1. Conference on Ethics in Mental Health, Toronto 26-27 May 2006 Patterns of Practice: Do they help in clinical ethics? Dr Julian C Hughes Psychiatry of Old Age Service, North Tyneside General Hospital and Institute for Ageing and Health, University of Newcastle UK

2. Aim Patterns of practice might be a useful way to think about ethical decision making

3. Objectives To suggest the various ways in which our lives, including our professional lives, are patterned To raise the possibility that, at root, our clinical decisions are justified by particular patterns of practice, either good or bad To consider how a particular pattern of practice may or may not be justified from the ethical perspective

4. For starters “The moral world has its being in, it rests upon, what we do and how we act. It is in our actions and the way we treat one another that values come into being and are preserved in being.” (Luntley, M. 1995. Reason, Truth and Self: the Postmodern Reconsidered. London and New York: Routledge, p. 218)

5. The place of patterns in our lives Patterns of behaviour (eating and sleeping) Social patterns (manners and driving) Cultural patterns (football and music) Patterns of worship Patterns of thought (adverts and politics) Linguistic patterns of expression

6. Professional patterns Learned patterns of practice – education Professional ethics – the Bolam principle A story: to hydrate or not to hydrate?

7. The discontinuity problem Clinical practice Ethical theory

8. PoP Solution Clinical practice Ethical theory Patterns of Practice

9. Linguistic practice We understand the meaning when we understand the use (Wittgenstein) Meaning and normativity Normativity and practice Patterns of linguistic practice as the prerequisite for meaning

10. Justification and practice The justification for saying that I understand: I have grasped a use ‘To understand a language means to be master of a technique’ (Wittgenstein, PI §199) ‘If I have exhausted the justifications I have reached bedrock, and my spade is turned. Then I am inclined to say: “This is simply what I do”.’ (Wittgenstein, PI §217)

11. Hence: Is a pattern of practice a justification? A ridiculous suggestion (Dr Shipman)! But I know what a pint of beer is! ‘What people accept as a justification – is shewn by how they think and live’ (Wittgenstein, PI §325)

12. The justification of clinical decisions This is simply what I do (hydrate) – is this all that we can say as a justification? The shared nature of patterns of practice What makes a particular pattern of practice right or wrong? –what constitutes a particular pattern of practice? –how are patterns of practice acquired?

13. Acquisition Education and training Informed practice Open to correction Shared, public nature

14. Patterns of Practice Education and training Clinical factors Experience Religious or spiritual factors Political factors Legal factors Cultural factors Social factors Moral factors

15. Ethical decisions as ordinary Clinical practice Ethical theory Patterns of Practice

16. Justification Coherence of patterns of practice –from within –from without E.g. Artificial nutrition and hydration Concrete circumstances

17. In sum, PoP: Ethical decisions as ordinary Engagement with concrete circumstances Reflect embedding culture Fixity from essential public and shareable nature Stem from education, training and experience Reflect dispositions Need to be genuinely informed and open to correction Require coherence

18. Summary I’ve suggested various ways in which our lives, including our professional lives, are patterned I’ve raised the possibility that, at root, our clinical decisions are justified by particular patterns of practice, either good or bad I’ve considered how a particular pattern of practice may or may not be justified from the ethical perspective

19. In conclusion “The moral world has its being in, it rests upon, what we do and how we act. It is in our actions and the way we treat one another that values come into being and are preserved in being.” (Luntley, M. 1995. Reason, Truth and Self: the Postmodern Reconsidered. London and New York: Routledge, p. 218)