No-blame culture and the loss of the sense of sin

When I was last working in a hospital (probably this would be a good point at which to say that I am a pharmacist) I was informed that we operated under a 'no-blame culture'. The idea was that if mistakes were made then it was important to be honest about them so that steps could be taken to reduce the causes of error. The rationale is obvious: a dispensing error can have serious consequences, but if you are afraid that you (or one of your colleagues) might lose your job (or be sued) over it you are unlikely to report near-misses.

 

To a certain extent, this makes sense. By encouraging reporting of near-misses you can look at the systems involved and take steps to reduce errors. The pharmacy I worked in was, like most hospital pharmacies, badly laid-out (usually because clinical pharmacy services have expanded rapidly in the last 20 to 25 years and most hospitals are older than that) and extremely busy. We provided pharmacy services to the equivalent of 3 hospitals and effectively needed to employ one person full time just to answer the phone for non-clinical enquiries (not helped when the town council once made a typo in some communication and we started getting all their phone enquiries as well!). Errors are bound to creep in with a turnover of this size, and it is important that systems do not faciliate them. By reporting near-misses you can take steps such as keeping all your high-risk (to the patient) medicines such as methotrexate and warfarin on a separate shelf; separate out the 6 types of Sinemet tablets and the 5 variations on Epilim instead of sticking to strict alphabetical order; check, double-check and triple check everything, and stick massive posters in your fridge so that everyone is careful to quadruple check the insulin. Manufacturers usually help by making the packs different colours (although it must be confessed that some of them appear to be more concerned with brand identity than patient safety). So far, so good.

 

But a no-blame culture can only go so far. Sometimes an individual is at fault. It is easy to mix up your Sinemet, true, but it is easier still if you are talking whilst checking, thinking about something else, have already been shouted at by a consultant that morning, rely on your memory when you aren't really sure, or were out the night before. A chief pharmacist I know once went a delivered an official reprimand to a cupboard (in another department) because whoever had filled in the incident form had stated that the error was 'the fault of the cupboard for being untidy'.

 

Pope Pius XII said that the 'sin of the century is the loss of the sense of sin'. We are all too ready to blame systems, or cupboards, or the fact that we weren't concentrating on the consultant who shouted at us, or the workload. No-blame culture may help improve patient safety, but it doesn't address the need to take responsibility for our actions. Often, when a patient is waiting to go home, it is 'pharmacy' who is blamed for the fact that they can't leave yet. Leaving aside the many occasions when actually the doctor hasn't written the discharge prescription yet, and the times when the medicines have been dispensed and delivered to the ward and carefully locked in a the medicines cupboard, if 'pharmacy' as a whole is to blame, then whose fault is it? The chief pharmacist? The ward pharmacist? The ward technician? The dispensary manager? The pharmacy rececptionist? The administrator who approved too much annual leave at once?

 

Following the Francis report there have been complaints that no-one at Stafford hospital lost their job. This situation is not quite the same as a dispensing error which is a genuine mistake, because a long-term, widespread cover-up of abuse is not a mistake. But in both cases, somebody must be responsible; there is a perpetrator (or more than one). Whether or not that person should be sued, or sacked, or strung up is another issue. The point is that we all need to recognise that we aren't perfect, we make mistakes, we choose badly, sometimes deliberately; we need to look at ourselves and admit that some circumstances are not beyond our control. And we need to start doing this on the small scale because some of us have jobs where errors are a matter of life and death. Some of us don't, but stop and think about the last time you broke a plate and whether or not you said 'the plate broke' or the 'the plate got broken' rather than 'I dropped it'. The truth will set you free: trust me, I'm a pharmacist.

Going under the knife

Considering (or perhaps because of) the amount of time I have spent working in hospitals I am still rather squeamish when it comes to surgery. I think it's amazing that it's possible to drill a hole in a bone and then tie a tendon or ligament through it or whatever it is they do, replace worn out ear drums using skin from behind the ears, or reconstruct a breast using tissue from another part of the body, but I don't much want to talk about it and I definitely don't want to watch. The idea of having unnecessary surgery is as incomprehensible to me as playing 'chicken' on a busy road, especially when I've trawled through enough medical notes to know that those wielding the knife don't appear to have the fine motor skills required to use a mere pen. Cosmetic surgery I find frankly icky (technical term, as I'm sure you can appreciate), especially the type where they suck fat out of one place in order to put it into another. Consequently I was surprised to read that this is on the increase.

