Be lucky

[摘要] Ask yourself, ‘Do I feel lucky?’ This often misquoted line from Dirty Harry, said by Clint Eastwood in the title role, serves to introduce the notion of moral luck. Gratifyingly, we do not often find ourselves staring down the barrel of a gun wielded by a violent cop in the course of our clinical duties. But we do need to consider how luck fits into our professional lives, and the lives of our patients. And we need to reflect on the normative aspect of luck, so-called moral luck, even if the term can at first appear oxymoronic.Think of it this way: we can only be morally responsible for that which we have at least partial control over — that could mean our actions, thoughts, and even the outcomes our patients endure. Yet in the messy, complex world of primary care this degree of control might be elusive, making the interaction between our moral responsibility and luck important to think about.CONSTITUTIVE AND CIRCUMSTANTIAL LUCK For example, to escalate concerns about a poorly performing, or alcohol overusing, colleague is a matter of courage, among other things, and an example of virtuous behaviour. Many of us have had to raise a concern in the course of our careers, and it hardly needs describing as a stressful and courageous act when done. Some of us would have never had to do such a thing and, as a matter of luck, would have never encountered a situation where that degree of courage — or judgement — was called for.It is a matter of luck regarding circumstances we’ve found ourselves in. Additionally, when we’ve brought a justified concern forward when it was necessary, the full spectre of the consequences was not in our control. Whether our action results in overall good circumstances — perhaps with the colleague getting appropriate assistance, and minimal strain to professional and team relations — is a matter of luck regarding the outcome of our action.Similarly, when we discuss the application of statins in the primary prevention of cardiac disease or the risk of breast cancer in hormone replacement therapy (HRT), we are rolling the moral dice. Research helps of course in offering us a number needed to treat (NNT) in the former or a number needed to harm in the latter, and such statistics will guide us and our patients in reaching a shared decision. However, they conceal a luck calculation: we simply do not know if the particular patient in front of us will lie in the larger NNT or the small group where it actually brings about success. The patient is lucky if she lies in the successful or unharmed group.

[学科分类] 卫生学