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Monday, June 20, 2022

Reflecting on being a responsible citizen in a suspect public square

 There are times when the welter of the weight of international evidence of war, famine, drought, fires, floods and nuclear tests and threats is simply too much. It is too much for each individual, not to mention too much for any single group or organization. And, in this cultural climate, we all feed dispossessed, emasculated (even females), alienated, ostracised and abused by the sheer weight of the despair and our impotence in attempting or even considering trying to make a difference, even leave a mark on the molasses of that culture.

A report of a shooting in an upscale, coiffed and preened and presumable affluent community just south of Birmingham Alabama, named Vistavia Hills, (Is the name from a Jane Austen novel?), at an Episcopal church, St. Stephens by name, in which two people were killed while engaged in a potluck supper, is, on one hand, just another in a long list of mass shootings that, like a weaponized pandemic, holds the nation hostage to its own rules, regulations and the attitudes and zealotry that clings to those attitudes and rules. From another perspective, it is also another incident that exposes and betrays the seemingly incontrovertible divide between those who ride the ‘highway’ of success, affluence, religious self-righteousness, and pride, and those whose lives confine them, if not to the literal “other side of the tracks”, certainly to a perceptual field of dispossession, alienation, anger and revenge. Are these shooters, mainly male, primarily full of shame at their lives and their persons and their prospects? Are they offended that others have climbed some sort of metaphorical ladder of social approbation, not to mention the insurance “policy” many of those achievers believe they have secured for an afterlife among streets paved with gold. We do not know the motive of this particular shooter; however, racism, and hate fused into a humanoid weapon (body-and-assault-rifle often) tell the story in too many of these shootings.

As a former Episcopal priest, who served in another American church, in a far different neighbourhood, on the western frontier where Smith and Wesson insured the pick-ups, whose rear windows were decorated by weapons on rifle racks, and where, on an especially warm sunny summer day, a former U.S. Marine who had boasted about serving in Viet Nam, without having set foot in that country, taunted his twelve-year-old daughter, asking her to watch as he aimed his rifle, ignoring her weeping and screaming protests, at a single sparrow sitting on a clothesline, and fired.

Whatever the lasting imprint on that girl’s mind and life of that incident, it has burned itself into this memory like a searing wood-burner into oak or pine, indelible and jagged and painful.

Naturally, we all have incidents that have seared themselves into our consciousness, perhaps even into our unconscious, that have shaped much of the manner/lens/expectation/attitude/even belief through which we encounter the world. That rifle shot was not the first, and it certainly is not the last such incident in this scribe’s life. Whether it encapsulated already forming perceptions seems more likely than not. It was another example of the abuse of power explicitly and incorrigibly before my eyes and ears. And that perception of abuse has been a central theme over the eight decades, not always or even predominantly aimed at this scribe, but evidenced in situations in which a far more empathic, compassionate and certainly ethical approach would have stood both the decision-makers and their “subjects” in far better stead.

Such incidents, as the shooting of the sparrow, while heinous and clearly avoidable, are only one kind of abuse of power that is blatant and extreme. Other situations see professionals abandoning their common sense role and responsibility as a way to avoid what appears to be ‘making a mistake’ and leaving the responsibility to the ‘expert’.

For example, a nonchalant recommendation of a home-nurse to have a surgical wound examined by the performing surgeon, only a few days after the surgery, motivated by the urge to ‘cover her/his ass’ in supervision where s/he is certain to be asked ‘did you recommend that the surgical site be seen by the surgeon? Illustrates the point. If that nurse believed s/he was not sure how serious were the symptoms in front of him/her, she could have recommended a visit to the family physician. However, many family physicians have surrendered their role and their responsibility to surgical patients after the specialist has performed the surgery. Decades ago, family physicians were evaluated by patients on their willingness to refer to a specialist, many of them preferring to ‘hold on’ to their patients, while others were open to the referral. Now, it seems the reverse is true: family physicians seem to do more referring to specialists that treating their patients. Those referrals and the welter of filling prescriptions seems, from the outside, to be their full-time job.

This last week we read, in The Star, of a deeply embedded practice in Ontario, centred around something referred to a MCR’s (Medical Condition Reports). In a piece by Robert Cribb and Declan Keogh, entitled, ‘You’re guilty until proven innocent;’ Doctors question Ontario’s automatic licence suspensions for drivers with certain medical conditions’, we read:

Ontario law requires doctors, burse practitioners and optometrists to report patients to the Ministry of Transportation ‘who have certain medical or visual conditions that may make it dangerous to drive’. Those conditions include uncontrolled substance use disorders where patients are non-compliant with treatment recommendations, some psychiatric afflictions, seizure-causing disorders, cognitive impairments, and other ‘hi8gh risk medical conditions.