 

This morning I was reflecting on the Holy Father's message for World Communications Day and I was initially surprised at how positively he spoke about social networks. I have read and heard a lot of comments about the evils of facebook, twitter et al which destroy interpersonal relationships, as individuals seek virtual relationships in which they can pretend to be whoever they want to be. However, as usual, Pope Benedict is right: social networks are neutral in themselves, it is how we use them which makes them positive or negative, good or bad. (I know I look like I've gone off topic: bear with me!) Similarly, plastic surgery is not intrinsically bad. There are many good uses to which it can be put, such as reconstruction following accidents or surgery or to correct physical abnormalities which present health risks in themselves. I am glad to see from the BBC report, though, that the number of 'man boob' operations has decreased because people are going to the gym instead. The operation, whilst superficially resolving a problem, does nothing to address the underlying cause, whereas going to the gym requires commitment and taking responsibility for oneself. At root it recognises that our actions have consequences.

 

When I say that there are good uses to which plastic surgery can be put, I don't know that think that all the others are bad. What concerns me is why people feel the need to have surgery to alter their appearance. In the same way that we can create an alter ego online, we can also project a different image by changing our physical appearance. We all constantly use 'masks' to hide our fears and insecurities, to make ourselves more likeable, or employable, or attractive (on whatever level). In other words, we take steps which we think will make us happier. In the drastic case of cosmetic surgery, it would seem that many people think that looking younger, or thinner, or having a certain body shape, will have consequences which in turn will lead to happiness. I question whether this is true. If a life is built on something which isn't real, can it lead to real happiness? And wouldn't our time and efforts be better spent on trying to be more like the One in whose image we are made, rather than attempting to alter our exterior to conform with any other image?

 

Keeping up with life

The Daily Mail (not my favourite source of healthcare/science, or indeed any other kind of news, but anyway) reports a worrying trend in the number of women taking stimulants in order to cope with life.

Aside from the fact that Ritalin and friends are not licensed for the treatment of ADHD in adults (ie their safety and efficacy in this group of patients is not proven) and that buying medicines on the internet is a stupidly dangerous thing to do there are some other concerning aspects.

The women taking these drugs are obviously experiencing extreme pressure to perform and conform, but more seriously still we can see a tendency to measure people by what they do. We are not ourselves, or what we eat, but what we do. This is massive problem because if you cease to "do" then you also cease to "be". In the case of the students using these drugs, their measure of themselves is how well they perform in exams: I am only as good as my exam results. Others struggle with the demands of juggling work and family life, or long hours and pressure to meet targets. But where is the weakness in admitting that something is hard? There is also, as so often with mental health, a reduction of the human person to the merely biological.

According to the article, women aged 25 to 34 are the most stressed demographic group in the country. No surprises there: we are the group who first experienced student loans, SATs at 7, 11 and 14 years, league tables, contraceptives for all, abortion virtually on demand... We have grown up being encouraged to turn down children in favour of career success, with the advice that giving up work for motherhood makes you a failure, that instant gratification is our right and we are also the generation whose parents lapsed in their religious pratices meaning that many of us have never stepped foot inside a church. We started life with the understanding that, as women, we would have to fight tooth and nail to be recognised as good enough and we have arrived at adulthood finding that most of the work has been done.We have moved on from the time where everything was blamed on our parents not giving us enough attention. Now we are our bodies. We have been formed by secularism and individualism and taught that an expensive pair of shoes can solve all our probelms.

We were promised the world, and the world turned out to not be worth the paper it was written on. Only God's promises are worth trusting, and the majority of this group have no idea what they are.

It's not my fault!

I was somewhat bemused to read yesterday morning that there is a gene for binge drinking. Further inspection suggests that this gene predisposes some people to experience a stronger physiological response than others when drinking alcohol.

