I recently read the novel Saturday by Ian McEwan. I have to admit that in the proverbial sense, despite all the excellent reviews this book has received since its release last year, it really is very good. Near the end, Mr. McEwan’s plot started me thinking about issues related to medical ethics, patient-doctor relationships and the difference between cure and healing. The book tells the story of a Saturday in the life of a neurosurgeon. Right from the start, this weekend is quite extraordinary starting with the doctor chancing upon the sight of an exploding airplane from his bedroom window in the early morning hours and evolving into an increasingly macabre day, finally ending with the doctor and his family held hostage in their own home. Without wishing to divulge any crucial aspect of the plot in this exceptionally well researched and equally well written book, I would like to get to the part that I found thought provoking. In the course of the evening, the criminal who has singularly invoked the wrath of the good doctor by abusing his beloved wife and their twenty-something daughter, retains a head injury. The police and ambulances arrive and the abuser is rushed to the hospital under police custody. No sooner has the family finally soothed their frayed nerves enough to have a drink and think about the dinner they never had does the phone ring and a medical colleague on the line requests the doctor’s expert services urgently at the hospital. The criminal who was just brought in with the head injury is turning out to be a complicated case and therefore in need of greater expertise than what the inexperienced registrar on call could offer. In fact, the neurosurgeon is badly needed. The doctor who called of course has no idea of any connection between the neurosurgeon and the injured patient. The neurosurgeon decides to go and lend his expertise to save that miserable low life who only hours ago had desecrated all that was precious to him. Here is the problem. If he does not go, the man is likely to die. If he does go and operate, can he be trusted to save the life of a man who just a short time ago had inspired the deepest hatred and anger that the doctor was capable of feeling towards another human. Can the doctor be impartial?
I faced an interesting dilemma myself some years ago which made me question my own ability to be impartial. I had received a scientific grant to review from a Government agency. I read it, took detailed notes throughout, and formed a generally negative opinion of the grant. However, before I wrote the formal review, I decided to read it yet another time since something somewhere in the grant had left me feeling uneasy. Sure enough, I realized the source of my discomfort rather quickly upon the next read. There were several passages in one of the published papers sent as supplemental material with the proposal which were much too familiar. In fact, I recognized them as having been written by one of my post docs in a paper we had submitted for publication, and which had been turned down by the reviewers. Now at least we knew who the reviewer was. Apparently he disliked our paper enough to recommend rejection, but liked it enough to plagiarize parts of it. More importantly, we had subsequently submitted our paper to another journal where it was already accepted for publication and was in press. This meant that when our paper finally came out, it would contain passages that had already been published by another author and ironically enough, we are the ones who would appear to be the plagiarizers. Plagiarism is a serious offense and needed to be reported and of course I felt angry and violated. The question was whether I should send in my review of the grant anyway or not. Eventually, I decided to excuse myself from the review process, even though my negative opinion had been formed prior to the discovery of the plagiarized piece, because I did not wish to even give an appearance of a conflict of interest.
It is worthwhile at this point to recall the following Principles adopted by the American Medical Association. These are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.
A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
I. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
II. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
III. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
IV. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
V. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
VI. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
VII. A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
VIII. A physician shall support access to medical care for all people.
Adopted by the AMA’s House of Delegates June 17, 2001.
Obviously, writing a negative grant review is not the same as saving a life, but the point is how each of our actions would be perceived given that they were performed while we functioned under a spell of psychic violation. Two important tenets of medical ethics are important in this context. In the words of Eric Issacs, M.D., Director of Quality Improvement, San Francisco General Hospital:
Beneficence: refers to acting in the best interests of the patients. This concept often is confused with nonmaleficence, or “do no harm.”
Veracity: is truth telling and honesty.
Clearly, as the only neurosurgeon on hand who could save the patient’s life, the doctor had no choice but to operate and therefore practiced beneficence. However, given the extraordinary circumstances under which the doctor was operating, it was all the more important for him to practice veracity. The patient was unconscious and there was no immediate family to whom he could have spoken, but there were other members of the medical staff and the operation theatre as well as the police escort. I think that under the extraordinary circumstances, the honorable thing to do would have been to practice full disclosure and then proceed with the operation to save the life of a fellow human.
Since the criminal had been caught, one can imagine that now the doctor could overcome his anger and afford to treat him only as a patient. The problem here is the paradox of cure and healing; the doctor may have been cured because the criminal was caught, but not healed. The doctor’s wife asks:
“You’re not thinking about doing something, about some kind of revenge, are you? I want you to tell me.”
“Of course not.”
The distinction between cure and healing is best summarized in this excellent passage by a real life good doctor, Abraham Verghese (“The Healing Paradox” The New York Times, 12-8-02): “If you were robbed one day, and if by the next day the robber was caught and all your goods returned to you, you would only feel partially restored; you would be cured but not healed, your sense of psychic violation would remain. Similarly, with illness, a cure is good, but we want the healing as well, we want the magic that good physicians provide with their personality, their empathy and their reassurance. Perhaps these were qualities that existed in the pre-penicillin days when there was little else to do. But in these days of gene therapy, increasing specialization, managed care and major time constraints, there is a tendency to focus on the illness, the cure, the magic of saving a life. Science needs to be more cognizant of the other magic, the healing if you will, even if we reach for the proven cures. We need to develop and refine that magic of the physician-patient relationship that complements the precise pharmacologic interventions we may prescribe; we need to ensure the wholeness of our encounter with patients; we need to not lose sight of the word “caring” in our care of the patient. And doggedly, in this fashion, one patient at a time, we can restore faith in the fantastic advance of Science we are privileged to witness”.