Compilation e-book

Introduction to ‘When Windows Become Mirrors’



When Windows Become Mirrors

The 5th collection of articles from Illusions of Autonomy



To the readers of my blog who through their interest have encouraged me to keep writing for 5 years, and especially to those who have helped spread the word on Twitter, that powerful but mercurial invention.


This is the 5th collection of blog posts from Illusions of Autonomy. When I wrote the introduction to the 4th, A Hand In The River, I wondered if that would be the last. The frequency of posts had dropped, due I think to my increasingly specialised role – more interesting on the one hand, but less involving in terms of the everyday human and ethical problems that accompany general medical patients. But then things picked up. There were controversies around under-performing or frankly injurious doctors. Increasingly I reflected on the role of the senior clinician, and how you maintain the skills required to be a good doctor while spending less time on the front line. My perennial interest in resuscitation decisions continued to be prodded by difficult situations in my own hospital, and the frequently lethal nature of the illnesses affecting the patients around me led to reflections on how we (okay, I) communicate in busy and pressurised environments.

Windows into mirrors; reflections. The title of this collection comes from the long walks down dark corridors at three in the morning, when, coming from particularly difficult or stressful clinical situations as a trainee, I used to look in the night-blackened windows and see a haggard doctor who was unsure if he had done a good job. At those times, when our patients’ pathology insists on progressing while the pace of the great machine dials down in the dead of night, there is ample time for self-examination.

Part 1: Night & Day – observations on everyday behaviour in the hospital, good and bad…
Part 2: In Court – arrogance, negligence, and other sins
Part 3: Relating to people near the end of life – how doctors get it right & wrong
Part 4: Resuscitation decisions – not getting any easier
Part 5: Assisted Dying – a true battle of attrition
Part 6: Illustrated essays – on the history of truth in medicine, and how doctors respond after doing harm


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Introduction to ‘A Hand In The River’


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This is the fourth collection of posts from Illusions of Autonomy, and possibly the last. From now on posts will be intermittent and far less frequent.


During my medical training I observed many situations that led me to reflect on how I, or my colleagues, had reacted. It was only after two years working as a medical consultant that I felt entitled and empowered to write about those reflections. While explaining the reasons and justifications for my decisions to nursing staff and trainees, I realised that it might be helpful to set those thought processes out in black and white. Recognising that I was personally accountable for the clinical decisions, judgment calls and interactions that took place in my name reinforced the sense that yes, my opinion mattered. No more than any other doctor’s of course, but the satisfaction I derived from recreating difficult situations in a creative way meant that instead of letting those lessons pass by in the endless river of human experience that is a hospital, I dipped my hand and examined the essence of those problems before they slipped out of my palm.


Some subjects had nothing to do with my day to day work, but I was driven to write about them from conviction – for example assisted dying. The media driven uproar about care of dying patients and the Liverpool Care Pathway stimulated another stream of articles, from the perspective of doctors whose actions had, I felt, been impugned. The thrill of seeing articles out in the blogosphere led me to broaden my research into other subjects too… hence the wide range of topics in the early days.


The process of posting an article, Tweeting the link and seeing it catch fire was massively stimulating. To see the Re-Tweets and ‘hits’ accumulate over a weekend… was addictive. Sometimes posts did not catch fire, and instead spilled from my laptop with a leaden thud. Like all writers, I soon learnt to put these to the back of my mind while I considered the next topic. During the blog’s peak I wrote every week – the most posts I wrote was five in a month. One consequence of moving on to different subjects quickly was that I did not spend much time replying to comments left on the blog – although I think that is an essential part of maintaining a living forum of ideas (this is a tip for any aspiring bloggers – you need to make time to reciprocate). Recently I have scarcely managed one article per month, reflecting the fact that my focus has shifted.


So why stop?


It may be because I have explored many issues to my satisfaction, and have run out of novel observations. I think a large part of a writer’s drive comes from a desire to marshal their thoughts, much as an adolescent might discuss religion until he or she decides what to believe and want not to believe. Through the blog I went some way to achieving that with regard to medical futility, resuscitation, escalation, assisted dying and candour. However, thinking about things too much can also muddy the waters and leave you in an unresolved soup of ideas… There are no absolutes.


Or it may be because my decision to move away from general medicine has separated me from the front line, or the ‘coal face’, where so many complex and demanding clinical scenarios arise. The patients I see now (as a specialist in a tertiary centre) are sometimes medically more complex, but younger, less frail, and generally further from death. The pressure to see huge numbers of medical patients has given way to a different kind of pressure, that of working out how to help a selected, smaller group. Giving up general medicine has allowed me to focus on the areas that I most enjoy, but the price to pay for that may be a diminished entitlement to comment on situations that continue to challenge colleagues on the general wards.


Whatever the reason, I look back on those four years of blogging with pride, and gratitude to those who gave me positive feedback. There is a deep well of generosity out there, 99% of it in colleagues I have never met but who came across the posts via social media and took the trouble to read and comment. The most critical comment I received was ‘more navel gazing from Dr Berry…’ That is so true! Everything on this blog came from examining other people’s misfortune through the prism of my own emotions and responses, while hoping that the ideas I recorded would chime with a wider audience. Generally, they did.

three covers

Collected posts volumes 1-3

Introduction to ‘Motives, emotions and memory – exploring how doctors think’

I have compiled an e-book from the most popular Illusions of Autonomy blog posts, and I have reproduced the Introduction here. It’s available on Kindle here!



