Personal views: How 9/11 thinking can impair doctors' clinical judgment
Authors: Ralph Crawshaw
Journal: BMJ (2003)

In preparing an address to the Western Institutional Review Board on the climate of medical morality in the north western United States, an unusual psychological phenomenon surfaced—9/11 thinking. The apparent prevalence of 9/11 thinking and its effect on clinical judgment merits wide consideration.

In preparatory talks with medical colleagues I discovered that American doctors' thinking has changed. Asking, “How do you feel?” usually elicited the answer “Fine.” Only when I repeated the answer back to them—“Fine?”—did speakers pause to think.


Subsequent responses were not what I might have expected. “Now that you ask, I do not feel fine. I feel anxious.” “I am angry and confused.” “I do not know what to feel about this war.” A visiting Canadian doctor said, “There is an elephant in the room and US doctors do not talk about it. If I say anything, I fear being misinterpreted.” 


Have current events altered doctors' capacity to reflect?



As strong emotions surfaced, colleagues were understandably cautious. Only as they sensed my neutrality did they disclose how heavily our present war weighs upon their thoughts. Trusting that he or she is not being judged, a typical doctor waxes surpassingly eloquent. “I simply do not know what to make of [the war]. I know that there are dangerous people in the world that need to be checked, if not disciplined. Although I do not make a habit of watching television, I cannot avoid looking at our men being killed. For what? It fills the television. Where is this going? I simply do not know.” Another said, “I am angry, frustrated, embarrassed, and chagrined. Angry is an understatement. I am furious at the overall approval of such a hideous act.”

Another said, “I do know that it leaves me anxious—not so much frightened as nervous about what is happening. Who can I talk to about it? It kills discussion since no one else knows where our nation is heading. Are we going to do as much for North Korea? No one knows. It is so difficult for caring people to think this war is for the good. I feel so isolated.” Isolation arising from fear is the common mindset. And herein lies a challenge—albeit a subtle one—to doctors' ability to arrive at clinical decisions.

Good judgment relies on curiosity fostered by reflection. Certainly, fearful times are not conducive to reflection. We also know that the first casualty of war is truth, and without truth reflection is merely worry and fantasy—anything but good judgment. Judgment is a mental process demanding broad thinking, including reflection. Of itself, reflection does not, nor should it, lead to action. Rather reflection opens the mind to the free flow of curiosity, needed for exploring possibilities. Reflection produces questions that lead to appropriate action. Who can deny that an enhanced capacity to reflect is a necessary skill of a thinking doctor?

Thus a relevant question surfaces. Have current events altered doctors' capacity to reflect? Have they impaired a doctor's full access to personal beliefs? How vulnerable are doctors' mental processes to war's distraction and moral ambiguity? I believe that doctors in general are just as vulnerable to the unwanted intrusion of 9/11 thinking as the doctors to whom I talked who reported disrupted thinking.

How vital is it for doctors to reflect on what they read, hear, observe, and experience? In other words, how necessary is reflection for integrating the resources of clinical judgment? Does anyone believe productive reflection flourishes in fearful minds? Consider an extreme case of fear displacing reflection. What would you think if you smelt smoke and discovered that your home was on fire? Would reflection turn to the business ethics of the company that produced a defective smoke alarm or, without the least reflection, would the immediate safety of your family fill your mind? Clearly extreme fear banishes reflection.

It therefore seems reasonable to expect that fearful insecurities stemming from terrorism and war impair doctors' capacity to reflect and use constructive curiosity. In pursuing their professional responsibilities doctors need consciously to recognise and engage with these fears and anxieties and to review their personal beliefs and values. But in the current climate they cannot expect immediate help from colleagues. In times of war reflection suffers for want of nourishing discussion. Listen again to the doctor who spoke candidly about his “nervousness”—“It kills discussion.” Certainly, doctors would be wise to work through anxiety, but such wisdom comes at a considerable cost.

Undoubtedly doctors will discharge their duties in times of war. However, as community leaders our critical thinking establishes the nation's standards of health and, to a degree, our morality. Therefore, doctors' constructive curiosity must be preserved, not left until the war is over.

In wrestling down 9/11 thinking it is imperative for doctors to be able to have open discussion with colleagues about how, when, and where 9/11 thinking blocks our efforts to serve patients.