Freedom to Roll the Dice

 

Introduction

If professional autonomy is a negotiated and co-constructed agreement between relevant agents, then it follows that such a contract should imply or clarify what is meant by “professional freedom to…” and “professional freedom from…” as part of the agreement. But some of those freedoms are negotiated intra-professionally. Here I focus on some of key internal issues and argue that self-imposed constraints on our clinical freedom affects how we perceive our professional role and identity as much as it reflects how we interpret our professionalism. This in turn may affect how we conduct our negotiations with agents outside our own profession.

Context

Being a professional involves practising within self-imposed restrictions and those agreed with society. It also entails reflecting on our practice and exploring the appropriateness of professional boundaries and what may lie beyond those demarcations. The purpose is to enhance professional performance and our value to society. The history of the healthcare professions teaches us that the emergence, development and disappearance of professions is a fluid and dynamic on-going process in which demarcations can’t be considered as being secure or static. Other professions and agents, including the managerial ones, challenge others boundaries, roles and freedoms within the complex dynamics of collaboration and competition.

As therapists have sought to expand their roles over the past three decennia we collaborated, negotiated and competed with other professions, but equally we had to justify and/or promote the benefits of role expansion within our own professions. Over the years a range of professional job titles such as “consultant therapist”, “extended scope practitioner” or “advanced practitioner” have been used. Each of these titles seemed to refer to a range of quite different grades, roles and scope of practice across the NHS-system. As Clinical Commissioning Groups across the system face different local priorities and seem to adopt varying strategies to meeting NHSE expectations, therapists are experiencing different pressures and expectations across the system.

In previous articles we explored issues around professional autonomy and  I argued that current definitions insufficiently reflect what the therapy professions require in order to ensure optimal clinical outcomes for their patients. Most definitions seem to ignore or discount the impact of organisational environments, nor do they reflect the level of authority therapists needs to control requisite resources. Levels of accountability and responsibility professional therapists have seem to be regarded as absolutes rather than proportional. This would pose a problem for the therapist if, irrespective of organisational expectations and pressures impacting their practice, the responsibility they have for their decisions and actions remains unchanged and assumes they have full control over requisite resources. The concept of ‘professional freedom’ is problematic within the organisational context in which power-dominant agents impose constraints on therapists’ practice which impact on her decisions about the kind and duration of treatment, but also decisions about service development, research initiatives etc.  While the professional therapist accepts responsibility for their actions, this is not necessarily reflected in the levels of delegated authority to control resources. Where this is the case, moral decision-making about kind and duration of treatment may be compromised and internal conflicts and stress may arise. As Charles Hardy asserts: “…responsibility without authority is masogiscm….

Intra-professional checks on ‘freedom’

Freedom to decide and act within ones scope of practice may not only be constrained by organisational influences and expectations but also intra-profession ones. Our clinical decisions are inevitably influenced (if not caused) by variables such as our own experiences, biases, “rules of thumb” and our individual interpretations of the knowledge/evidence base. Whilst we aspire to base our practice on Evidence (assuming that we all agree what the phrase refers to), inevitably we, individually, have developed strategies to manage the significant amount of information we need to process. Part of the various strategies is to be selective. Much more could be said about this, but it is enough to say that our ability to elicit, process and integrate information and data from a variety of sources in real time clinical decision making and practice,  is bounded by the capacity of our working memory. We have individual preferences for this/that approach or combination of approaches and in accordance with our biases, engage with sections of the total body of knowledge that we are personally familiar with and have accepted as being justified and true. This in turn, reinforces, our preferences and biases. These kinds of issues have been explored extensively in the psychological literature over the past few decades (Newell and Simon 1972 Human Problem Solving  would be a good starting point if you wish to explore this further).

What are the underlying variables, values and believes that drive us to impose constraints on our self and our peers? To what extent are these real or perceived? In order to understand professional autonomy better, we ought to reflect on that word ‘freedom’ in the context of professional practice in more detail. I will explore this issue from two angles: 1) professional culture and 2) ethics/morality.

