Medical Catastrophe

by Ronald W Dworkin

is to lead a group of people under discipline toward a clear goal. A

  general commands a group of soldiers. A dictator commands a whole

  society. Both expect to be obeyed. To govern, however, is to lead people

  toward unclear and shifting objectives, with nothing really compelling

  people to obey.

  A doctor governs rather than commands a patient. A patient is not

  compelled to obey a doctor. When a patient is healthy, he or she is even

  less likely to obey. A doctor also has other constituents, including a

  patient’s family, nurses, and other doctors, all equally free. A patient’s family is not compelled to obey a doctor. Officially, nurses are compelled to obey, but, unofficially, they will push back if doctors use the wrong

  tone with them. Other doctors are no more compelled to obey a doctor

  than a patient is. The impulses of these free people—patients, patient

  families, nurses, and other doctors—are at all times a parallelogram of

  forces. They are hard to synchronize. A doctor must know what these

  forces are. Sometimes he must say to himself, “I can go just so far and no farther”; he must say “no” and refuse to do something he thinks is unsafe.

  But he must also have a sense of what is possible; he must calculate how

  much he can move one party without offending the others; he must fore-

  see the inevitable reactions of the other parties when one party is ap-

  peased; he must always be taking the temperature of the various parties to see if one party’s willingness to compromise has bled into anger, hurt

  feelings, and obstructionism.

  Just as a governor is careful not to appease one class at the risk of

  angering another, a good doctor should not shield another doctor at the

  expense of his patient. Yet this must be done tactfully, with finesse—to

  keep the parallelogram of forces from working at cross-purposes. If I

  could do it over again, I would tell Mr. D in the pre-op area, “Your

  urologist is a very thorough surgeon and takes longer than average to

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  perform a TURP. So it would be safer for you to have a spinal.” It might

  have done the trick. Mr. D might have been nudged onto the safer path,

  while his urologist would have been spared direct criticism.

  All this may seem trivial, silly, and even slippery. But in doctoring, as in politics, it is useless to formulate grand theories of human relationships if, due to the parties concerned, they are irrelevant. Doctors know how to make polite bows to theories of human behavior to appease those who

  guard temple gates. But doctors actually occupy themselves with taking

  care of people’s real needs. If they find obstacles, they make detours; if they encounter resistance, they cajole, sweet talk, finesse, and even play games. The true doctor says, “Let the principles go and save the patient.”

  A year ago (and twenty-five years after taking care of Mr. D), I at-

  tended a conference on a new concept in medicine called “patient-cen-

  tered care.” Its purpose is to give patients and their families more say in their medical decisions. Although I went to the conference to investigate, I met an anesthesiologist from out of state who had been compelled to

  attend. She told me her story.

  She had come in on her day off to take care of a morbidly obese

  twenty-five-year-old woman needing gall bladder surgery. The patient

  had requested her. She met the patient and the patient’s father in the

  holding area. The father insisted that he be allowed to accompany his

  daughter into the operating room to hold her hand while she went to

  sleep. He also insisted that she be given gaseous anesthesia before receiving an intravenous, as his daughter was afraid of needles. In regard to the first request, the anesthesiologist told him that bad things can happen

  during an anesthetic induction, and that a parent’s presence can interfere with a quick response. 2 Exceptions are made in cases involving children, the anesthesiologist said, but not in adult cases. In regard to the second request, she told the father that a gas induction in an adult increased the risk of serious complications, including loss of the airway and death—

  especially in morbidly obese adults. It’s much safer to use a conventional intravenous induction, she said. Despite her reasoned arguments, the

  father refused to back down. They argued back and forth. Finally, the

  father gave way, but later he complained to the hospital administration

  about his “mistreatment.” He was especially angry that the anesthesiolo-

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  gist had called his daughter “morbidly obese,” although this was the

  official diagnosis according to medical terminology. (Morbidly obese is

  defined as twice one’s ideal body weight.) Instead of supporting the an-

  esthesiologist in her decision, the hospital, which employed her, repri-

  manded her and gave her a Wikipedia article on patient-centered care.

  They said the patient and her father were “customers,” and that her job as an employee was to satisfy them. They ordered her to attend a conference

  on the subject, issuing vague threats about what might happen if she

  didn’t.

  We entered the conference room together. Doctors from all over the

  region were there. Four panelists sat on the podium: a Stage IV breast

  cancer patient, a hospital administrator, a doctor, and a nurse practitioner (with the ominous appellation “BSN, MSN” after her name).

