For a number of years, I have been collaborating with colleagues in surgery, health services research, and bioethics in studying how and why a community of surgeons changes their practice and the consequences of how and why they change their practice. It could be argued that any study of contemporary surgery could or should play a part in guiding policy, but in our work such an argument feels especially pressing – we have focused on pelvic floor surgery, the area of medical practice responsible for the highly controversial adoption of transvaginally-implanted synthetic mesh for the treatment of some kinds of prolapse and urinary incontinence in women.
We have collected extensive qualitative data on this topic, and while based at the University of Edinburgh as a Nominated Fellow at IASH and visiting scholar at STIS, I have been writing up our findings and carrying out interviews and research for a case study of the transvaginal mesh controversy in Scotland and the UK.
As a result of the collaborative nature of this research, some of the explanations for the widespread use of transvaginal mesh that I would have once seen as sufficient are now less so. Transvaginal mesh should not have been so widely used. Yet many of the widely-accepted ideas about what good medicine is entail explanations of medicine’s failings that are arguably too removed from the messiness of practice to be the basis of effective intervention (on this messiness in pelvic floor surgery, see my recent co-authored article and one of my favourite articles, by Catherine Pope). Health care services research today is often oriented around good medicine as evidence-based; much of bioethics makes recourse to principles for practice, such as “first do no harm”; and critical medical sociology calls for medicine that is independent from the influence of corporate interests as well as social categories such as gender, class, and race that have been used to render some lives and bodies less valuable than others. Our research approach has not been to assess whether medical professionals live up to such standards in their actions, but to document the processes through which medical practitioners make sense of things and determine they have acted responsibility – through actions and interactions that are always particular to a patient and case, but also always affected by extra-individual forces that make some ways of acting more possible. In the case of transvaginal mesh, action was often not based on sufficient evidence for safety and effectiveness; many medical professionals did not appear to adhere to ethical principles; and treatment decisions were influenced by bias and self-interest – but even together, these factors do not fully illuminate the transvaginal mesh debacle. As a result, many typical ways of trying to prevent such debacles in the future are likely to fall short. The question that therefore shadows our account of how transvaginal mesh came to be so widely used is: might our ethnographic, qualitative account inform better interventions?
For the purpose of this blog post, I will skip over important details and arguments only to suggest that a better intervention might be to facilitate surgical judgment – to assist those who decide when and how to operate in recognizing and navigating the array of trajectories and contexts in which they are situated: the trajectory of the profession in terms of how surgical skills and privileges are distributed and controlled; their personal history of training and experience and awareness of what works in their hands; the context of a market and regulatory regime that does not and almost always cannot make determinations of whether and when to use any particular device; the nature of everyday decisions as inherently clinical and moral; the emotional and personal ramifications of patients’ expectations and surgical outcomes. This line of thought owes much to my collaborator Barry Hoffmaster’s work on judgement and non-formal reason.
There are necessary policy changes at the level of organizations and regulations that should be implemented and are beginning to be implemented because transvaginal mesh devices came to market with little to no data on their safety and effectiveness and were additionally sold and adopted at unprecedented speed and scale (Carl Heneghan at Oxford has an excellent timeline available and our group published a paper on the lifecycle of a particular mesh device in this kind of market. See also this important commentary led by my collaborator Sue Ross). But extended, interdisciplinary engagement with the case of vaginal mesh shows the extent to which what happens in surgery escapes the typical ways of knowing and intervening undertaken in health services research, formal ethical review, bioethical analyses, health technology assessment, and even critical medical sociology. Many apparent remedies to situations such as the transvaginal mesh case will not affect important aspects of surgical practice, culture, and values. Most importantly, they will likely not affect surgical judgment, in which we must still place our trust and our bodies.
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