 

Scenario

Imagine four experienced physiotherapists undertake an in-depth audit of their clinical practice and outcomes. Their clinical results are comparable and they equally prioritise all aspects of patients’ safety and wellbeing. Their success-rates differ slightly and they use different decision-making strategies. Lesley has a 72% success rate, undertakes in-depth patient assessments, identifies the source of the problem, which informs her treatment decisions. Jo has a 75% success-rate, undertakes global functional assessments, and selectively investigates specific symptoms/signs if needed. Her treatments are guided by her patients’ responses. Hilary has a 78% success-rate basing her treatment decisions primarily on the information her patients provide about what makes them feel better and she empowers the patient (and/or relevant others) to self-manage their condition. Bobby has a success rate of 80%. She has developed a decision making strategy which involves using special dices (one for each quadrant). She pioneered and developed this approach  by  keeping meticulous notes, reflecting on her decisions, practice and outcomes over a three-year period prior to making this her mode of deciding. Each of the six sides shows a unique management strategy. The first throw of the dice tells her what to do re patient management. She progresses/regresses the selected treatment in response to the patient’s reaction to the treatment. She has collected data over the years, justifying her confidence and ability to predict clinical outcomes. In addition she treats 15% more patients then her colleagues (similar case load characteristics). Apart from these differences, their interventions are equally safe and all their patients are satisfied with the process, treatment and outcomes. Lesley, Jo and Hilary each have different explanations as to the efficacy of their interventions, but they refer consistently to a discrete number of treatment concepts. Bobby does not offer such explanations, but she is confident that her method consistently generates effective treatment suggestions.

 

We reflect on this scenario through the lens of professional freedom as if it were a real-world scenario. You may be intrigued by Bobby’s approach or you may already have judged Bobby to be unprofessional or unethical. Her approach certainly seems to be outside our comfort zone, especially if deterministic reasoning is your preferred mode of thinking. But lets try and suspend our judgment in order to explore on what basis we would deny Bobby the freedom to continue with her current practice. After all, to have autonomy as a person involves having the capability to not act on internal or external inclinations or stimuli (Emmanuel Kant) but to reflect on the facts and the interests of relevant agents involved in the scenario. To imagine that random choosing could be more effective than the trodden modes of deciding poses a major challenge, professionally. But to explore the possibility open-mindedly is a feature critical thinking and practical reasoning.

Freedom curtailed by “Clinical Reasoning

The fact that our 4 professional therapists have developed particular strategies suggests that they had the actual authority to choose and act in accordance with their preferences and judgements. In other words they have sufficient freedom from external interference, enabling them to do so. All four could claim that their priority is to offer best value for money and optimal benefits, to their patients, employing organisation and society. I suspect that the approaches used by Lesley, Jo and Hilary may feel more familiar or comfortable than Bobby’s. But the Bayesian theorem suggests that we should review our practice in the light of new evidence. Therefore, based on the evidence (in this scenario) Lesley, Jo and Hilary should to prepared to learn from Bobby and consider adopting her practice, assuming that all their data is valid and accurate. You may of course disagree, but you should explain why and consider that Bobby seems to have the stronger case. On that basis we couldn’t claim that dice rolling is ‘immoral’ or ‘unprofessional’, because it does seems to generate better results. To defend the claim that Lesley’s Jo’s and Hilary’s approaches somehow represent a more moral/ethical or professional approach to patient care would therefore seem a difficult position to defend, if we were able to suspend our inclination to conform to what we believe to be professionally acceptable and ethical practice.