  The breast cancer patient spoke first. She talked about how, when

  diagnosed with metastatic cancer, a surgeon had given her only one op-

  tion, a mastectomy, not to cure her but to give her a little more time to live. An equally narrow-minded oncologist had recommended only

  chemotherapy. “This is what I give to all my patients,” the oncologist

  reportedly said. When asked if there were other options, the oncologist

  said, “Nope, that’s it.”

  At this point, something between a hiss of detestation and a murmur of

  horror ran through the audience. The woman then talked about how she

  explored other options on her own. She finally decided on palliative care so that the time she had left wouldn’t be filled with the painful side

  effects of chemotherapy. “It’s important that consumers be given all their options,” she concluded. “They are when buying cars, so why not in

  health care?”

  The woman was sweet and sincere. And dying. The audience reacted

  sympathetically. I was surprised that such arrogant, close-minded physi-

  cians still practiced. Why not give a breast cancer patient all her options?

  Even as a medical student in the 1980s, I was taught to do so. In that

  respect, patient-centered care seemed like another variation on the old

  patient autonomy movement that began in the late 1960s. Still, I was

  surprised to hear patients called “consumers.”

  The hospital administrator followed. He spoke more as if reading out

  an indictment. Doctors were charged, collectively and individually, with

  gross insensitivity to patients and their families, refusing to accommodate patient wishes and needs, refusing to give weight to patient opinions, and

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  covering the traces of their crimes with appeals to science, claiming that science guided their behavior when, in fact, it was arrogance, dictatorial tendencies, and a lack of empathy. He cited Dr. Donald Berwick, former


  head of the Centers for Medicaid and Medicare Services, who had spoken

  recently at his daughter’s medical school graduation about a woman who

  had been denied access to her husband’s deathbed because of physician

  policy. 3 It had been “cruel,” said the hospital administrator, which was the same word used to describe the incident in Dr. Berwick’s speech. The

  administrator added more incriminating stories—for example, a doctor’s

  refusal to pray with a nervous patient before surgery. Finally, having

  piled up all the evidence he required, the administrator smiled trium-

  phantly and pronounced a new age of patient-centered care, an age of

  “transparency,” “dialogue,” and “inclusion,” in which patients would no

  longer be “marginalized.”

  The audience remained silent. No one thought of presenting the other

  side. No one was even sure if there was another side. Personally, I didn’t disagree with the administrator, although his language disturbed me. I

  smelled ideology. “Marginalization,” “inclusion,” a more “just culture”—

  these were all catchwords of the political left. And why the revolutionary fervor? The patient autonomy movement had already been around for

  forty years.

  Next, the doctor on the panel spoke. He described a YouTube video

  that had gone viral and showed doctors and nurses dancing in the operat-

  ing room as the patient entered. Apparently the patient was nervous and

  to ease her fears had requested not only that music be played but also that the staff dance to it. The audience chuckled. This seemed a bit over the

  top. We assumed the speaker was reassuring us with an example of the

  new policy’s outer limits: true, in the future, doctors would have to be

  more flexible in the face of patient demands, but they wouldn’t actually

  have to go to such ridiculous extremes. Instead, the doctor on the panel

  praised the video as an example of good patient-centered care.

  I think the audience and the speakers at the podium understood each

  other at this point. A fundamental shift in the power relations between

  doctors and patients was under way. Patients were consumers now, and

  the doctor’s job was to give them what they wanted no matter how ridicu-

  lous their request seemed. It only remained to present the new concept in PowerPoint form, to dress it up in its proper ideological clothes, and to link the talks of the four speakers into a more or less coherent whole.

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  The doctor went on to confess how he had ignored patient desires in

  the past. During this part of his speech he seemed to shrivel and contract.

  His shoulders were hunched, his head bowed. If the panel had wanted to

  convey what they believed to be the grotesque past of doctor-patient

  relations, they could have chosen no better means than this penitent fig-

  ure. After confessing his crimes, the doctor talked about the future. Doctors, nurses, and patients would all be on the same “team,” he proclaimed.

  Doctors would embrace “patient preferences and values” rather than ig-

  nore them. Doctors would be “advocates” for their patients. His words

  reeled off like a well-learned lesson. Indeed, they almost seemed to be

  delivered as if he were under the influence of some drug or hypnotic

  spell. His statements didn’t really add anything new to what the others

  had said; in fact, they were altogether superfluous. Nevertheless, he was a doctor who had given a confession, and one sensed a ripple of satisfaction passing through the other panel members. Having played his part, he sat

  down and fell silent.

  Finally the nurse rose to speak. After declaring her deep passion for

  patient-centered care, she admitted that doctors must follow the standard of care when practicing medicine. “That’s paramount,” she said with

  confidence. But doctors also had to integrate a patient’s values into their decision making, she declared. “Standard of care and patient needs are

  never mutually exclusive,” she insisted.