Personally, I would say that binge drinking has more to do with sin, freedom and the perennial search for happiness than genetics. Obviously binge drinking can't make us happy, any more than sleeping around can (and there does seem to be a strong correlation between the two). But whether they know God or not, everyone has a hunger for him, a longing for the infinite, and without knowledge of God this leads us to look for happiness in many places where it isn't to be found. Furthermore, I would say that not finding this happiness, not being able to satiate this desire we have (because for so many people they haven't chosen to reject God, it's just that faith has never been suggested to them as an option) we end up trying to fill up our lives with <i>anything</i> that might make us feel something, be it sex, drugs or rock n roll. Of course this self-destructive behaviour leads us into a downward spiral of increasing unhappiness: only in God and his loving Plan can we find happiness. He has made us for Himself and our hearts are restless until they rest in Him, to paraphrase St Augustine.

I am not some sort of neo-luddite who wishes to exclude science and technology from every facet of life. If people have genetic tendencies towards certain behaviours or illnesses then of course identifying that and seeking solutions can be a good thing. But the increasing tendency to identify genes is part of both the "loss of the sense of sin" bemoaned by Pope Pius XII (once we blamed "the system", now we blame our genes) and also constant reduction of the human person to the merely biological. Yes, I have a body, but I am not my body. Neither am I my DNA. And while we continue to place all our hopes on genetics we will never find the answer to those situations which many would agree are a problem.

The majority does not rule

A Bangor University study on assisted suicide reveals that two-thirds of people accept it. Apparently  62,000 people were included, which I first thought was quite a lot. However, it turns out that this was an international survey, and so actually this isn't a very large proportion. "Accept" is also a rather ambiguous word, which makes me wonder what people were actually asked. Careful reading shows that this study was in fact a literature review which brought together the results of studies already carried out. Hmmmmm.

Something which strikes me as interesting is the fact that this report states that a recent review shows that doctors consistently resist assisted suicide. Let's leave off the pity plea and be realistic: "assisted suicide" is an attempt at making "euthanasia" sound better. And the reason doctors are resisting it is hardly surprising, since they are the ones who would be assisting. A person might want to die, their relative might think that they should be allowed to, but if you are the one writing the prescription or supplying the drugs then you are not assisting, you are enabling.

Researchers apparently also said that 'headlines tended to feature professional arguments against celebrity campaigners, with ordinary people "less clearly represented".' When they speak of professional arguments, do they mean that they come from professional arguers (eg. Chris Moyles...I don't know his views on euthanasia but I'm prepared to bet he'd have an arguement about it, Richard Dawkins, possibly one of the most argumentative men on the planet, or anyone's youngest brother providing the person they are arguing with is an older sibling), or medical professionals. Because if it is the latter than surely this puts 'celebrity campaigners' on a level with 'ordinary people'. As Blessed John Henry Newman said:

All bow down before wealth. Wealth is that to which the multitude of men pay an instinctive homage. They measure happiness by wealth; and by wealth they measure respectability... It is a homage resulting from a profound faith... that with wealth he may do all things. Wealth is one idol of the day and notoriety is a second... Notoriety, or the making of a noise in the world -- it may be called 'newspaper fame' -- has come to be considered a great good in itself, and a ground of veneration.

One commentator said, 'The medical profession needs to recognise and have respect for this majority view even if we don't agree with it.' And a palliative care expert (who I suspect may have been quoted somewhat out of context, on the basis that palliative care is all about not walking away) said that doctors must 'never walk away from patients'. All this makes me want to label the article with a big flashing sign saying !RELATIVISM ALERT! Combining these two comments makes it sound as if doctors are neglecting their duties by not allowing the majority (otherwise known as 0.0006% of the world's population) to dictate how they do their jobs. Even if 99% of the world's population were in favour of euthanasia, it wouldn't change the fact that helping your patient to die with dignity has a lot to do with helping your patient to live with dignity and nothing to do with ending their life prematurely. It also would not affect the intrinsic wrong of killing. So-called "assisted suicide" is the final step in the wrong understanding and use of freedom. Funnily enough it's the same as the first step (when Eve took the apple): I am free and therefore I have the right to choose...so I choose death. I refuse to accept my limitations that I am a creature and am finite. I reject God. I want to be God without God.

