Quality as Moral Progress: Science and Conscience.

“Quality is nothing but care writ large and sure”  with abject apologies to Rudolf Virchow.

There are two defining characteristics of human beings: The need to know and the need to improve. The foundational question in any science including medicine is an epistemic one: How do you know that you know? Similarly, the very nature of any science is its capacity to progress. In the traditional practice of medicine, while research is the methodology that answers the first question: is something true. Evaluation is the methodology to answer the second. Does something work?  This conception seems reasonable, and the majority of the current generation of practioners are accustomed to the description of medicine as a science. That is what brought quiet a few of us into medicine in the first place: the heroic vision of curing humanity. However, the current situation in medical education  is so bland, that anyone claiming to join medicine motivated by a passion to care, would be viewed with suspicion or as someone incapable of original thinking.

Understanding the nature of medicine and for that matter its other derivative disciplines such as nursing etc is a prerequisite to answering the question of why bother about healthcare quality?  Is medicine really a science? Is there a universally accepted theory of medicine? But to do this well we need to ask a more basic question : what is the nature of science?  Neither of these set of questions are convenient to ask nor can they be answered in brief. Thus it is little wonder that we do not come across these questions during the period of training and most clinicians probably retire without any such intellectual doubts. The characterization of medicine as a science is a convenient one and has definitely served its purpose of detaching itself from the shamanic origins. An agenda set in motion by Hippocrates of cos , in  6th century BC. That diseases have natural causes. Yet, this would be a partial reading of history: the Hippocratics or the Coan school were considerably holistic, compared to the Cnidians, like our modern day evidentialists,  who were compulsive about the specifics.

The idea of medicine being a science is derived from the notion of it being research based and thus by corollary  science based. Carrying out research does justify the use of the term medical scientist. But this only refers to the medical researcher, who need not be a practitioners. The true description of medicine is that it is a practice [ regardless whether it is based on science or not ] and constitutively ethical. Medical practice is by its very nature evaluative. Thus caring is the most central nature of medicine. You are clinician [ physician , nurse etc] because you care for the sick. Thus medicine is foundationally relational [to care there must be an ‘other’] and though not merely transactional, but social. “Medicine is a social science, and politics nothing but medicine on a grand scale.”

Medicine seems to have been seduced by the characterization of science that entirely based on facts and being immune to values. Its ambitions to emulate the exactness of Newtonian physics is itself a incomplete understanding of the history of science, given that physics has long since redefined itself with the arrival of quantum mechanics.  Just as the question of what can be known is always only an approximation of the truth, so also what works is an approximation of the perfect or good. This clearly fits in with our daily practice of medicine, where the results of actions are not precisely predictable. Often times we rationalize this predicament by erroneously calling medicine as also an art.

The question what works carries the burden of accountability and aspiration. Am I doing the right thing the right way is based both on facts and values. Improvement is not merely what you do or create, it must be ‘what you want’.   Do I want to do good or pursue excellence is a prior question. There cannot be any deontology without teleology. If evidence and science gives roots to medicine, quality gives it wings. The patient centeredness is not romanticism but the holistic conceptualization of accountability. While the clinician asks: have I done the right thing right, the patient who makes a value judgement of whether he feels better, safer and cared for. has a “felt need”. If that need is met, quality is created. Value is always subjective. If caring is placed central to the practice then and only then is there room to ask and answer the question: why bother about healthcare quality. Quality is an ingredient of caring. Quality originates in empathy. A passion for medicine is the true impetus for quality, something that entitles every clinical student to learn improvement science at the very beginning of their initiation into their professions.

However caring is incidentally devalued in modern medicine as something residual and not as a apiori [ie from the first ] principle. I say incidentally because if cure occurs caring seems to be deem unnecessary.ie current characterization of clinical practice is transactional and contingent. Caring is mistakenly attributed to a state of helplessness. There is nothing more I can do to help; therefore at-least let me care. This is symptomatic  of an over-exaggeration of doing and the subjugation of being. It prejudices ‘acting on the object’ over ‘relating to a subject’.

These arguments are under the assumption that the practice of medicine is what transpires between the patient and the physician. It is more fundamentally ,what transpires between the profession and the society. Social activism is integral to any modern definition of professionals. There can be no quality without equity. An idea that Don Berwick , in a recent  plenary speech , eloquently  called the ‘Moral Test’.

Improvement is the essence of being and becoming. It is determinant of ‘quality of life ‘ of professionals and patients.This the reason, regardless of all the methods and models available in improvement science , it is mahatma Gandhi who has the last say: be the change , you wish to see in the world. Only if improvement begins in value will it end in fact. Improvement requires multiple ways of knowing. Improvement science is more than scientific Improvement.It is about creating ‘value’ and ‘virtue’.

Keywords: Value , Virtue, Improvement Science , Scientific Improvement, Care Ethics, Doing, Being, Becoming, ‘acting on object’, ‘relating to Subject’,  Research, Evaluation, Social science, Foundational, Constitutive, Equity, Passion.

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