The stark choices that can mean life or death
HEART BEAT:Patients’ wishes can make life more difficult for doctors
“And for these ends, to practise tolerance
and live together with one another in
peace and as good neighbours”
THESE INSPIRATIONAL words come from the United Nations Charter of 1945. A brief glance around you shows that we’re not quite there yet. It should be an easy concept to grasp and subscribe to, but it’s not.
I am not entering philosophical debate here; one man’s tolerance constitutes an abomination for another. Most want to live in an evolving and progressive society with norms that the vast majority accept. Sometimes, this comfortably woolly concept assumes a hard shape and pins you to the wall, requiring decisions that you would rather not be forced to make.
During my surgical sojourn in England, my chief, Leon Abrams, had a large practice among Jehovah’s Witnesses. In those days, a lot of blood was used in open heart surgery. It was used to prime the capacity of the machine itself, and all the tubing connecting to the patient’s vessels. Blood was replaced as it was lost during surgery, and was given freely post operatively.
Nowadays, blood is used sparingly if at all, but is available if required. This is so in emergency cases and in trauma, as recently witnessed in the case of the young Irish footballer with the ruptured hepatic artery, dealt with so capably by my old friend and colleague, Gerry McEntee, in the Mater. There are many other surgical and obstetrical emergencies that require blood urgently. We have an excellent blood transfusion service in Ireland, serving the patients who need our unstinting donations.
One morning, faced with a difficult re-operation in a Jehovah’s Witness, the team discussed the problem with Abe. It quickly came down to the bottom line. Would he let the patient die, knowing that blood transfusion might well save them?
Abe, as he was known, looked thoughtfully at us all. By chance the team on that day comprised Jewish, Catholic and Muslim surgeons. “Gentlemen,” he said, “we are all members of minority religions here in Britain; we must all respect and tolerate each other’s beliefs.”
I am not sure how much we all agreed with his stance and, indeed, how it stood with our medical ethic, Primum non nocere, or “First, do no harm”, but in time I was to find out. Some of the patients became very pale after their surgery, but in my time with him, Abe never lost such a patient.
On my return to a consultant post in Ireland, I was asked to undertake surgery on a number of such patients. It was my turn to take responsibility and be other than a spear holder in the group photograph.
I had to explain to the patient and their family that their faith placed them in greater jeopardy than similar patients who did not share their beliefs. They always explained their stance to me and quoted the biblical references upon which it was based. I told them that as a doctor I respected their beliefs and would do my very best for them. It made life more difficult, but that was a consequence of agreeing to undertake the operation in the first place. In practice, I never had to face the unspoken stark choice in this moral and ethical minefield.
Adults have the right to exercise such choice we are told, but do they – and is it absolute? Would I have let the mother of three young children die?
Would I have let a child die because of the parent’s beliefs? I never found out, but the problem remains for surgeons who have to face up to such challenges and make a judgment that is personal and cannot be delegated to committee. It’s your call and, as Edmund Burke wrote, “Your representative owes you, not his industry only, but his judgment; and he betrays, instead of serving you, if he sacrifices it to your opinion.” Burke was referring to politicians and, indeed, it should apply to all public representatives. It applies equally to doctors. Medicine is not best practised by committee. Somebody has to make the decision regarding treatment, explain it and stand by it. “Doctor knows best” is regarded as paternalistic in these sophisticated times. If you feel, as is your right, that committee knows best, then good luck to you. There is no universal decision that will be right all the time. If patients approach their doctor with suspicion or distrust, the results may well be bad for both.