One other thing struck me from Bill B’s article, it has this four-point matrix about constructionism and objectivism, and dynamic and not dynamic, static and dynamic. But what it lacks, and this is what is sort of a heartfelt problem for me, is the third dimension of ethics. In what way can you ethically adopt these narratives? And in what ways is there an ethical line about what you can do to curate your narrative in a self-serving way? But when do you cross the line to make it really an ethically challenged narrative? So, one of the interesting things is the notion of dynamic constructivism. This concept has not been introduced before.

Bill B

This concept doesn’t originate with me. It comes from a Norwegian colleague. She said, “Bill, constructivism itself is a construction”. And she said, “Here in Norway and here all over Europe, we know that things are shifting all the time”. I was recently thinking about Orbán and his authoritarian construction of Reality in Hungary. In some sense, that dynamic constructivism is going on in the United States. We’re becoming more European. That is, the constructed narratives are constantly shifting.

So, Bill G., one of the challenges is that ethical standards are themselves constructions. Part of the challenge concerns what it means to be ethical when the very notion of ethics itself is arbitrary. Are there ten commandments that come down from some God that are irrefutable? Are there statements out of the Koran that are simply God-given? Are there universal codes of conduct given by Yahweh or some person or institution?

Bill G

The ten suggestions, right. So, that was the basis for opening this up for discussion and people’s thoughts and reflections. With the bottom line being: How is it that we can actually impact a positive dynamic change in a broken healthcare system? Or maybe just save ourselves from Trump? So, just to evoke some conversation around this, one would speculate that perhaps in a pure constructionistic perspective, we could construct a compelling narrative about primary care and behavioral health that is absolutely compelling, and yet we know has falsities in it.

And then I guess the question would be, would that be more compelling than a similar compelling narrative that was anchored in our sense of ethical truthfulness? Because part of it is that through the rational approach to planned change. This is one of the five change strategy from Bill B’s essay. We’ve been banging our heads against the medical establishment and the general public for 30 years using the rational model. It has been ineffective. We can declare the rational approach to be ineffective in part because it is based on trying to stay truthful.

And then we can shift into a more political realm. Politics, as all of us know, is an uncomfortable ethical zone for most physicians. We tend to avoid politics. If you look back to construction of the Declaration of Independence and the Constitution, there were not a lot of doctors involved in that process. We have a tendency not to get involved in politics, historically. Is that all about our discomfort with being untruthful or two-faced, as political narratives tend to be? So, I just bring that out as a question as we try to do this. Are we trying to create a politically energized narrative here? Should this be part of our strategy?