Foreword

In reading this well organized assembly of essays - in particular its Introduction, Preface, various chapters, and the Conclusion - two things stand out: courage and the need for narrative in medical education. There is no question that this book is an exercise in courage; for the risk its contributors, mostly oncologists, and its editors take in acknowledging errors in clinical oncology opens a truth that some may find best left unsaid. However, its confluence of narratives does so in order to point its collaborators and readers toward ways to reduce errors in clinical oncology. Indeed, as the editors recognize, clinical oncology renders the discipline and practice of oncology both vulnerable to the difficulties associated with identifying, understanding, disclosing, and managing medical error and its aftermath and uniquely situated to provide medical leadership regarding medical error within and beyond its disciplinary boundaries to medicine.

This collection represents the initiation of a needed conversation about medical error in oncology and a salutary invitation to the wider community of professional clinical oncology - its physicians, physician - scientists, specialized nurses, and others, notably cancer patients such as myself - to listen to this conversation and perhaps enter into its continuation. It is a mindful and responsible call to arms, and it will reward the reader who hears and understands the personal and existential as well as the clinical dimensions of its various narratives. In response to the generous invitation from the editors, Drs. Surbone and Rowe, I offer the following Foreword as a patient's perspective for the reader and also to call upon you to enter this important conversation.

According to the early modern philosopher, Baruch Spinoza, presentation of fear originates from a natural fear of death. So the fear of physical pain or emotional pain is an expression of the fear of death. For the most part palliative medicine is close to alleviating physical pain adequately, but it is far from close enough to addressing the existential pain at the core of emotional suffering. Indeed, this is the case because the latter belongs to a "form of life" which crosses a divide between physical and emotional pain. The existential pain that arises in the doctor - patient relationship may be more or less bearable. Too often when it is less bearable for the patient due to a clinical error she or he, or the family, turn to legal action. The resultant adversarial relationship also falls short of addressing adequately the existential, emotional pain because it belongs to a different "form of life" and exacerbates the harm of the disease. Consequently, when medical errors occur and harm is done, there is emotional suffering for both the patient and the doctor which complicates and inhibits the art of clinical medicine. Most important, the resultant harm obstructs getting closer to the truth of the error and restoring the needed balance and trust in the subsequently altered doctor - patient relationship.

Our - that of both doctors and patients - need to console ourselves from the outset of the dis-ease, especially in the case of cancer, is often expressed as an assurance that the oncologists armed with modern, science based medicine are in control of the patient's dis-ease. But such "control" rarely, if ever, happens, and the needed trust in the doctor - patient relationship can hide from us our vulnerability to accident or even malice, and no legal instrument can restore the needed trust. The truth is that the trust required by both cancer patients and clinical oncologists, lies with a presupposition of control over the invisible lives of our own insurgent, rebellious cells that give clinical oncology its life and meaning. But if Karl Popper is right, and I believe he is, and even our best scientific theories are fallible and therefore provisional, then the control on which science-based medicine is predicated seems haunted by a myth of control of the invisible "malady of all maladies."

The practice of clinical oncology may be done more or less well, and excellence in it is achieved not by memorizing formulae or consulting algorithms for diagnosis, prognosis, and prescriptions for therapy. IBM's Watson may assist the well-informed clinician but it cannot substitute for the clinical art. Excellence in clinical practice is achieved not by formulae alone, but by developing a highly nuanced sense of what is more fitting in the particularities of a presenting clinical situation. This nuanced sense within the practice of a craft/art is a knowing how, a practical judgment within and on the particularities of the concrete situation. It is what Aristotle called phronesis, a deliberation and judgment of what action to take - whether in legal matters, or in moral matters, or in political matters or in medical matters. It is a medical phronesis learned by a kind of imitation of those who have learned from experience how to practice their craft or art well. Learning it begins in the clinical curriculum of medical schools, and continues in the apprenticeship of post medical school residency. However, it must continue beyond residency and renew itself in the experience as the art of the judgment is executed and incorporated within the individual toward her perfection as a clinician. This art must learn, from both its successes and its failures, how to correct its errors. As such it calls for what might be the habits of good practice, the virtues of a good clinician as a clinician. At the least these include courage, truthfulness, confidence balanced by truthfulness to counter the temptation to hubris in so powerful a knowledge, and a kind of Socratic wisdom about the practice that calls forth a perfecting of the art of medicine.

This learning how to learn from one's errors in practice has very real consequences which call for a courage, first to face your own theoretical fallibility and existential vulnerability, and to acknowledge it in the clinical situation to yourself, your peer oncologists, and to your patients if an error is made and to learn from that error. It is not the fallibility of an uneducated ignorance, but rather that of a well-established science-supported practice. Indeed, inasmuch as both the science and the practice are fallible, it proceeds with an attitude of truthfulness which is ever mindful that there is always more to be learned. Consequently, this attitude proceeds as an educated ignorance that generates the confidence that acknowledges what experience teaches and fails to teach, the perspicacity to sense the difference, and a humility to learn from this difference what had worked in clinical practice but no longer will without reform. The needed reforms are reforms of standards of practice as heuristic guides which may or may not need to await the reform of the best theories underlying the clinical practices. As heuristic the standards are not universal, abstract rules but guidelines embedded in the practices of good clinicians whose own clinical phronesis enables them to recognize tacitly the heuristic guidelines in the medical practices of their best colleagues. Nonetheless, identifying and imitating the best practices of individual oncologists is not enough, for as some contributors to this volume recognize, the best medical phronesis that reduces medical errors needs to enter the medical leadership at institutional and systemic levels if an internalization of the individual clinical virtues is to become a virtue characteristic of the clinical medical community as a whole. It's a daunting challenge to reduce medical errors and the existential pain it brings to both patient and doctor; but well worth the needed effort as the following narratives by concerned oncologist and associated scholars make clear.

Dominic J. Balestra Professor of Philosophy, Fordham University and cancer patient Former Dean of Arts and Science Faculty Former Chair of the Department of Philosophy

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