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Becoming a “Moral Agent”
Authors
Paul Batalden, MD, Professor of Pediatrics and of Community and Family Medicine, Dartmouth
Medical School
David Leach, MD, retired CEO of the Accreditation Council for Graduate Medical Education
Marge Piercy wrote in her poem, “To be of use” –
The work of the world is common as mud.
Botched, it smears the hands, crumbles to dust.
But the thing worth doing well done
has a shape that satisfies, clean and evident.
Sometimes we see or sense that things are not right in the care for patients and their families. It’s
like this great professional work we’ve been preparing for might have been “botched.” The thing
“worth doing well done” didn’t have “a shape that satisfied,” to use her words. What’s a
thoughtful, morally alert student to do?
How do you have good conversations about times like this? With whom do you have them?
Why have them at all?
In what sense are health professionals “moral agents?” How do you train or prepare yourself to
be one?
Today, care is really given by many professionals who are in some relationship with a single
patient, though it used to be the case that there was a single professional who cared for a single
patient. In this “many professionals, one patient” world of care, what is an individual health
professional responsible for? What are you responsible for?
Some things to consider doing:
1. Have a daily conversation with yourself. With practice and experience find the courage to
broaden the conversation to include other learners and sympathetic faculty. Lastly on
your experience further to encourage reflection as a habit using these four questions in
each of the microsystems (e.g. wards) and mesosystems (e.g. services) and macrosystems
(institutions) in which you work. The questions begin with “How did I do today in:
a. Discerning the truth;
b. Telling the truth once discerned;
c. Putting what is good for the patient ahead of what is good for the health
professional;
d. Being creative - harmonizing the best science with the particulars of the
patient in such a way as made my judgments creative and even beautiful?”
David Leach
Paul Batalden
May 15, 2009
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2. Ask your chapter advisor if he or she knows of anyone interested in participating in a
regular session to explore these topics and have conversations like this—to understand
and to improve health care.
3. Related to the issue of “many professionals, one patient,” explore the following question
with your chapter and faculty advisor: “What goes into making good promises in health
care today? What if a promise can’t be or isn’t kept?”
4. Interview five patients to map the health professional accountability for health-related or
treatment decisions which have been made recently or are needing to be made now or in
the near future. Which professionals are ultimately responsible for making different
decisions about the patients’ care? As you inquire about the decision-making, be sure
you understand the situation well enough to know the actual players in the decisionmaking – to know who actually is responsible and accountable, and who could change
the decision if the patient or family wanted or needed the change to occur. Explore
whether the patient and family know how to have conversations with that person and
whether they have had such conversations. Explore the patterns found among several
patients. Use the matrix if it’s helpful.
Decision about:
Accountable
health
professional
Patient/family
knowledge of
“accountable
professional?”
Comment
5. Create a lexicon of the ways in which a student’s concern is “languaged away”—find the
words, phrases, answers that diminish a student’s questions about the actual decisionmaking, real accountability in health care. . Begin by identifying a commonly used term
such as that found in the column labeled “Term.” Note the way it is commonly used in
the column labeled “Common reference.” Create a definition for what the term might
actually signify, noting the inadvertent dismissal and diminishment of the student’s
deeper desires to learn about real accountability in health care.
Term
“good case”
“This is not a
medical student
case”
Common reference
An example of a
pathophysiologic
process or sign,
preferably one that is
uncommonly seen.
Not a straightforward,
single disease process.
Reflective interpretation
An example of a patient’s
pathophysiologic process met
with an appropriate health
system response.
A situation where the
professional work has not been
equal to the need…Actually,
this term is often used to mask
a “not-good-fit” between
patient need and the health
David Leach
Paul Batalden
May 15, 2009
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care system response—but this
situation may therefore be a
wonderful teaching case about
why that may be so.
David Leach
Paul Batalden
May 15, 2009