Filing Right and Wrong: Fictitious Philosophy presented by a Physics Man (excuse my improvisation, but it cut off the title)

post by jones (apparently whom i needed to send an invitation to post?! forgive me!)

"Although I've taken a 4 year college degree in physics, I don't know if I'd exactly say that my specialty is physics. I know quite a bit, but I also know quite a bit about Ubuntu Linux and a little about frisbee, and climbing, and skiing, and whatever else. My point being, I didn't exactly know how to contribute to this blog, so I'm just going to do it any which way.

And that way is going to be with a little philosophy. Recently I read a book called Shantaram. Beyond the fact that I highly recommend it, there was an interesting section where Khaderbai, a wise old muslim-scholar-mafia-lord1 elaborated an ethical framework, which I think is worth looking at because it attempts to form an moral-ethical basis upon which people of all different religions (or lack of religions) can agree. This is ambitious. It's also very prescient. In this world where evil deeds can be done in the name of beliefs, religious or otherwise, a common system from which everyone could start is more than just desirable, it may be essential. So, let's talk about a moral system of ethics, which can be defined simply as a framework in which you can easily decide what actions are good and which actions are bad2.

Khaderbai begins with the generally accepted, scientific history of the Universe. First, there was a big bang, an infinitely small point "full" of structures below the level of even being particles3 quickly exploded out of oblivion. As this point expanded and cooled, particles were able to form. Then from particles, atoms (mostly just hydrogen and helium). Then from atoms, some basic molecules. As these molecules clumped together they began to form stars which could make new elements in their hot, dense cores. These stars eventually "died" shedding these new elements which were able to form more complex molecules ... eventually to the point of life4 ... and so on. His point in telling this story is that the universe is moving from structures which are simple to those that are more complex.

Here is where he leaves the general science by extending history into the future and saying as the universe gets more and more complex we are moving towards an Ultimate Complexity, which from his Muslim stance he is willing to call "God."5 But as he suggests, let's just leave it at Complexity. Now, moving toward Complexity is construed as a Good thing and moving backwards towards simplicity is Not Good.

So, lastly if we'd like to judge an action we can ask ourselves these two questions:

* What would happen if everyone did this?
* Would that help or hinder the movement toward Complexity?

So, for example, "Is it good or bad to kill?" Our answer becomes, "well, if everyone killed, we'd all be dead and we're pretty complex so that would hinder movement towards complexity, so it is bad to kill."6 Khaderbai then continues on to say that in absolutely all cases it is bad to kill. It can get sticky, however, when one asks, "Is it bad to kill that lunatic who is about to kill everyone else?" Khaderbai would say "Yes, it is wrong. If you were to kill that man you would be doing wrong for the right reasons." (remember now that Khaderbai is a mafia leader and does plenty of "wrong" things by his own definition) If you kill Mr. Lunatic, you do wrong, but you are doing it with the idea of complexity in mind. Many people might then say, "well, I guess it was actually right in the end to kill Mr. Lunatic" but the point here is it is your action that matters and if yours is to hinder movement toward complexity, then it is wrong.

Let me quickly summarize his points:

1. The universe is moving from simple structures to ones with increasing complexity.
2. This movement towards complexity, especially the idea of some future Ultimate Complexity is what we can call "good" (and if we're religious we might say we are moving toward God).
3. To judge the rightness or wrongness of an action we must ask, "If everone did this would it help or hinder the movement toward Complexity?" If the former, it is right; if the latter, it is wrong.

This is a very simple, even elegant system. It could be just as easily accepted by many secular people as by many religious believers. It's quite admirable in that aspect.

Unfortunately, there's a bit of a loophole7. The sticking point I came across was not really in the first two points, but in the two questions we ask to find out if something is wrong or not. Specifically, with the first part, "if everyone did this" and the way that it applies firstly to human social structures.

Take this example of a frisbee team. There's a pickup game of frisbee down at Greenlake. Two teams have formed, Blue and Red. Both teams begin playing, but the Red team is going every which way--directionless. Our moral question is, "Is it right for one team member take over and begin directing the other ones around?" (I know, not exactly a huge moral quandary.) The framework above would yield the answer, "No, it's not right because if everyone tried to direct everyone else, none of them would be paying attention to what they're doing and the team would be worse off than before: a simple yelling match instead of at least individual players running around." But, I think it's easy to see that it is right if one player leads. The team then becomes more complex and can use it's individual players in a coordinated fashion. Extending further, maybe one player might become the "handler" (thrower) and another be designated to chase when the frisbee is hucked into the in-zone. The point is that these specializations shouldn't be classified as wrong, which seems to be the case from the above reasoning. It's not wrong, as long as everyone doesn't do it. In fact, it moves us towards Complexity. Actually, it has been said by many8 that in order for evolution to occur you first need differentiation then reintigration, and unfortunately point 3 of Khaderbai's universal system doesn't allow for differentiation to be right or good. So, that's a bit of a problem.

