Ruth Armstrong: Look both ways

THE last time I looked in the dictionary, the word “uncompromising” wasn’t something to aspire to.

“Showing an unwillingness to make concessions to others, especially by changing one’s ways or opinions” might be admirable if high morals are at stake, or perhaps if you’re playing sport or making art, but as much as we hate to admit it, the ability to compromise is an essential life skill.

It’s a skill that is particularly useful in medicine, where there is often a need to balance risks and benefits with evolving knowledge and multiple perspectives to reach that particular shade of gray — the one that is best for your patient.

Compromise involves thinking multidirectionally — looking at as many aspects of a problem as you can see before settling on a way forward and being willing to change direction when new information arises. A good clinical example can be found in our first news story.

A clinical trial published last week in JAMA, which examined the efficacy of a new technique for preventing malignant transformation in Barrett oesphagus, was stopped early because the intervention was so clearly superior that the investigators thought it unsafe for the control group to continue.

Should we call for immediate changes to practice and funding for this condition? Questions about cost-effectiveness, patient selection and long-term outcomes might temper our enthusiasm.

According to an expert commenting for another news story, when to make a diagnosis of dementia is also a matter of compromise, involving a judgement about the right time for the patient and his or her family. The process will be flawed if social and emotional wellbeing, management opportunities and multiple perspectives are not taken into account. “That’s clearly where primary care comes into its own, because in primary care … we know the people, and we can do all that sussing out and working with them”, our expert observes.

An article published in PLOS Medicine last week threw out a challenge to medical journals. The authors wrote that, if editors bow to threats of litigation or even have legal concerns in mind when assessing material for publication, it could bias the medical literature. They suggested that journals develop a policy of publishing any litigation threats they receive, to discourage specious and intimidating claims, and expose the threats to public scrutiny.

To discover if this strategy is possible or even desirable in Australia, we asked a defamation expert, an editor and an experienced author to bring their differing perspectives to another news story.

A recent defamation case between doctors is the subject of a comment from our regular legal correspondent, Bill Madden. He outlines how one doctor’s attempt to warn patients and other interested parties about a threat to adequate care, became another’s perception of a damaged reputation.

Two of our comment articles this week might make you stop and consider your stance on two hotly contested issues from another direction. A few weeks ago in MJA InSight, bioethicist Wendy Lipworth encouraged us to take a more sophisticated approach to pharmaceutical companies and conflicts of interest. Following on from this theme, we asked MJA Deputy Editor Christine Gee to talk about her experience of working with pharma.

And Jane McCredie chaired a recent session at the Adelaide Writers’ Festival with euthanasia campaigner Dr Philip Nitschke. She uses a recent Australian court case to illustrate another facet of the debate about the right to end one’s own life.

In the course of a long and distinguished military and political career, we can assume that former US president Dwight Eisenhower learned something about compromise. He said: “People talk about the middle of the road as though it were unacceptable. Actually, all human problems, excepting morals, come into the gray areas. Things are not all black and white. There have to be compromises. The middle of the road is all of the usable surface. The extremes, right and left, are in the gutters.”

I would add “and if you’re wondering where the road leads, look both ways”.

Dr Ruth Armstrong is the medical editor of MJA InSight.