There is little to no room for medical discretion in Ontario, where doctors could make a judgement, as there apparently is in other provinces such as Alberta. And yet, the “safety” on Ontario roads is not congruent with the tight-assed regulations in this province. Tight-assed regulations, without room for judgement, however, do not provide evidence of additional safety on the roads. Those who have cared for patients and families whose lives have been forever upended by unsafe drivers, for whatever reason, hold to the tight non-discretionary approach. On the other hand, some regard it as “guilty until proven innocent”. And the process of recovering one’s removed driving license is both costly, and clearly not always successful on appeal.

Reporting a rise in depression to the attending emergency room physician by an Ontario nursing student who was providing care for two adults in order to pay for her education, this nursing student was informed by the Ministry of Transportation that her license had been suspended. The student nurse was never told that her licence was about to be suspended, on the order of a doctor. And the reporting psychiatrist who submitted the MCR was not among those who treated her in hospital when she went to the Emergency Room. Working under considerable stress, while attempting to complete her fourth of five years of professional education, the nursing student was aghast, disappointed and despondent. For the ensuing months, prior to her recovery of her licence, she had to rely on others to drive her, including Uber and taxis mounting to a $1000 bill, and there is considerable justification for others to refrain from reporting such a condition as depression, given the way her case played out.

Of course, we all want safer roads, especially those insurance companies, renowned for their legal moat protecting them every which way but Sunday, from coming clean on a claim. And, there are clearly drivers who ought not to be behind the wheel, likely most of whom have never even considered reporting a medical or intellectual condition that might impair their ability to drive.

These black-and-white-tight regulations (Ontario’s MCR’s for example), like minimum sentences for judges, have serious implications for the long-term in our culture. First there is the subservience to the political class who write and pass the most stringent kind of regulation, in their firm belief that such laws will appeal to their most conservative constituents. And then there is the issue of curtailing the professional judgement, discernment of the professionals to whom jurisdiction has been given. More than these implications, ordinary people, once they become familiar with the existence of, and the strait-jacketing regulations that bind them, those Medical Condition Reports, will think twice about disclosing their medical condition, and as a consequence, will refrain from seeking appropriate treatment. And that resistance to disclosure to medical professionals, to social workers, and even to other professional care-givers that leaves many of them operating in the dark, as to the full context of whatever situation they might be facing. The lives of both potential patients/clients and professionals are limited by such an unnecessary and unjustified kind of regime.

We live in an era in which human rights have risen to the top of the cultural, language and legal totem poles. And there is considerable justification for that elevation. However, we have to be careful that one set of ‘rights’ (highway safety, for example linked to insurance and police costs as well as political reputations of both individuals and parties) are not stamping on those rights of individuals to seek appropriate health care. 

Here are a few minimal suggestions:

Obviously, no report should be signed and submitted without the full disclosure that such action is being taken.  Also, there needs to be a clause in the MCR regulations that requires a medical professional who signs such a report, to at least have held a clinic visit with the subject patient. Perhaps, too, a second medical professional’s opinion would be warranted, and should the two medical professionals disagree, an ethics committee could have the authority to review the file, before any report is issued.

There is another implication of this kind of evidence of the potential relationship between the state (as in the health care system) and the general public. And it regards the linking of both the over-reporting on MCR’s, without oversight, and the under-engagement of that home-care nurse above, and the general practitioner, both of whom defer to the specialist. If the state is permitted to issue, and then to execute and to enforce the MCR, in such a cavalier manner, including the murky appeal process, then such a model establishes and reinforces that mind-set, now publicly endorsed, and embedded into the culture, that power-down, needs to be exercised in order to prevent potential accidents. And this principle has serious implications if and when it overrides such highly significant and relevant issues that are legitimately included in the phrase “patient care”….

The confidentiality of medical records is a deeply embedded principle with which most are comfortable. The risks to that principle’s erosion have risen with the onset of digital technology, even with the extra care taken by the technology professionals. However, in a period in history in which labels of especially psychiatric labels are thrown around, out of the mouths and pens of persons who have no legitimacy even to use those diagnostic labels, individual human lives are impacted daily by those making judgements about the “suitability” of individuals for specific assignments, based, not on the available evidence of competence, trustworthiness, and ethical standards, but on the glib and free application of a word, an adjective or perhaps a noun of a condition that the candidate does not represent, and the judge has no reason or justification for uttering.

And once uttered, such epithets cannot and will never be retracked, or erased from the ‘ether’ of public opinion. And reclamation of the damage often never ends, prior to the end of the person’s life. Impunity, however, for the person who utters such defamatory ‘judgement’ is both conventionally tolerated and even endorsed.

The task of being a sentient, responsible, collaborative and trusting citizen of the public square is growing not only more tense, and thereby more exhausting and anxiety-inducing; it is also generating a significant demographic of people who are losing, or already have lost, complete confidence that the system (public institutions and the people and the guidelines that pertain and prevail therein) is worthy of our trust and our support.

And, on that street lies danger!

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