In the context of the above-mentioned scenario it would be irrational to argue against dice rolling by saying that there is no supporting evidence; clearly there is. Admittedly, we need to appraise the quality of Bobby’s data, and insists she does further comparative research. But the same applies to the data presented by Lesley, Jo and Hilary. So there may be something else making us feel uneasy about Bobby’s approach. Possibly our bias may be to avoid regret should “things go wrong”. Regret bias can be a strong factor affecting decision making (and in a litigious culture even more so). The hesitation we feel may reflect the disapproval we fear from peers, the regulator, professional body or the law? But to reject dice rolling without a rational justification seems to equate to saying that we are not primarily interested in outcomes per se, but that we value something else more. These may include the narratives (concepts, theories etc.) and approaches that we feel reflect our professional identity, or the professional culture we wish to maintain and develop. After all we are actors operating in a professional culture that we value and one that is important to us individually qua person.

From that position, we could say that the ‘end’ does not necessarily justify the ‘means’ and that we as  professionals consider dice rolling to be unethical (or immoral). But objections on the basis of morality are likely to fail, unless it can be demonstrated that rolling dice in order to choose effective interventions is actually immoral i.e. wrong. I will come back to this point, after saying a few things about professional culture first.

Professional Cultural

Assuming for now that we are unable to condemn dice-rolling on moral grounds or for reasons to do with efficacy, we would have to look else-where: the professional culture, ‘the way we do things’. That culture includes rules of conduct, prevailing beliefs, norms and values and a common sense of a shared purpose. In other words our professional culture inadvertently frames our professional behaviour and modes of practical reasoning and acting. But this culture also is something we personally identify with and being part of it is part of our professional identity and role perception.

If we denounce dice-rolling we should be prepared and able to offer a rational explanation. We’d owe Bobby such an explanation, especially because her interventions seem to be safe and effective, offering society value for money. We would need to explain that her mode of decision-making is unacceptable from a moral and legal perspective. But explanations like “it is unprofessional” or ‘it’s immoral” won’t do, because they are not explanations at all. Even if these kinds of claims are said with sincerity and gravitas and even if most members of the profession agree with these claims that does not make them true in themselves.

The profession may well judge her practice to fall outside the accepted norm. We may argue that so far Bobby and her patients have been lucky but that rolling the dice does not constitute clinical reasoning. But why would that matter? If randomly choosing consistently generates better results  in this scenario and some other real-world contexts (see also Nassim Taleb 2007 Black Swan) then why should we dismiss the value of random choosing? Possible answers to that question would address issues such as accountability, risk-managment and the need to gain understanding in order to inform and improve future decision making and practice. Those kinds of replies would prioritise issues of professional culture and some notion of morality over efficacy and societal value.But they would  ignore the facts about the efficacy of dice-rolling in the here and now (or give this a lower weighting than other factors).

From the body of literature dealing with judgment and decision-making it seems that within professional cultures, there is a tendency towards conformity and the drive to reduce and manage clinical uncertainty. But it seems that where decision making under uncertainty prevails (because of a paucity of verifiable facts, and research based solutions) our professional narratives  provide us with a sense of certainty, to some extent at least. For example, the notion of core stability provided many of physiotherapists with an explanation regarding low back pain,  providing them with framework for clinical reasoning and treatments.

Reflecting on this and other examples we could say that we seem to have an inclination to accept well-presented explanations (irrespective of their validity) in order to help us manage our uncertainties. It seems that the stronger the consensus about the validity of some explanation/concept, the less uncertain we feel. As critical thinkers and professionals we may be well aware that an explanation/concept does not derive its truth-value from the breadth of consensus within the profession, but from its verifiable and falsifiable facts.

Explanation versus Prediction

As professional therapists we rate our ability to gain understanding about our patients’ problems and to provide explanations (such as diagnoses) and predictions (prognoses re the outcome).

Lesley, Jo and Hilary seem to value both explanation and prediction, while Bobby’s approach seems to favour prediction over explanation. Obviously it matters how we define ‘explanation’ in this context. If we define it as identifying the anatomical tissue at fault, our explanations are likely to be incorrect (or only partially correct at best). If our explanation involves a balanced conversation with the patient about the salient factors such as behavioural, physical fitness, environmental issues, and how best to manage them, we are more likely to communicate meaningful and helpful information i.e. explanations that the patient can actually relate to.

