[Originally posted to my personal blog, reposted here with edits.]
Introduction
You could call it heroic responsibility, maybe,” Harry Potter said. “Not like the usual sort. It means that whatever happens, no matter what, it’s always your fault. Even if you tell Professor McGonagall, she’s not responsible for what happens, you are. Following the school rules isn’t an excuse, someone else being in charge isn’t an excuse, even trying your best isn’t an excuse. There just aren’t any excuses, you’ve got to get the job done no matter what.” Harry’s face tightened. “That’s why I say you’re not thinking responsibly, Hermione. Thinking that your job is done when you tell Professor McGonagall—that isn’t heroine thinking. Like Hannah being beat up is okay then, because it isn’t your fault anymore. Being a heroine means your job isn’t finished until you’ve done whatever it takes to protect the other girls, permanently.” In Harry’s voice was a touch of the steel he had acquired since the day Fawkes had been on his shoulder. “You can’t think as if just following the rules means you’ve done your duty. –HPMOR, chapter 75.
Something Impossible
Bold attempts aren't enough, roads can't be paved with intentions...You probably don’t even got what it takes,But you better try anyway, for everyone's sakeAnd you won’t find the answer until you escape from theLabyrinth of your conventions.Its time to just shut up, and do the impossible.Can’t walk away...Gotta break off those shackles, and shake off those chainsGotta make something impossible happen today...
The Well-Functioning Gear
I feel like maybe the hospital is an emergent system that has the property of patient-healing, but I’d be surprised if any one part of it does.Suppose I see an unusual result on my patient. I don’t know what it means, so I mention it to a specialist. The specialist, who doesn’t know anything about the patient beyond what I’ve told him, says to order a technetium scan. He has no idea what a technetium scan is or how it is performed, except that it’s the proper thing to do in this situation. A nurse is called to bring the patient to the scanner, but has no idea why. The scanning technician, who has only a vague idea why the scan is being done, does the scan and spits out a number, which ends up with me. I bring it to the specialist, who gives me a diagnosis and tells me to ask another specialist what the right medicine for that is. I ask the other specialist – who has only the sketchiest idea of the events leading up to the diagnosis – about the correct medicine, and she gives me a name and tells me to ask the pharmacist how to dose it. The pharmacist – who has only the vague outline of an idea who the patient is, what test he got, or what the diagnosis is – doses the medication. Then a nurse, who has no idea about any of this, gives the medication to the patient. Somehow, the system works and the patient improves.Part of being an intern is adjusting to all of this, losing some of your delusions of heroism, getting used to the fact that you’re not going to be Dr. House, that you are at best going to be a very well-functioning gear in a vast machine that does often tedious but always valuable work. –Scott Alexander
Recursive Heroic Responsibility
Heroic responsibility for average humans under average conditions
I can predict at least one thing that people will say in the comments, because I've heard it hundreds of times–that Swimmer963 is a clear example of someone who should leave nursing, take the meta-level responsibility, and do something higher impact for the usual. Because she's smart. Because she's rational. Whatever.
Fine. This post isn't about me. Whether I like it or not, the concept of heroic responsibility is now a part of my value system, and I probably am going to leave nursing.
But what about the other nurses on my unit, the ones who are competent and motivated and curious and really care? Would familiarity with the concept of heroic responsibility help or hinder them in their work? Honestly, I predict that they would feel alienated, that they would assume I held a low opinion of them (which I don't, and I really don't want them to think that I do), and that they would flinch away and go back to the things that they were doing anyway, the role where they were comfortable–or that, if they did accept it, it would cause them to burn out. So as a consequentialist, I'm not going to tell them.
And yeah, that bothers me. Because I'm not a special snowflake. Because I want to live in a world where rationality helps everyone. Because I feel like the reason they would react that was isn't because of anything about them as people, or because heroic responsibility is a bad thing, but because I'm not able to communicate to them what I mean. Maybe stupid reasons. Still bothers me.
I'm not sure that the doctor and I disagreed on that much. So we had this patient, who weighed 600 pounds and had all the chronic diseases that come with it, and he was having more and more trouble breathing–he was in heart failure, with water backing up into his lungs, basically. Which we were treating with diuretics, but he was already slowly going into kidney failure, and giving someone big doses of diuretics can push them into complete kidney failure, and also can make you deaf–so the doses we were giving him weren't doing anything, and we couldn't give him more. Normally it would have been an easy decision to intubate him and put him on a ventilator around Day 3, but at 600 pounds, with all that medical history, if we did that he'd end up in the hospital for six months, with a tracheotomy, all that. So the doctor had a good reason for wanting to delay the inevitable as long as possible. We were also both expecting that he would need dialysis sooner or later...but we couldn't put him on dialysis to take water off his lungs and avoid having to intubate him, because he was completely confused and delirious and I had enough trouble getting him to keep his oxygen mask on. Dialysis really requires a patient who stays still. We couldn't give him too many medications to calm him down, because anything with a sedative effect would decrease his respiratory effort, and then he'd end up needed to be intubated.
Basically, it was a problem with so many constraints that there was no good solution. I think that my disagreement with the doctor was over values–specifically, the doctor thought of the scenario where we intubate him and put him on dialysis on Monday as basically equivalent to the scenario where we delay it as long as possible and then end up intubating him on Thursday. Whereas to me, latter, where my patient got to spend four extra days writhing around, confused and in pain and struggling to breathe, was a lot worse. I think nurses are trained to have more empathy and care more about a patient being in pain, and also I was seeing him for twelve hours a day whereas the doctor was seeing him for five minutes. And I was really hoping that there was a course of action no one had thought of that was better...but there wasn't, at least not one I was able to think of. So the guy suffered for five days, ended up intubated, and is probably still in the hospital.
I would be terrified all the time of doing the wrong thing. Maybe even more than I already am. I think as a nurse, I basically have causal power a lot of the time anyway–I point a problem out to the doctor, I suggest "do you want to do X", he says, "Yeah, X is a good idea." That's scary, despite the presence of a back-up filter that will let me know if X is a terrible idea. [And doctors also have a lot of back-up filters: the pharmacy will call them to clarify a medication order that they think is a bad idea, and nurses can and will speak their opinion, and have the right to refuse to administer treatment if they think that it's unsafe for the patient.]
Well, from your description it may be that doctor has less hyperbolic discounting (due to having worked longer). Being more able to weight the chance of avoiding intrusive procedures and long term hospitalization, which carry huge risks as well as huge amount of total pain over time.