Sterilizing our children

This week there have been two articles worth mentioning in the news about contraception and teenagers.

The first is from the Telegraph and gives the details of girls as young as 13 being given contraceptive implants (effective for 3 years) and injections (3 months) at school, or in clinics, without parental knowledge or consent. First of all, I believe that patient confidentiality is essential, regardless of the age of the patient. However, confidentiality is intrinsically tied to consent: the person consenting is entitled to confidentiality. All medical treatment (legally this includes contraception - Medicines Act 1968) requires informed consent, and those under 16 can only give informed consent if they are deemed to be Gillick competent. Competence varies with every individual and intervention and I do not believe that any teenager, however smart can be deemed to be competent where a long-acting contraceptive is concerned. We see enough adults who struggle to conceive after years on the Pill; I cannot see that a teenager, who is unlikely to be considering the probability that they will one day want to have a family, would be able to give informed consent. Actually, come to think of it, there probably aren't many adults capable of giving fully informed consent to such an intervention, but unfortunately we aren't subject to the same criteria. If you are consenting to contraception, that assumes that you are consenting to sex, and that requires a level of psychological and spiritual maturity, not just intelligence. As such, not being competent, they cannot consent and therefore they are not entitled to confidentiality.

Secondly, we have an age of consent in this country which is 16. Why do we bother if promiscuity is going to be encouraged in this manner? Who are these 13 year olds sleeping with? Granted, there may be a small proportion who seek contraception as a badge of honour (a GP I knew who also worked in a Family Planning Clinic told me that she was somewhat plagued by teenagers who wanted contraceptives for the purpose of having them rather than using them), a rite of passage if you will. But given all the concerns over internet grooming and child abuse should we not be asking more questions? Teenage girls are not usually interested in boys their own age; even if a girl is 15 and her boyfriend is 16 that is still illegal.

This strategy is derived from the desire to decrease the incidence of teenage pregancy (I get it) at all costs (I don't). Given the current rates of STDs, especially the chlamydia epidemic, why aren't we thinking outside the box? What we need is a culture of openess: parents should not be their childrens' best friends or their worst enemies, but children should be able to talk to their parents. And the only guarenteed way to prevent pregnancy and STDs is through abstinece and I do not think we can promote abstinence without teaching young people about their own intrinsic dignity. Of course we have a problem in that we are now in the 2nd generation of permissive behaviour, the belief that freedom is all about doing what you want when you want, and the total absence of God which leads to seeking value in pleasure.

The other article states that girls are choosing the pill over condoms. Around 2006, the student newspaper in Manchester published the results of a survey which found that female students didn't want to go on the pill because they didn't want to be considered "easy". (It also discovered that a significant proportion of students believed that it was not possible to conceive whilst standing up, which says something about the level of education they had received, but I digress.) This suggests that they were not considering the pill because they were already in a sexual relationship but because they were expecting to have what I think could be termed 'random' sexual encounters. Someone who knows you is not likely to be judging you on being easy.

What am I bothered about? Well, firstly, these articles are about girls. No-one is talking about boys. Granted there are not so many contraceptive options available to them, but it appears that the current strategy is completely targeted at young women, and comes from an anti-life basis rather than the promotion of health and well-being. There was recent outcry when it was proposed that girls be taught abstinence. I agree that it is rather ridiculous, because boys also need to know about their dignity and worth (and sadly, teaching only one half of the population about abstinence would likely lead to an increase in the use of prostitutes). It could be argued that girls choosing these longer-acting forms of contraception are sleeping with their long-term boyfriends. But I think it could equally be argued that actually what is happening, extrapolating from the prevailing attitude of Manchester undergraduates, is that at least some girls are effectively sterilizing themselves in the expectation of casual sex. It is time that sex education was based on something real (anything! but preferably good anthropology) rather being completely out of context and taking sex out of context. Bring on existential sex education.

Who takes responsibility for this guesswork?

