Tuesday, April 24, 2007

The ought problem in medicine

The is-ought problem is a philosophical argument first discussed by David Hume, that challenges the use of statements of what ought to be, versus statements of what is. Hume challenges the translation of what is (the observable) into what ought to be (the moral). His description of the problem (a single, elegant paragraph), challenges the very derivation of moralism (in any form) from what observably is. Hume seems to believe that is and ought are not as closely related as most moral arguments make them seem, and that the determination of what ought to be is far more complex than the simple extension of what is.

There is a great mythology in medicine that patients 'ought' to behave rationally, and that they will somehow behave rationally if only they are compelled through argument of their physician. Rationality, through the physicians eyes, often involves the preservation of good health through the avoidance of detrimental behaviours, or through the treatment of disease. In the office this usually sounds like 'You should stop smoking', 'You should stop eating fried food', 'You should submit to screening for any number of various diseases', 'You should take better care of yourself'.

The usefulness of recognizing that this interaction is part of the is-ought problem is through recognition of the fact that much of the advice given by physicians is (in a philosophical sense) moral advice. The moral basis behind all of this ought advice is the presumption that patients ought to do what is best for their own health. In many ways this is a reasonable philosophical assumption; in other schools of thought the idea could be thought of as maximizing utility, or as a soft duty, within the confines of personal liberty.

The problem with this particular ought to is of course that it bears no resemblance what so ever to observable reality. Patients (in fact all people) simply do not make their choices in a way that optimizes health. I doubt I have ever seen a patient without a health impairing vice. People continue to smoke, lead stressful and sedentary lives, eat (delicious) fried foods, and generally take care of themselves poorly. Rarely is the moral advice of the physician heeded, though often it is given. You ought to do this, you ought not to do this, is a refrain throughout medicine. Often given, rarely heeded.

One of the premises of this medical moralism is the presumption that people will behave rationally. Again, this is a nice idea, but is in great conflict with observable reality. 'I know I've gotta stop smoking Dr. J.' my patients tell me. They have the capacity for rationality. They recognize that they are hurting their health. They recognize the implicit ought. '...but I just don't want to yet."

As a pretender to the hard sciences medicine gravitates towards rationality. In proving objective truth about health and disease it serves a great function. In inflicting the burden of rationality on to patients it goes too far. When I give my moral advice to patients, I am not surprised that they often take a pass. The rational thing to do of course would be for all of us to maximize our health. The problem is that rationality doesn't work well for non-rational people. So I understand why my patients wave at me with their cigarette in-hand when I walk to my car, as well as I understand why I continue to enjoy a big bowl of ice cream. Knowing what we ought to do, is in many cases simply besides the point.

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