Mind the Gap

This week I did something reckless. I put a patient at risk of potential harm without informing them of the fact. I purposefully denied them of their right to weigh the pros and cons of the treatment I was offering and thus make up their own mind as to whether they wanted to accept it. It was crazy of me I know, but I paid no heed to the high severity warning that EMIS flashed at me when I prescribed some flucloxacillin to a patient already taking paracetamol and thus wilfully exposed my patient to the increased risk of high anion gap metabolic acidosis associated with that combination of drugs. I did not practice caution in my prescribing in the way that the manufacturers of paracetamol advise.

It seems to me that one can barely prescribe anything these days without receiving a warning of the potential harm one may be causing a patient such that it is a wonder that anyone ever leaves my consulting room alive. Perhaps I am the only one who for years has prescribed flucloxacillin with paracetamol with ne’er a care, perhaps I am the only one who has been fortunate enough never to have run into trouble with the associated high anion gap metabolic acidosis, but I rather suspect that the high severity alert I received was a tad exaggerated. Correct me if I’m wrong but I rather expect I may not be the only one who, as well as struggling to explain what high anion gap metabolic acidosis actually is, had never heard of its association with what I previously had considered a pretty benign combination of drugs.

Why then the marked increase in these alerts which, apart from anything else, make it more likely that we will fail to notice appropriate warnings for genuine prescribing errors that we may be at risk of making? Part of the answer to that question no doubt relates to the desire of all and sundry to cover their backs in the belief that, if a warning has been given, they will no longer be culpable for any harm that may result from their product. This is understandable to a point but the consequence will be that, with nobody else being prepared to take responsibility for a management plan, in order for a patient to decide to accept a proposed treatment they will require a higher medical qualification than their doctor who is is somewhat unsure of the finer details of the warnings that they are passing on.

I wonder, however, if another reason for the explosion of warnings that we are currently being exposed to might lie in the belief that if we simply have enough information we will always be able to make the right decisions and thus always ensure a happy outcome – that if we are well enough informed, the means for success will surely lie entirely within us. To believe as such is however, not only a mistake but one that puts an ever increasing burden on us to be what it is, in reality, not possible for us to be – that is perfect.

We have, I think, adopted what might be called a ‘Philosophy of Victory’ – a philosophy which results in us believing that our goals are always attainable. We are essentially invincible – if we will only try hard enough we are always sure to win. Health, wealth and prosperity, can all be ours and we have only ourselves to blame if they are not. But our excessive desire for these things, and our belief that they are ours for the taking, has resulted in a society where the strong succeed and the weak can go to the wall. Ours is a culture where pride and self advancement are heralded as virtues and humility and self effacement are seen as weakness.

But if I have learnt anything this week from the existence of high anion gap metabolic acidosis it is not so much the dangers of simultaneously prescribing paracetamol and flucloxacillin but rather that, the more we learn the less certain everything becomes.

In his book ‘The Uses of Pessimism and the Danger of False Hope’, Roger Scruton warns against what he calls ‘the best case fallacy’, the illusion that we are prone to believe that progress will inevitably bring about a future state of affairs when all will be well. ‘There is’, he writes, ‘a kind of addiction to unreality that informs the most destructive forms of optimism: a desire to cross out reality…and to replace it with a system of compliant illusions.’ Scruton advises that we act as a ‘scrupulous optimist’ might. Alongside other characteristics, Scruton suggests that a scrupulous optimist ‘knows the uses of pessimism’, that conscious awareness that things may well go wrong, and that we ‘live in a world of constraints’. Scrupulous optimists, he says, ‘like all rational beings’ take risks ‘as part of their desire to improve things’ but do so ‘always counting the cost of failure and evaluating the worst case scenario.’ They know that things sometimes go wrong and that they, and those around them, are limited. Was this ever more evident than this weekend when, uncertainty around Covid-19 abounds and we find ourselves anxiously wondering what the coming weeks will bring?

Both those who are ill and those working in the health service to support them in their sickness need to have this healthy dose of pessimism. We aren’t always as clever as we would like to be and it can’t always be assumed that we’ll get things right. We need to take risks, even go ahead and prescribe that flucloxacillin to our paracetamol taking patient, but, at the same time, be aware that things may go wrong.

Because sometime bad things happen – and they always will. That is, sadly, inevitable.

Rather then than a ‘Philosophy of Victory’ perhaps we’d be better off adopting a ‘Philosophy of Defeat’, a philosophy which acknowledges our weakness and, therefore, the inevitability of suffering, pain and sadness. This is not to suggest that happiness is not something to be had, or indeed that good outcomes should not be desired or sought after, but rather to acknowledge that there is a gap between what we might hope for and what we may actually experience. Accepting this may just serve to leave us less discontent than when we deny the fact and so continue to constantly strive to attain the unattainable.

As Leonard Cohen once said,

“Everybody has experienced the defeat of their lives. Nobody has a life that worked out the way they wanted it to. We all begin as the hero of our own dramas in centre stage and inevitably life moves us out of centre stage, defeats the hero, overturns the plot and the strategy and we’re left on the side-lines wondering why we no longer have a part – or want a part – in the whole damn thing. Everybody’s experienced this, and when it’s presented to us sweetly, the feeling moves from heart to heart and we feel less isolated and we feel part of the great human chain which is really involved with the recognition of defeat”.

The result of accepting such a ‘Philosophy of Defeat’ would, as Cohen suggests, leave us less isolated. Instead of finding ourselves all alone as we seek to promote ourselves as unique and special, seeking to advance ourselves to the potential detriment of others, we may find that, by losing sight of ourselves and our need to be something we may just end up finding out who we really are and being content with who we already are. Accepting our ordinariness and seeking to serve others despite our weakness may result in our finding ourselves happier and more connected with those with whom we come into contact even if we come to harm ourselves. What is certainly true is that if faced with a full blown pandemic, we will not be well served by an ethos of every man for himself.

We need to walk through this thing called life together, the strong supporting the weak, and all the more so when times are hard. Manage to do this and we may just find that the distance between us, far more dangerous than any high anion gap, will be considerably narrowed.

And that would be very good medicine indeed because some of us have been self isolating for far too long already.

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