Faglig forsvarlighet

Farlig uforsvarlighet eller faglig forsvarlighet

Selv det mest uforsvarlige kan være forkledd som faglig forsvarlighet.

Juristene og lovgiverne elsker den faglige forsvarligheten. Begrepet gir enkle løsninger på vanskelige og ofte uløselige problemstillinger. Når lovteksten åpner for faglig forsvarlighet, så overlates ansvaret til fagfolkene.  Politikere, forvaltere og dommere løser uløselige problemer med å vise til to ord, – faglig forsvarlighet.

Faglig forsvarlighet kan gis mening blant annet ut i fra situasjonen som introduserte begrepet. Lossiusutvalget stilte i 1985 spørsmål med den etisk- og faglig forsvarlighet i tvangsbruken under HVPU. Lossiusutvalget fikk til en viss grad svar på hva lovgiverbetraktet mente var etisk- og faglig forsvarlig tvangsbruk da vi fikk lovverket om bruk av tvang og makt overfor mennesker med utviklingshemning i 1999. Lovverket forklarte i det minste hva som verken var faglig eller etisk forsvarlig tvangsbruk. Etter den tid har nok forståelsen av begrepet endret seg mye, uten at noen helt vet hvordan eller hvorfor. Det er all grunn til å tro at den faglige forsvarligheten varier både med tid og sted. Forsvarligheten kan til og med variere innen samme kommune.

 

Av og til er faglig forsvarlighet et fornuftig og godt krav. Andre ganger er det en inngang til moralisme og i verste fall den absolutte uforsvarlighet. Sykehushistorien startet med moralisme og sosial renovasjon. De rundt femhundre første årene var sykehusene først og fremst en helsefare for pasientene. Forholdene er blitt bedre i nyere tid, men de prinsipielle utfordringene består, eksemplene er lette å finne, spesielt når det er snakk om folk som oppfører seg annerledes enn de fleste.

 

Helsevesenet for psykisk utviklingshemmede (HVPU) var regulert av sykehusloven, men ingen ble noen gang friske av å være der. Det var tilsynsleger og det ble ført kontroll. Til tross for dette, er det vanskelig å finne de helsefremmende komponentene i HVPU. Sausen av fordommer, diskriminering og fag overlever det meste. Norsk psykiatrisk forening anbefalte avdiagnostisering av homofili i 1977. ICD-10 har fortsatt diagnosen F65 "Forstyrrelser i seksuelle objektvalg", selv om Helsedirektoratet har bedt helsepersonell om ikke å benytte flere av underdiagnosene.

 

Ser en på bruken av tvang og makt overfor mennesker med utviklingshemning som fikk mediaomtale på 1980- og 1990-tallet, så var det fagmiljø som mente at tiltakene var både faglig forsvarlige, etisk forsvarlige og nødvendige. I dag har vi verken slike fagmiljø eller slike holdninger.

 

Jeg kjenner til ei kvinne hvor tjenestene mente at det var faglig uforsvarlig at hun bodde sammen med sin samboer. Jeg kjenner flere som forvaltningen finne det faglig uforsvarlig å spørre om hvem som skal være deres nærmeste pårørende. Hvor ofte kan en ung voksen mann bli hissig, før det er faglig uforsvarlig å ikke fotfølge mannen?


Nylig ble det avdekket krenkelser og ulovlig bruk at tvang og makt overfor elever på ressurssenteret på Grannes skole. Fagfolkene som sto bak, betraktet helt sikkert tiltakene som faglig- og etisk forsvarlige, i tillegg til å være nødvendige. Forståelsen av hvilke tiltak som er faglig forsvarlige varierer, men manglende variasjon kan være verre.

 

Redskapene som fagfolkene har i verktøyskrinet sitt, varierer også. Fra psykiatrien vet vi at utbredelsen av alvorlige tvangstiltak kan variere mye mellom institusjoner som tilsynelatende har rimelig like oppgaver og arbeidsbetingelser. Det er en velkjent sak at fagfolk som er opptatt av å korrigere problematisk oppførsel også er flinke til å finne problematisk oppførsel å korrigere.

 

I nyere tid har evidensbegrepet blitt svært populært i fagmiljøene. Spesielt fra vernepleiere og psykologer som er yngre enn meg, får jeg greie på at det meste er «proven by evidence». Behandlingseffekt er blitt til et tall som kommer ut av formler basert på sannsynlighetsteori. Men en glemmer at formelen som benyttes bygger på antagelser som ikke er oppfylt, antakelser som er av en slik karakter at en heller ikke kan finne ut om de er oppfylt. Ingen har heller en fullgod forståelse av tallet som kommer ut av formelen. En kan finne uhorvelig mange undersøkelser som viser at medisinering av ADHD har god effekt. I USA blir 9% av barna medisinert mot ADHD. I Frankrike medisineres 0,5%. Selv om det finnes metervis med empirisk forskningslitteratur på emnet, så kan en slå fast at den faglige forsvarligheten varierer svært mye mellom USA og Frankrike.

 

Spørsmålet om en behandling virker, kan være ytterst vanskelig å besvare. I følge Ketil Lund registreres positive effekter av antipsykotika i 10-20 % av tilfellene ved akutte psykoser. Vi har altså evidens for at antipsykotika virker, men vi har samtidig evidens for at antipsykotika ikke virker i 80-90% av tilfellene. Den faglige forsvarligheten i bruken av denne typen psykotrop medikasjon, er ikke bare faglig, men kanskje først og fremst et spørsmål om etikk, moral og menneskesyn. Det er langt i fra opplagt hvilke dimensjoner en skal måle eventuelle effekter langs. I tillegg er det logisk umulig å besvare spørsmålet om evidens entydig ved hjelp av empiri. I mange situasjoner vil det å stille spørsmålet om behandlingen virker, være en overforenkling av problemer som aldri kan gis et opplagt, uproblematisk og omforent svar.

 

Av og til er det samfunnet som bør behandles og ikke pasienten. Da Norsk psykiatrisk forening i år 2000 vedtok at homofili ikke skulle behandles, så var en erkjennelse av at pasienten var frisk og at helt andre krefter enn psykiatrien var på god vei til å behandle samfunnet.

Jeg er verken mot faglig forsvarlighet eller evidenstenkning. I våre første hospitaler dominerte diagnosene smittsomhet, drikkfeldighet, vanvidd og lettsindighet. Både tuberkulose og spedalskhet er sykdommer som er under god, faglig forsvarlig kontroll. Når det gjelder smittsomme sykdommer, er det mye god fagkunnskap. Lettsindighet eksisterer ikke lenger. Vi kom til den erkjennelsen at det var samfunnet og ikke pasienten som burde behandles. For drikkfeldige og vanvittige, er det fortsatt mye uavklart om hvem som bør behandles, hvilken behandling som bør velges og hva som er effektiv behandling.

 

Jeg vet ikke hva en bør gjøre med den faglige forsvarligheten. Av og til er den nyttig, andre ganger er det en trussel. I lovgivning kommer en neppe utenom begrepet faglig forsvarlighet. Men før en bygger for mye på den faglige forsvarligheten, kan det være greit å forvisse seg om at den finnes.

Jens Petter Gitlesen

30 oktober 2016

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