To consider explanations of the first kind to be more important than the ability to accurately predict an outcome would be justifiable if such predictions followed from the explanation. But that is seldom the case in physiotherapy, as we know. Bobby’s results suggest that explanations may matter less than we thought and maybe that is why we may feel uncomfortable  about her practice (even though we have not been told what the six/twelve approaches on the dices involve). We may be tempted to believe that a successful outcome confirms the correctness of our explanation (or diagnosis in some cases). But that would be a reasoning error, also referred to as “confirming the consequent” (See Edward Damer 2001 Confusion of a Necessary with a Sufficient Condition. Attacking Faulty Reasoning).

Part of a professional culture is the level of consensus about how things are, how they ought to be, and ought to be done. David Hume (a Scottish philosopher) argued that how things “ought” to be can’t be derived from “how they are” (or are claimed to be). If we were to condemn dice rolling as “unprofessional” we would be implying that cultural conformity trumps efficacy. But that is not a sentiment we would express differently and we would use a term such as unprofessional instead. Based on the above discussion it is not entirely clear that Bobby’s practice should be deemed to be unprofessional. Her case at worst is borderline and challenging, but it hopefully has elicited a number of relevant issues. So now we need to reflect on our suspended judgment that her practice could be considered as immoral.

Would we be right to deem dice-rolling wrong?

If morality deals with questions as to what is right or wrong to do for and to others (as it does according to Ronald Dworkin 2013) and we believe (as we do) that it is always right to get the best outcomes for our patients, it becomes difficult to explain why Bobby’s decision-making strategy should be regarded as immoral. If the moral case against Bobby’s practice can’t be made, we need not explore the ethical dimension, because ethical questions are only different from moral ones in that they focus more on questions about what we ought do to in order for our lives go better (Dworkin 2013). If however we believe that ethics is about questions of what is right/wrong to do to others, then morality and ethics would in fact be same things.

Either-way, our concern here is not about whether this is an ethical or moral issue. Rather it is about what is right and wrong in professional practice. As far as I am aware there are no explicit rules prohibiting Bobby’s practice and the ethical/moral case against it may be proof to be problematic.

If our intension is to make such a case, we wold first have to decide which ethical (moral) theory is most applicable to our scenario. We are spoiled for choice: Moral Realism, Relativism, Contractarianism, Pragmatics Ethics, Divine Command Theory, Naturalism, Moral Intuition, Deontology including Non-consequentialism, Utilitarianism, Act-Utilitarianism, Rule-Consequentialism, Libertarianism, Virtue Ethics, Feminist Ethics. I am not  trying and overcomplicate the issue but if we are going to claim that Bobby’s practice is wrong, we need to clear why and on what basis we consider it wrong. We can’t claim that Bobby is acting unethically or immorally without presenting a sound justification for our claim. We may use the terms immoral or unethical to express that we merely feel uncomfortable about Bobby’s practice even before we have analysed our sense of unease. But to make a moral judgment involves more that venting an intuition. The various ethical/moral theories seem to approach the process of making moral/ethical judgment quite differently. “There seems to be no rational way of securing moral agreement in our culture’ (Alasdair MacIntyre 2007 After Virtue). The facts of the case, and the interests of all relevant agents must be considered. The problem is that the various ethical theories offer different perspectives, and seem weigh different factors differently. Of course the regulator or professional body can state that Bobby’s practice is not permissible, but they could make such a ruling without referring ethics or morality. Not all prohibitions have or need to have a moral basis: parking on a double red line is forbidden for traffic technical reasons, not for moral ones. Should the regulator or professional body rule against Bobby, the question who will be disadvantaged by that ruling (in the short and long term) is a pertinent one, raising actual moral issues: is it right to allow professional norms to trump the development of un-orthodox but safe and effective treatment?