So, you might ask, "Well, why in the hell did you even write about this moral philosophy from a mafia-lord in a half-fictitious book9 which can't even be right?" Well, because I think it's admirable10 and I think he's definitely on to something with points 1 & 2. Asking the questions, "Is what I'm doing good? Is what I'm doing right?"is essential to a well-lived life (or at least Aristotle thinks so). Being a volunteer in Uganda I ask myself these questions a lot more than I think I would back at home in the US. Maybe what's more interesting is when I know the answer to be "no" and still have trouble changing that which I am doing...

Anyway, enough spinning the philosophical cogs. Thanks for reading my musings.
~JONES
Footnotes

1 - I know this description, although accurate, sounds far-fetched and might immediately turn someone off to his words. Let's just look at the ideas for now.
2 - Or right and wrong. I'm going to use these terms interchangeably so as not to split linguistic hairs.
3 - Particles being things like electrons, protons, neutrons, etc.
4 - Sorry biologists. I know there's a lot of history here too, more in fact, but in the interest of time and not sticking my foot in my mouth, I'll leave that section to you.
5 - His argument makes a lot of sense, although a strict science perspective might raise the disagreement that increasing entropy implies increasing disorder, which is simpler than order. Also, we're going to ignore talk of the Heat Death of the Universe.
6 - I hope everyone agrees that should be the answer. I also encourage you to try out some other moral quandary in the system. I'm going to take a minute to do it now too, "Is it bad to only sit in my house and read all day?"
7 - Mystics might say that as long as we're using words to try to describe reality we can never capture the Truth.
I also wanted to add on the point here that we're talking about human actions, but you could also try to extend this other "acts of nature" and say that a planet-killing asteroid hitting Earth would definitely be "bad." However, similarly to how I will argue in a moment, it doesn't apply well to predators - "if everyone (now including herbivores) decided to exclusively kill other animals to eat that would be hinder movement toward complexity and be bad." But, complex eco-systems of predators, herbivores, scavengers, etc. is fairly clearly closer towards captial-c Complexity.
8 - I'm thinking specifically of Wilber in The Marriage of Sense and Soul and Arthur Koestler in The Sleepwalkers. A quote from the latter:

The process of evolution may be described as differentiation of structure and integration of function. The more differentiated and specialized the parts, the more elaborate coordination is needed to create a well-balanced whole. (527)


9 - Also, I don't know how fictitious this book is. I know it's at least partly, if not mostly true. If someone's bored and wants a research project...
10 - With my interest in secular philosophy, I've been told I really need to read some Bertrand Russel. Can anyone give me some suggestions on where to start (or be so indelibly kind as to send me something by him)?"

Another story

First, thanks to BurnPTCruisers for the in-depth comment. I should clarify that I was not in med school at the time of this incident and didn’t have the knowledge I have now (which, granted, is still extremely limited in actual clinical usefulness). But I did what I think any of you would have done in the same situation, which is to say, “If the poor bastard needs oxygen, then let’s give him oxygen!” It is very difficult to hurt somebody with too much oxygen.

I think the bottom line here was that our boss was thinking very short-sightedly, and did not realize that if we had done what he told us to do and the patient was harmed, the company would have been in MUCH bigger trouble. In his defense, he eventually came around to this (but for crying out loud, it shouldn’t even have been an argument!).

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Below is a report that I wrote up after a particularly sticky encounter with a patient at the hospital. The issue here is: the patient snapped her own IV line and walked out of the hospital. This is dangerous, because if the IV is not properly discontinued, she runs the risk of bleeding out. I caught up with her, wrestled with her a little bit, but eventually let her go because I didn't want to get MY ass locked up for assault. In case anything legal ever came of that situation, I wrote up my version of the story...

18 May, 2007

Patient was mid-30 year old female, possibly Native American, brought in by ambulance with a chief complaint of “too drunk for detox.” Patient was admitted to [the hallway where we put the inebriated to sleep it off], remained unarousable for most of her stay. Fluids were administered through an IV to her left hand. After approximately 2 hours, the patient awoke and I witnessed her sitting upright in bed. At approximately 1930 hours, patient was noticed by nurse and myself to be missing. The IV line had been severed and the patient’s belongings (coat and hat) had been left in orange bag beneath bed. Witnesses reported patient to have exited the south end of the ER.

I began searching the hospital for the patient while the nurse contacted security. I found the patient near the main staircase of the lobby, and called her name several times without response. I caught up with the patient and tried to convince her to return to the ED simply so we could pull out her IV and she could get her belongings. The patient refused, asking me on two occasions to pull out her IV there in the lobby. When I asked the patient if she wanted her belongings, she answered “They’re just possessions. Why would I want more possessions?” On two occasions, I took hold of the patient’s arm and attempted to escort her back to the ER, but on both occasions she resisted and said “No touching.” Several people witnessed this exchange. About two minutes after I had initially made contact with the patient, she exited through the lobby doors.