I wrote these posts to explain the words and actions of doctors in ethically challenging situations. It was a cheeky thing to attempt, as I could not pretend to speak for others in presenting the results of my own reflections. However, feedback from medical and non-medical readers alike soon confirmed that the descriptions reflected their own experiences, which came as a huge relief.

The posts fall into eight categories, but they have a common theme – a desire to explore how doctors balance their human qualities and frailties with what is expected of them. I focus on the way normal men and women react. How do they maintain compassion and reason despite constant exposure to the misfortune of others? How do they move between emotionally intense scenes without allowing the impact of the first to colour the outcome of the second? How do they discuss end of life care sensitively when time is short and the right thing to do seems ‘so obvious’? How, on a bad day, do they make patients feel central in their thoughts…when their thoughts are miles away?

One method is to take the essence of a real situation (drawn from my years of experience as a hospital doctor) and to enlarge it, dissect it, using imaginary dialogue. Another is to make a quick survey of the literature, or to examine a particularly hard case known to all in the media. In one post I analyse the evidence given in the Court of Protection (‘Quality of life projections: do doctors have any idea?’). In ‘A Never Event and the chain of blame’ I construct a completely fictional set of lethal circumstances. Throughout, care is been taken to dissociate fictional patients from those who were involved in the historical scenario that stimulated the essay. Confidentiality is never compromised.

Decisions taken with patients towards the end of life are developed within the framework of ‘Good Medical Practise’ (GMP), a series of guidelines published by the GMC. If all decisions adhered to GMP there would be no controversy. Every management plan would result from mutual understanding between patient and doctor. Their goals, their understanding of risk, burden and benefit, their fully informed consent to treatment, would be ascertained well in advance. If they lacked mental capacity, those factors would be agreed by those who knew them best. If only it were that straightforward! Many of these blog posts were generated by my reflections on scenarios that did not fit easily into that scheme; situations in which major decisions about life extending treatment had to be made quickly, in the absence of background information, in isolation from patents’ representatives… At times like these accusations of paternalism can arise; and autonomy can become illusory. The good intentions of doctors making those decisions have to be presumed, and the sensible application of their years of experience respected.

Something happened in 2012 to undermine that presumption of goodness – the Liverpool Care Pathway controversy. It was my horrified reaction to accusations of immorality and systematic euthanasia as they multiplied in the press that spurred me to begin writing. I could see trust in my profession eroding, and unjustifiably (in my opinion). The LCP furore appears to have died down now, but other scandals, such as wrongdoing at Mid-Staffordshire, or alleged cover-ups at the Care Quality Commission, have compounded the damage. There is much rebuilding to do. Perhaps, by being open and honest about the way doctors handle ethically complex situations, these posts can contribute in a small way to that recovery.

I am hugely grateful to the support of readers, especially those I have found via Twitter. Their positive feedback has kept me motivated.

Here is the table of contents:

Part 1: The psychology of doctors

The Onion Cellar: crying at work, crying at home

Disappearing doctors: the limits of medical debate on Twitter

The evolution of authority: confidence vs arrogance

The limits of responsibility

Part 2: Compassionate care

Medical relativism: on prioritisation, excuses and kindness

“It was as though I wasn’t there”: the problem of the invisible patient

Meaning it: acting, (in)sincerity and compassion on the wards

Compassion in healthcare: the separation trap

The visit: an interrogation of caring

Part 3: At the coalface

Hazard in context: the psychology of medical continuity

When paternalism = bravery: a ‘slow code’ dilemma

What we talk about when we talk about death: a case

Medicus Mendax: false final words

Hazard in context: the psychology of medical continuity

Part 4: Assisted dying

The day assisted dying became legal: choices

Assisted dying and The Christian Medical Fellowship: the mercy paradox

The Tony Nicklinson Judgment

Part 5: Medical error

Memory failure after medical error: the building blocks of experience

A ‘Never Event’ and the chain of blame

Fatal error: a doctor deals with the harm she did

Why Michael didn’t blow the whistle: pub scene

Part 6: Care towards the end of life and resuscitation

Not For This and Not For that: emphasising the positive in care for the elderly

Complaint: a grieving son meets the consultant who signed a DNAR form without discussion

A form of words: honesty kindness, coercion and early resuscitation discussions

Painful procedures at the end of life: a growing dilemma in healthcare for the elderly

A soft task hard to do: why we fail in engaging relatives at the end of life

Missed opportunities: the diagnosis of dying and the risks of delay

Substituted judgment and resuscitation: a case

Part 7: Quick, topical medical ethics overviews

Futility redux, and reset

Quality of life projections: do doctors have any idea?

Deeper water: religion, end of life care and the case for public disclosure

Part 8: The Liverpool Care Pathway controversy

Back to the source: a response to Patrick Pullicino’s Liverpool Care Pathway paper

Derailed: how the LCP controversy has changed family discussions

An assault of trust: in defence of the patient-physician relationship at the end of life

Paternalism at the end of life: a narrative from two angles

‘Challenge everything’: a junior doctor questions the LCP

London, June 2013