Over at the Hermeneutic of Continuity, Fr Tim Finigan mentioned (and I believe I am supposed to touch my forelock to him, but am new at this whole blogging thing so I am prepared to stand corrected) the case of Adrian Smith who was demoted from a managerial position for posting comments on facebook about same-sex marriage taken place in churches. I went and found the article in the Manchester Evening News because surely for such measures to be taken against him, citing gross misconduct, he must have written something actually bigoted (rather than just expressing an opinion, which is what is taken for bigotry these days) or incited people to burn down churches where same-sex marriages are performed or something equally extreme.

In fact, no.

Then I thought that maybe this is part of the recent spate of facebook/twitter crimes, by which an individual writes something more or less offensive (often whilst drunk) and gets sent to jail for it. I heard of a newly qualified teacher who didn't get the job he applied for because the governors saw pictures on facebook of him acting stupidly whilst drunk and decided that he didn't have the necessary character for forming young hearts and minds. People need to realise that twitter is public (and should be avoided when drunk) and that there is nothing private on the internet, including facebook. And, I think, the law needs to take account of modern means of communication which are changing much faster than the law ever can. Did Mr Smith, then, say something which he thought he was just saying to his nearest and dearest but turned out to be public?

In fact, no.

Mr Smith's 'crime' (bearing in mind that he is not being prosecuted, just sanctioned) turns out to be breach of his employer's code of conduct which, according to the MEN, states that employees must not "expressing religious or political views which may upset co-workers".

I think that warrants closer inspection...

Firstly, if you express views which may upset co-workers as long as they're not religious or political then that's fine. So if you were to express "Darcey's earrings are way too big but at least she's a better judge than Arlene was", or "I hope that Saddam rots in hell", "I am saddened and disappointed by the content of JK Rowling's new book. She may not agree but I think as a well known children's author she has a certain responsibilitiy" or even "I can't believe anyone thinks (insert name of celebrity) is good looking. He/she looks like they've been hit by a bus, and is also completely devoid of talent" all those are also fine. However, if you say "I don't see how Nick Clegg in conscience can remain head of the Lib Dems seeing as how he did a U-turn on tuition fees which has always been one of their manifesto promises," or "The government don't have a mandate for same-sex marriage and I can't help thinking that the furore is a cover-up to distract us from the failing economy, much like the issue of the Falklands in Argentina" that is not OK. And secondly, I feel there is a problem with the wording "may upset co-workers". It doesn't matter if no-one is actually upset by your religious or political views, just as long as they might be. But in this case, who decides? We're back to people being told that they can't wear a cross because someone "might" be offended. If no-one is offended, what is the basis for thinking they might be. And is there a difference if I say "I think abortion is wrong" and am a Catholic or if I say it and am an atheist. The statement equally "might" offend someone who has had an abortion but only in one case could it be argued to be a religious view.

It would seem that Adrian Smith has made two mistakes. Firstly, signing up to work for a company with such a ridiculous code of conduct and secondly using facebook whilst Christian.

Doctor What?

I am a big fan of Doctor Who. I watched it (and hid behind the sofa from it) and I remember being told that a particularly scary alien had been made by school children in their classroom. I didn't buy that: said alien was clearly going to come and get us all.

Although I watch Doctor Who, if I had children of my own I wouldn't let them watch it, because of the obvious agenda which has been present since its reincarnation with Christopher Eccleston as the Doctor, that is, the normalisation of same-sex relationships. I feel this is particularly relevant now with the current move towards the legalisation of same-sex marriage (despite the fact that the government has no mandate for this, but don't get me started). OK, so we all know that the BBC has a very liberal ethos, but it worries me that such ideas (not to mention the level of sexual innuendo) are being blatantly targeted towards children.

In the episode The Doctor Dances the Doctor (Eccleston) tells his assistant Rose that humans from the 51st century (ie. the pansexual Captain Jack) are more "flexible". The implication is clear, that we mere 21st century beings are limited in our understanding of human sexuality. By the 51st century we have come to realise that everyone can sleep with whomsoever they wish...be they man, woman, Ood, Time Lord or headless monk...and especially if they're Captain Jack. If there was ever an example of a person who sought, and failed to find, fulfilment in the concupiscences Captain Jack is that man.

