making powers. Our thoughts are distorted by psychological biases, so we make worse decisions than we would were we to use scientifically tested formulae. For Kahneman, our reverence for ‘intuition’ is a delusion. He observes that when you compare clinical predictions based on subjective impressions of trained professionals with statistical predictions made by combining even a handful of ratings, the algorithms are more accurate 60% of the time.
Kahneman gives many examples: longevity of cancer patients, length of hospital stays, prospects of success for new businesses, evaluation of credit risks for banks, winners of football games – even future prices of Bordeaux wine. He cites bookmakers as the perfect example of the supremacy of algorithms over human guesswork – the wisest and most informed punter may win sometimes, but with simple rules on their side the bookies will always triumph in the end.
Kahneman’s long-standing colleague, Gary Klein, favours the more natural approach. Klein rejects Kahneman’s conclusion because it is mostly drawn, he argues, from ‘artificial tasks assigned in laboratory settings’. He focuses instead on ‘naturalistic decision-making’. Klein spent years watching fire commanders, fighter pilots, paramedics and others making ‘split second decisions on the job’, which led him to conclude that ‘the expert decision-maker who behaves according to rational models’ is more of a myth than a reality. Klein found that expert decision makers do not go through a mechanical process of ‘comparative evaluation’ – there is just no time to do this. Rather their experience allows them to identify the most reasonable reaction as the first they consider, so they do not bother with any others.
The tension in healthcare
In healthcare the tension between obedience and independence is manifested in a conflict between practical wisdom and bureaucracy. Using practical wisdom, clinical care is an interpretive art in which health professionals apply ‘tacit knowledge’ or ‘unconscious knowing’ gained through experience to diagnose and care. As Klein discovered, seasoned health professionals grasp patients’ situations intuitively through unconscious pattern recognition, often more quickly and reliably than following step-by-step diagnostic algorithms.
At the bureaucratic end, echoing Kahneman, while we all experience tacit knowledge in our daily lives (cooking automatically, riding bikes without thinking, absorbing text on billboards unconsciously) in complex, organised systems it is necessary to have uniform procedures rather than leave things to chance. The managerial mind does not trust personal judgement – it is simply too risky, too maverick, too inconsistent. And there is a significant probability it will come to the wrong conclusions.
The ‘Mid-Staffs Scandal’
The ‘Mid-Staffs Scandal’ is a largescale example of this tension in a clinical setting. The scandal took place between January 2005 and March 2009, when hundreds of hospital patients at two hospitals in Mid-Staffordshire in England died because of substandard care and staff failings. Some patients received the wrong medication or no medication; receptionists rather than doctors decided which patients to treat; nurses switched off equipment because they did not know how to use it; and there was pressure to meet arbitrary targets set by NHS managers, including a 4-hour limit to treat people in Accident and Emergency.
According to the Daily Telegraph, the scandal is thought to have occurred because managers attempted to cut costs and meet targets for caring for patients within certain time limits, in order to achieve a coveted ‘foundation status’ for the Trust.
These targets apparently ruled supreme, overriding any other considerations – including personal judgement. NHS managers staffed the hospital so thinly that there were never enough consultants to supervise junior doctors adequately, so the juniors took their instructions from senior nurses and matrons, who religiously enforced the arbitrary targets. Health workers who failed to meet them were threatened with the sack. Junior nurses and doctors were repeatedly forced to abandon seriously ill patients to treat minor cases who were in danger of breaching the four-hour Accident & Emergency waiting time limit.
An extensive Inquiry chaired by Robert Francis QC recommended reforms designed to embed personal judgement in the system as a humanising element. Francis identified an ‘unhealthy and dangerous culture’, highlighting a failure to ‘put the patient first’, and pinpointing characteristics which contributed to this failure including a lack of candour; low staff morale; disengagement by medical leaders; and secretive, defensive cultures.
Francis made an astonishing 290 recommendations, chief of which was that the NHS should operate according to a common set of values and standards. He also proposed a process called ‘values-based recruitment’ – a mechanism to appoint people with ‘the right values’ by using psychological tests and asking them what they would do in situations which require a ‘caring approach’.
Francis wanted to move NHS culture toward ‘practical wisdom’. He was alarmed by how easily orders to follow insensitive instructions outweighed personal judgement in staff, none of whom were unusually cruel in everyday life. His recommendations might have been expected to lead to more autonomy for staff – and indeed they were encouraged to ‘whistle blow’ and be ‘candid’ about uncaring practice.