I returned to the ER and reported to the nurse that I had made contact with the patient, but she had refused to return to the ER. The nurse and I reported this to three security officers and the on-duty police officer. Security told us that once the patient was off hospital property, there was nothing they could do. The police officer and myself went outside to the ambulance bay and witnessed the patient walking eastbound on the north side of [omitted] Street. A security officer also witnessed the patient walking away. Security contacted the precint police with a physical description of the patient, who reported they would begin looking for the patient. I returned to the ER and took possession of patient’s belongings, arranging for them to be deposited in the lost and found.

A half-assed contribution

Disclaimer: I wrote this essay for an ethics assignment a few days ago. It was a throw-away paper, so I probably put less time into it than I would have put into a real blog post. I don't even know exactly what the hell I'm talking about by the end, but if you have some time to kill, you might find this interesting.

Our last patient of the day was a middle-aged gentleman with terminal lung cancer. He was being discharged from the hospital back to his home to begin hospice care, where he would likely die within a few weeks. He needed a constant supply of high levels of supplemental oxygen just to stay conscious, but when we entered the room, he smiled and waved.

I was working as an Emergency Medical Technician (EMT) for a small, private ambulance company and we were dispatched to transport this patient to his home. This trip would likely take close to an hour, but long-distance transfers were common for our company. However, when we reviewed his chart and noticed the amount of oxygen this patient would require, my partner and I realized we did not have enough on the ambulance that day to make the trip. We called our supervisor on the radio to give him this news, and he informed us that it could be another hour before the next available ambulance could get to the hospital. To our surprise, we were then advised to transport the patient anyway, while giving him less oxygen than he needed.

With this case, I can identify a conflict between patient care and business. First, with patient care, we were being asked to place the patient in a situation that could easily have been harmful to him. However, in terms of the business, it was likely that our superior had feared that delaying this patient’s transport for another hour would have reflected poorly on the company, which could have jeopardized future business with this particular hospital.

My partner and I were in agreement that it was simply too risky to transport this patient with the limited supply of oxygen we had on-hand. By knowingly placing the patient in a potentially dangerous situation, we would have been violating our professional ethics as EMTs, as well as our moral standards as human beings. In addition, we clearly would have been acting under negligence and could have faced legal repercussions if the patient had suffered any injuries. For these reasons, it was an easy decision to refuse to transport the patient and request that our supervisor call the next available ambulance.

Though I was taken aback by my supervisor’s request, I was also able to see the issue from his point of view. Like the operator of any small business, his top priority is the company. As a small business, his company must remain competitive with larger companies. Consequently, a single contract with a single hospital comprises a larger percentage of the total revenue earned. In an economic sense, a single contract is more valuable to a smaller company than it would be to a larger company. This is a reasonable business model for most companies; however, there are many more ethical issues at stake when the product being sold is patient care.

At our patient’s bedside, it was clear to us that we could not transport him. As EMTs, we had been trained to think with protocol in mind, and to always remember the legal consequences of negligent action. I do not know of a single EMT, paramedic, or physician who would have made a different decision than we did, and even our supervisor later admitted that he had been hasty and careless in his handling of the situation. This situation was unfair to everyone involved: we were asked to knowingly endanger a patient, and as a result, we were forced to stand up to our supervisor and put our own positions as employees on the line. Even if we had agreed to transport the patient, he would most likely have preferred to wait for the next ambulance.

Though I have never operated an ambulance company and have no experience with medical administration, I imagine that balancing business and medicine is a formidable task. As a former EMT and current medical student, I have been trained to think of the patient as priority number one. But medical administrators have to balance patient care with the demands of the business; if the company suffers or fails, patients may be negatively impacted as well.

So how is this balance determined? In the case I have described above, it might have been useful to have a third party mediator who could look at the case from both my perspective as an EMT and my supervisor’s perspective as the company operator. From my perspective, the refusal to transport the patient put him in no additional harm, but did have the consequence of placing me in an uncomfortable position with my supervisor. From my supervisor’s perspective, my decision may have somewhat tarnished the ambulance company’s reputation as a fast and reliable provider of care, but in the long run, it likely protected the company’s reputation as a safe provider of care. It would have been helpful to have a third party mediator who could have identified these issues and presented them to both parties.

I believe that the best patient care is delivered when both the healthcare provider and the administrator has a basic understanding of the issues that the other party faces. It is easy as a healthcare provider to only think of the patient in front of you and forget about all of the other hidden elements that contribute to (or detract from) that patient’s care. As a newcomer to medicine, I hope that there will be communication between the healthcare providers and the administrators wherever I decide to work in the future. If I do not get involved in medical administration myself, I can only hope to have the opportunity to learn enough about it to begin to see these hidden elements, and to use this knowledge to the advantage of my patients.