Chapter IX: on therapy.

Author:Fenigsen, Richard
Position:Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia

Dr Loeb's Five Rules of Therapeutics. Dr. Robert F. Loeb was said to be "in semi-humorous vein" when he proposed his Rules:

  1. The Golden Rule: Don't do to the patient what you wouldn't like to be done to yourself.

  2. If what you are doing is working effectively, keep it up.

  3. If what you do is not working, stop it.

  4. If you don't know what you are doing, don't do anything.

  5. Keep the patient out of the surgeon's hands.

"Semi-humorous" or not, the Rules 2, 3, and 4 are simply valid, and wise is the doctor who follows them to the letter. There is also some truth at the core of the other two rules.

Dr. Loeb's First (Golden) Rule. My friend John M. Dolan, the philosopher, observed quite rightly that unqualified application of the Golden Rule of ethics to the doctor-patient relationship would be inappropriate. Doctors may have personal weaknesses that would prevent them from accepting a treatment they know would be most advantageous to their health; or, being healthy, they may display a "cavalier attitude" toward their own lives. Such failings of the doctor should not be visited upon his patient. The doctor's duty is to propose to the patient not what the doctor would choose for himself but what he knows is the best course of action.

Yet there is some merit to applying a personal standard. Before I read Dr. Loeb's excellent set of maxims, for years I used to apply a "first rule" of my own. Whenever in doubt I asked myself: "How would I treat my aunt, were she in the same condition as this patient?"; and I used to ask the residents how they would treat their aunts. The "aunt" word reminded the doctor that the patient was not only a problem to be solved but a fellow member of the human family, in need of tender and cautious care. Ultimately, strictly following the rules of the art should prevail because this is what gives the patient the best chance; but applying Dr. Loeb's Golden Rule, or, preferably, the "aunt test," is useful as a first approximation. It may prevent some annoying or dangerous mistakes.

A patient whom I knew very well fell and broke his hip when he was 99 years and nine months old. The surgeon knew that immediate hip replacement was the patient's only chance to stay alive, but temporized, "waiting for the general condition to improve 2 Meanwhile the patient was kept in an intensive care unit. A bladder catheter was introduced and left in place, as was the department's routine with all bedridden elderly. It's a pity the intensive care physician, Dr. H, did not apply the "uncle test." Had she done so, had she considered the pain and anxiety bound to occur with the catheter, had she taken into account the transurethral resection of the prostrate the patient had undergone 20 years earlier, and has had no trouble urinating ever since, she probably would have tried to maintain the patient without a catheter, risking--what? At worst, wetted sheets. She might have waited for the "Texas catheters" which I was bringing, condom-like devices that may not be as leak-proof as an indwelling catheter, but are non-invasive and non-irritant. But no, catheter was introduced, causing the patient's constant anxiety and repeated attempts to pull the thing out. Morphine had to be given to relieve this torment, and after the second injection the patient stopped breathing.

Dr. Loeb's Fifth Rule: "Keep the patient out of the surgeon's hands." How could Dr. Loeb give such advice?! More than any other branch of medical practice, surgery saves lives. Just think of the abdominal catastrophes, the intestinal blockage, the perforated ulcer! How about a gallstone blocking the common biliary duct, an operable cancer of the colon, a kidney full of pus, a young female suffocating from tight mitral stenosis?

Of course, Dr. Loeb did not mean these obvious cases. But his Fifth Rule is a warning against seeking "radical solutions" when the situation calls for patience and moderation. One should not choose an invasive intervention if it may cause worse injury than the patient's complaint. When somebody hurts his knee and within minutes it swells to twice the normal size, a panicky doctor would immediately think of bleeding which might make the joint stiff forever. He would, therefore, grab the needle and puncture the knee, intending to proceed, if necessary, to arthroscopy and surgery. Even the first step, the...

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