Professional culture revisited

Bobby’s case has hopefully provided a borderline scenario, without presenting an example of blatantly wrong practice. Admittedly a lot more information could be presented within the scenario, but the information provided is sufficient to elicit some of the most salient issues. So far we can’t condemn her practice as unprofessional nor can we say that she is acting unethically. And yet there is something that stops us from agreeing that Bobby’s dice-rolling strategy is preferable on account of its results. Somehow we would consider her practice is deviant from the norm. Undoubtedly social control within the profession is a significant driver, influencing our behaviour and thinking.

We may feel inclined to disapprove of Bobby’s mode of decision-making because we somehow feel bound to adhere to a set of tacitly known “ethical rules” which we’d be reluctant to break. The professional body may even rule that it is unprofessional and therefore not allowed. Or we could say that we think that dice-rolling in the eyes of the law might be deemed to be negligent and that Bobby would be liable should a patient bring a claim in case she came to harm while in Bobby’s care. But the underlying question is whether the results of random choosing are consistently inferior to those achieved by deterministic (or even probabalistic) reasoning and if evidence to that effect exist. The idea that an expert witness could probably be found to condemn the practice does not necessarily mean that the practice should be condemned when its risks and outcomes compare favourably with other approaches. The fear that the claim against dice-rolling could be upheld, acts as a deterrent. Regret avoidance can be a powerful motivator and may possibly become part of the professional culture. I suggest that this may act as a self-imposed restriction of our freedom needed to take the initiative to explore better ways of making decisions.

To be clear, I am not arguing for or against ‘dice rolling’, but believe that unless we explore the issues open-mindedly we can’t claim to be autonomous. So, what if Bobby system were the silver bullet we’ve been looking for?

Following rules!

Professional rules and standards reflect its members’ agreed values and norms and can be said to serve two major purposes: first to preserve the integrity and the viability of the profession. Secondly to contribute to the preservation of social viability, which after all depends on professional groups (and institutions) acting justly and with integrity (among other things).

Members of the profession are considered to have autonomouy and therefore can’t be treated as ethical robots, programmed to follow rules, unquestioningly. Being autonomous as a person and as a professional involves having the capability and opportunity to freely reflect and discuss standards and rules, in the light of new insights, information, evidence etc. It would be reasonable to say that this kind of capability is an essential feature of any mature profession that values its own long-term development and viability. In other words for therapists to “have freedom to….” we need to do two things: first to act in accordance with our autonomy as individual agents who exercise their agency within a particular professional role. Secondly we need to realise that this also entails having the ability to claim the intellectual space to explore issues without referring to tacitly known and/or simplistic rules, which remain unquestioned and unexplored. Exercising social control require care reflection and an inquiring attitude, not a judgemental one.

Of course, one can rightly object that being autonomous does not mean you can do what you like. But such a response would be silly and superfluous: nobody believes that we can just do what we like. To exploit professional freedom to explore different/new modes of working and practising or to reflect on and debate professional rules, standards, and practices requires us to have and understanding of the relevance of professional standards as the only credible starting point for such explorations. After all some standards reflect the law, while others are directly/indirectly associated with patient safety and the integrity of the profession and its value to society. What it does mean however that (for example) disapproving of dice-rolling on the basis that ‘that is not what we do’, or ‘that would be unethical’ is not only inadequate, it reflects the presence of a kind of ‘fear that we might be held responsible if things go wrong’. It would be reasonable to say that we owe  our patients and society an explanation as to why we wouldn’t role the dice, if it were likely to generate better results. We therefore need to identify to what extent we, intra-professionally, curtail our own professional freedom (and that of our peers) and whether our reasons for doing so are rational and to the benefit of society and our patients.

While managing constraints drives us be or become more creative problem solvers, undue and irrationally constraining professional freedom is likely to cause internal conflict and create a culture of worry/fear.

 

 

 

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