Understanding “Unwise Choices”


Dr. Hanna Pickard presented the first lecture of the 2015-2016 Killeen Chair of Theology and Philosophy series on Wednesday, Sept. 2 at 7:00 p.m. in the Fort Howard Theatre. “Unwise Choices: Thinking about Responsibility, Blame, and Compassion in Healthcare Contexts” focused on the problem of separating accountability and blame in medical care, the reasons for doing so and the opportunities it presents for the healthcare system and society in general.

Pickard is a Reader in Philosophy at the University of Birmingham in the United Kingdom but also works as a therapist for the Complex Needs Service, a service from the U.K.’s National Health Service for people with personality disorders and other complex needs.

Pickard began her lecture by explaining how she became involved with the Complex Needs Service 10 years ago. Deciding to work not just academically but also clinically, she left the “ivory tower” of All Souls College at Oxford University one day a week for a Complex Needs Service clinic, without any prior experience or training.

“Working with these patients (at the clinic) was a transformative experience,” Pickard said.

Pickard explained that patients with personality disorders are often stigmatized as “patients nobody likes” because of the destructive behaviors they often exhibit, such as self-harm, disengaging from medical care or threatening others. Pickard identified these as “unwise choices,” choices that foreseeably or intentionally harm the self or others.

Unlike the traditional healthcare model, Pickard’s workplace functioned as a community, where physicians shared responsibilities with their patients, developed close emotional ties with them, and treated them with responsibility but without blame.

Pickard stated that she wondered, “How could I do it? What did responsibility without blame mean?”

This query led Pickard to three questions that she used as the body of her lecture: 1) Why distinguish responsibility from blame in healthcare? 2) What does doing so mean, in theory and in practice? and 3) How far should we aim to change attitudes within and without healthcare?

Pickard answered the first question by focusing on the increasing trend of labeling conditions like addiction as disorders or diseases. Doing so makes people into helpless victims, when usually these people can still make choices that affect themselves and those around them. Pickard mentioned that drug addicts can resist taking drugs if they have other alternatives, such as receiving small sums of money for clean urine samples.

She claimed that many patients are caught in the “Rescue-Blame Trap”: On the “rescue” side, patients cannot help their behavior but also cannot get any better. On the “blame” side, patients that seem to choose their behavior are seen as making poor choices and thus undeserving of help.

Pickard covered the next question to offer a solution to the “Rescue-Blame Trap.” Instead of blame and punishment, she said, patients with complex needs should be shown support with care. Pickard stated that not only do these patients have choices in how they act, but we also have choices in how we respond to them. She argued that we need to approach patients as individuals and understand what led them to make certain decisions.

“If we know their story, we know much better what they need,” Pickard said.

Pickard herself stated that she would dodge the last question of how far the change in thinking about responsibility and blame should go. Instead, she stressed that “We as individuals should shift our thoughts, blaming others less but still giving them responsibility.”

She used parents’ relationships to their children as the best example of responsibility without blame, and she expressed hope that the medical sector would follow this example to create “the skeleton of a moral yet practical healthcare system.” Pickard ended her lecture by recommending that we should question any sense we have of entitlement to blame.

Said Pickard, “Simply, if we blame, we should do so responsibly.”


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