Yet Francis’ reforms brought about a significant increase in Codes of Practice and checkbox protocols. Despite Francis’ emphasis on the importance of value judgements, the stronger impulse was to try to ensure that every patient would receive the same standard of care and be ‘safeguarded’ above all else. Values are notoriously open to interpretation and cannot be relied upon to produce consistent practice, so the bureaucratic urge won out and a deluge of reforms followed. Thanks to the Prime Minister David Cameron, it also led to a practice called ‘intentional rounding’, which requires nurses to see patients every hour to ask them set questions about their needs, whether or not it makes clinical sense to do so. Naturally enough, such regimentation has driven many experienced health professionals away, so alienating them that many feel they may as well be replaced by robots.
Are rules inevitably dominant?
Examples of the apparent dominance of rules occurs in all spheres of society. Schools assert independence, individuality and creativity yet, the world over, they teach and examine the same, limited number of subjects, set in stone in a hierarchy with maths and languages at the top and dance and drama at the foot.
In the early 1970s, presaging the contemporary preoccupation with health and safety, Lord Robens was asked to investigate factory safety in the UK. He concluded there was too much prescriptive law, which expanded every time a new hazard arose. Instead Robens recommended a new form of legislation which laid down principles rather than precise instructions. His concept eventually took shape as the curiously named Health and Safety at Work etc Act of 1974 which required those in charge of safety to do everything ‘reasonably practicable’ to reduce risk, in a bid to emphasise the salience of personal judgement over a blanket application of concrete rules. To Robens’ dismay, however, this merely prompted a flood of further guidance from various quarters, each offering different interpretations of ‘reasonably practicable’.
Children’s play is a pointed example of distrust in personal judgement. The provision of stimulating play space provides the young with opportunities to develop and gain experience in experimenting with risk. Yet for the last thirty years this aim has been increasingly impeded because of fear of injury and – perhaps more importantly – of litigation, even leading to traditional swings (and roundabouts) being banned in some areas. Managed play has become progressively safer, and ever more unsatisfying.
Which brings us to today’s predicament. In 2020, to control the spread of a virus, citizens around the world have been subject to restrictions on civil liberties undreamt of a few months earlier. Governments have relished their power, rushing to control citizens without involvement or consent. The authorities have swiftly copied each other, as if in competition to see who can get away with the harshest policies.
Despite the severity of the measures, and in the face of clear evidence they are causing more damage to health and the economy than the virus itself, the great majority of citizens have conformed. When governments tell people to stay at home they mostly do; when they shut hospitality outlets people shrug and accept it; when they are told to wear masks, they wear masks; and when government measures contradict themselves – even when the latest law is the exact opposite of the previous one – most go along with them. A few people protest, in writing and through civil disobedience, but the majority either believe what they are told or find it safer to toe the line than rock the boat.
Personal judgement is intrinsic to human existence
Over the last few months opinion polls have repeatedly shown that people want greater restrictions on their freedom. People value safety, certainty, predictability, and assurances about the future. We are condemned to be free and we resolutely resist our freedoms.
There are countless examples of the human willingness to conform, even in the most extreme circumstances: junior pilots choosing not to challenge their superiors even to avoid their own deaths; prisoners preferring prison to freedom; experiments in psychology in which subjects will inflict painful punishment on strangers when instructed to by an authority figure they have never met; soldiers committing barbaric acts in their thousands – mass mutilations, torture and rape –because their unthinking acceptance of the assumed morality of their group overruled any individual sense of right and wrong. It can seem that obedience is the strongest force.
Yet, the need to be free is more deep-seated than the apparent haven of conformity. Ultimately it is what it means to be a human being. As disruptive and unwelcome as it may be, we cannot be without personal judgement. We have no choice but to make choices. If we are unable to choose then there is no reason for us to exist.
Personal judgement is everywhere
Arguing for the importance of personal judgement requires an understanding of what it is to be a person. Though we tend to think of ourselves as being consistent in our judgements, reflection on life’s experience shows that we are changeable creatures, made up of all sorts of influences, most of which we are usually not aware of.
Each of these influences, and many more, continually combine to create us. Some of the influences are relatively static (our personalities for example), some are volatile. Just as our moods fluctuate, so our stresses, health status, pain levels, relationships, knowledge, and emotions change us incessantly. The John Smith who woke feeling calm and beneficent is different from the John Smith who ten minutes ago opened an email from Human Resources summoning him to an urgent performance review.