  I looked over at the anesthesiologist whom I had walked in with,

  hoping she might tell the room about her case. I raised an eyebrow when

  she looked back at me, as a cue for her to speak up. Instead, she privately waved me off. I was not surprised. She had come to the meeting to learn

  correct thought and to clear herself of the slightest suspicion in the eyes of her employer. The last thing she wanted was for her hospital to hear

  that she had been difficult.

  So I spoke. While leaving her name out, I described her case, focusing

  on the dangers of breathing down a morbidly obese adult with anesthetic

  gas before placing an intravenous.

  “In this case the standard of care and what the patient’s father wanted

  were mutually exclusive,” I concluded. “The standard of care should have trumped patient desires in this case, correct?”

  There was a stir of interest in the audience.

  The nurse stared at me and declared, “No, they are never mutually

  exclusive. In the case you describe I’m sure a compromise was possible.”

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  “But it wasn’t,” I replied.

  “It always is,” the nurse shot back.

  “But in this case there wasn’t. The father refused to budge,” I said.

  “I can’t imagine that. I can’t even consider that,” insisted the nurse.

  The entire panel looked annoyed. They were not used to someone in

  the audience declaring opposition to the new program. They also knew I

  was saying things that, for some physicians, might not be without their

  attractions.

  Another anesthesiologist in the audience spoke up. “Breathing an

  adult down with anesthetic gas is not actually a breach of the standard of care,” he said.

  The panel members seemed to relax for a moment. I caught the nurse’s

  eye and found her regarding me with a significant smile, as though to say,

  “You slipped up.”

  “But it is a breach of the standard of care in obese patients,” I coun-

  tered. “Such patients have a much greater risk of aspiration,”

  The other anesthesiologist said nothing in response. Yet no one else in

  the room backed me up. Even the anesthesiologist whose case I cited

  remained silent. I felt alone, like the last survivor of a vanished race—

  doctors who value safe practice above any other consideration.

  Another doctor tried to effect a compromise: “Can we at least say that

  patients with special wants and needs should contact their surgeons or

  anesthesiologists in advance, so there will be time to accommodate

  them?”

  “That’s a good idea,” replied the nurse, hoping this would end the

  exchange.

  But I refused to remain quiet. “In the case I mentioned, the father’s

  desire expressed in advance wouldn’t have changed anything. Breathing

  down his obese daughter with gas would still have been dangerous,” I

  said.

  “There was a way. There was a way,” replied the nurse, angrily. “The

  doctor involved in your case could have done something. He probably

  just refused.” Deliberate sabotage on the part of a doctor was somehow a

  much more satisfactory explanation to her mind than a doctor’s desire to

  follow practice guidelines.

 
; I disagreed. This time the nurse sought refuge in generalities. “Listen,

  medicine used to be a one-way street, with doctors telling patients what to

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  do. Now, it’s going to be a two-way street,” she said, with a note of scorn in her voice.

  The hospital administrator piled on. “That’s right. It used to be that the doctor was in the front seat, driving the car, while the patient was in the back seat. Now, the patient is going to be in the front seat, too. Not

  necessarily in the driver’s seat, but definitely in the front seat,” he said.

  These were nice metaphors, but they bore no relation to the reality of

  the case we were discussing. I said so, and then harped again on the rules governing anesthesia safe practice.

  The nurse grew angrier. The hospital administrator adopted a more

  self-satisfied expression. He was the kind of businessman who is obsti-

  nately sure of himself and thinks only he sees the big picture. He laughed sarcastically as I spoke. “Some rules are important. But other rules are

  silly. Everyone knows that. Sometimes you have to break a silly rule. You can let the hospital know if there’s a silly rule. We’ll make a note of it,”

  he replied.

  “But what if a doctor thinks a rule isn’t silly? And what if the doctor

  breaks that rule, gets a bad outcome, and gets sued? What’s the doctor

  supposed to do then?” I replied.

  The physician on the panel shifted uneasily in his chair. From some

  last remnant of professional pride, or from some strange feeling of hones-ty surviving all other emotions, he quietly said, “That’s a good point.”

  The nurse glared at him. He fell silent, back to whatever limbo he had

  come from.

  Instead of answering my question directly, the nurse sidestepped it. “If

  you and a patient have issues, just call for a mediator on staff,” she said.

  “Is the mediator a doctor?” asked a physician in the audience.

  “Sometimes the mediator is a nurse,” replied the nurse, defensively.

  “So we’re supposed to let a nurse decide what is best, and the doctor is

  supposed to accept the nurse’s ruling as final? That doesn’t make any