In the recent episode A Town Called Mercy the Doctor asks the town preacher if he can borrow his horse. The preacher tells the Doctor that the horse is called Joshua, meaning deliverer. The Doctor replies that he speaks horse, "His name's Susan and he wants you to respect his life choices". Yes, that's right, gender is a choice. LGBT orientation is so natural that its even found in animals.

I had hoped that when Russell T Davies (whose writing frequently centres on sexuality - his series Queer as Folk portrayed a gay sexually active 15 year old - see Wikipedia for his complete works) left the series that this element would disappear. However, it was obviously not to be. Whilst A Town Called Mercy contains an interesting exploration of revenge, mercy and reconciliation, it also clearly portrays the aforementioned idea that we can choose our gender, as well as touching on the assertion that it is fear which leads to prejudice, hatred and violence, and the illogical inverse that all prejudice (or perceieved prejudice) stems from fear. How often have we recently heard gay-rights activists claiming that Christians are afraid of homosexuality?

If I am afraid of anything it is that the normalisation and acceptance of intrinsic wrongs lead to the perception that they are objective goods and that the confusion of freedom with licenciousness will continue to reinforce the dictatorship of relativism and the culture of death. Which is why I write with one eye on the screen, and the other firmly firmly fixed on a crucifix.

Harm reduction: Relativism in action?

Many of our healthcare strategies are based on harm reduction. We use methadone to treat drug addiction, substituting long-acting methadone for short-acting heroin. Many people live stable lives on methadone, but very few of them manage to get off the methadone. We have simply substituted one addiction for another, but we accept this because it reduces crime and anti-social behaviour. It does have some benefit for the individual as well, they are not committing crime or anti-social behaviour, but the benefit to society as a whole is much greater than the benefit to the person in question. They are still an addict; their dealer is now the government.

Pharmacies provide needle exchange services. Clean needles and sharps bins are given to drug users and dirty needles can be exposed of. Users do not need to share or reuse needles and therefore they have a reduced risk of contracting blood-borne diseases and other infections, using drugs is made safer. The NHS spends less money treating them and there is a clear public health benefit. But the individual is still an addict.

These strategies are not a total waste of time, and do bring some other benefits to users in terms of physical health. They are brought into contact with a health care professional whom they see regularly and/or frequently, and thus are enabled them to access other medical services. The problem is that that both these strategies are based on the premise that people will always take drugs (being intrinsically bad), an assumption that the person will not and is not able to change, and the reduction of the person to their body. We think we are choosing a lesser evil, but actually we are settling for a lesser good.

We were created good, and whilst are capable of misusing our freedom and choosing the bad, we are also capable of exercising that freedom in the way that it was intended and choosing the good. Choosing between good and bad is not the best use of our freedom: even a lab rat is capable of doing the same. The proper use of our freedom is choosing between good and better. Obviously our ability to exercise our freedom is serverely impaired by behaviour such as drug misuse and abuse, but it is not gone.

Reduction of the person to the physical is also seen in the way we attempt to address the epidemic of sexually transmitted diseases and teenage pregnancy: again, on the basis of harm reduction we throw contraceptives at the problem. Once again it fails to address the root of the problem which is a lack of understanding of what a person really is. Made in the image and likeness of God, we have an inherent dignity, a dignity further raised by the incarnation: God became man. The Lord Jesus worked with human hands, thought with a human mind, acted by human choice and loved with a human heart (GS 22). 

We have a body but we are not our bodies. We also have a soul and a spirit, and in the hierarchy of body, soul and spirit, the body is the least. We are capable of entering into relationships on more than a merely physical level. Understanding of this dignity leads to respect of self and others, a better basis for decision making and surely a change in the way we choose to behave. Quick-fix solutions of short-term harm-reduction are not the answer to problems which come from a disordered desire for instant gratification on a physical (and psychological) level and a wrong undestanding of the human person. They are much easier to measure which is good for government statisticians, but that is a topic for another day.