We see circumstances differently dependent on our personal makeup at the time. We perpetually combine ourselves with external conditions, creating endless, unique situations.
Personal judgement varies as we vary. In every meaningful context it is both necessary and unpredictable, placing the responsibility to choose on individuals, whatever the rules.
Personal judgement is the daily reality of coalface healthcare. Consider some examples: you find your colleague in the staff room eating food from the patients’ trolley. The food is left over and will be thrown away, but it is against the rules for staff to eat it. Your judgement of the circumstances is a personal matter. Others will judge differently from you. Maybe you see theft, maybe you see need. Maybe you are irritated, maybe you are empathetic. Which would it be?
Or perhaps you are a doctor in a pain clinic. Your client wants more pain relief, but you worry he is becoming addicted. How do you balance these considerations? There are rules and scales you can use, but ultimately pain is subjective, and interpretation is necessary. How would the situation seem to you?
Or maybe you’re a third-year student nurse working on a busy Care of the Elderly Unit. It’s your first day. The Senior Nurse is showing you around. You’re stopped by an 82-year-old woman, who’s sitting beside her bed. She grabs hold of your trousers, asking, ‘What’s the time?’ ‘What’s for lunch?’ She is obviously in need of comfort. Before you can help, the Senior Nurse states loudly and impatiently, ‘Mrs Smith’s demented. She forgets everything. Come on dear, she’ll have you there all day.’ Would you stay?
Towards collective personal judgement
Margaret Thatcher famously declared that society is a myth. Specifically:
There are individual men and women and there are families and no government can do anything except through people and people look to themselves first… There is no such thing as society. There is living tapestry of men and women and people and the beauty of that tapestry and the quality of our lives will depend upon how much each of us is prepared to take responsibility for ourselves and each of us prepared to turn round and help by our own efforts those who are unfortunate.
One reading of this is fiercely individualist: people are naturally separate and responsible for ourselves. An ardent admirer of Hayek’s philosophy, Thatcher believed there was no sensible alternative to free market libertarianism. It was the collective outcome of personal judgements, rather than central planning and control, that made nations prosperous.
Arguments for the primacy of personal judgement are often used in support of this outlook, but this is not the only interpretation available. The idea that ‘there is no such thing as society’ can also be understood as an apolitical expression of a fundamental philosophical truth, namely that personal judgement is the quintessence of meaningful life and precedes politics.
A belief in the power of collective planning and trust in personal judgement are not necessarily at odds. Encouraging personal judgement does not imply a narrow political view of individuals as distinct entities in perpetual competition. Since persons are fascinatingly complex, with varied knowledge and life experience, praising personal judgement not only celebrates difference, but can also support a case for implementing decision-making methods which tap into our rich subjective wisdoms.
An obvious alternative to top-down decree is to broaden decision-making processes to include diverse voices, knowledge, values, experiences, and cultures – as an effective way to arrive at well-informed consensus. This could be achieved by properly organised and funded Citizens’ Assemblies, with decision-making powers, where policies like lockdown could be properly explored and debated, and different personal judgements could be heard. Our current leaders would be invited to present their viewpoints, which would then be subject to scrutiny from assembly members from many walks of life. In these Assemblies our leaders would have to defend and justify their opinions and would, in the process, learn about and be able to reflect on intelligent and compassionate alternatives, improving their own capacity for personal judgement in the process.
This is not a new idea. There are many successful examples of collective decision making including a wide-ranging project in the USA – Citizen Voices on Pandemic Flu Choices – which explored what should be done in an influenza pandemic. The idea was to enable policymakers to understand the range of society’s values via public engagement which involved both experts and hundreds of citizens with diverse backgrounds and perspectives. It was an inclusive public process which provided an opportunity for frank, open dialogue and careful deliberation. It is worth noting that despite the different backgrounds of their members, the groups involved reached a ‘very high level of agreement’: namely that the first immunization goal should be to assure the functioning of society, followed by the goal of reducing individual deaths and hospitalisations due to influenza – the very opposite conclusion to the current consensus among a bunkered group of scientists and politicians.
The pandemic has revealed a decision-making crisis rooted in the preference of ill-equipped officials to command rather than to listen. If society is no more than a ‘tapestry of individuals’, as Margaret Thatcher controversially asserted, then we are all equally entitled to decide what happens to us.