This book is about the transformation of traditional medicine into the modern "scientific" variety, and the patients' and doctors' adventures on this journey. It is also about losses. The ethical and intellectual costs of modernization are proving painfully high. The curative powers of medicine have enormously expanded, but doctors' clinical skills have suffered, resulting in a medical practice that is less rational, less beneficial to patients, and more expensive than it need be. Doctors' practice and bed side manners have deteriorated, making the medical treatment a trying experience for many patients. Traditional ethics, to which the profession owed its good name, is being forcefully challenged.
The losses incurred in the process of modernization are understandable, but such losses were not necessary. I am convinced that many losses could have been avoided. And 1 firmly believe that the doctors' lost skills and high ethical standards can be restored. To bring this goal a little closer is the main purpose of the present work.
I shall also try to dispel certain misconceptions. In recent decades, medicine, health care, and the medical profession have been blessed with the attention of scholars from various domains: lawyers, philosophers, theologians, psychologists, sociologists, and business managers. A number of "models" of medical practice have been proposed and utilized in the debate. The genuine physician does not recognize himself in these proposed models. He finds his motives misread and his reasoning grossly simplified. I shall try, therefore, to throw some light on doctors' motivation, and that little known subject, the functioning of the medical mind.
The acceptance of euthanasia or physician-assisted suicide would profoundly change the practice of medicine and the physician's very calling. I shall try to show that the choice for euthanasia or assisted suicide is a choice for a medicine, a society, and a world that would be different from the ones we know. I shall also argue that the legalization of euthanasia will ultimately require a change in the system of government now prevailing in Western nations.
Part One: In Defense of Medicine
Chapter I. Bioethics Versus Medicine
Lay Adventures in the World of Medicine. What the public thinks of doctors and medicine is often true, sometimes wrong, and at times touchingly amusing. A lady once told me: "Oh, doctor, you are so marvelously calm, even when 1 get sick, or when I tell you of the terrible things that have been happening to me. You have such a soothing influence on me!" And I thought, "Holy innocence! Were you to know what doubts, tensions, what boiling anger I stifle inside myself in order to show you that calm face, you'd flee this place screaming!"
I recall leaving a concert hall on a winter night in the company of R, a musician who was an acquaintance and a patient of mine, and his wife. Walking a few steps in the street provoked R's chest pain, he had to stop, and we all stopped, watching him and waiting for his pain to subside. A few days later Mrs. R said to me: "Oh, you have so much empathy, I saw you were suffering when you watched my husband in pain."
What I really thought when we stopped near that concert hall was that in cold weather R was getting angina pectoris with the slightest exercise, like walking, but he never had pain while conducting the orchestra at the opera house, vigorously throwing his arms about for three or four hours. Apparently the simplifications that had been our most fruitful approach to coronary heart disease, the "plumber's view" of pipes clogged and flow impaired, the imbalance between oxygen demand and oxygen supply, did not explain everything. Other mechanisms supervened. Some have thought that in cold air the contraction of blood vessels in the skin increases peripheral resistance to blood flow, raising the workload--and the oxygen demand--of the heart's left ventricle, thus provoking an attack of pain; and I tried to recall whether this was just an educated guess, or was it a mechanism actually shown in physiological studies. The good lady believed that I was a better soul that in fact I was.
It is not at all surprising that lay people may have some mistaken ideas concerning doctors and medicine. The same is true of any profession or trade. When at sixteen I started my first job, as a lumberjack in the North Russian forest, I quickly learned how wrong and naive I had been about that trade before entering it.
What about bioethics? While analyzing medical situations bioethicists often display an admirable command of the subject. But we should not be surprised when it turns out that the same bioethicists are not aware of basic medical facts and practices. They have been educated in various fields of knowledge, but not in the one they must now deal.
In 1991, at a committee meeting in Ede, Holland, to which I was invited as the only physician, we were supposed to discuss a draft statement on ethical principles of medical care. It was presented by the director of an institute of medical ethics, a theologian. "When the patient suffers from an incurable disease," one of the proposed guidelines read, "it is justified to withhold or discontinue all medical treatment." The people attending the meeting gravely nodded in agreement.
"Gentlemen," I exclaimed, "diabetes, arteriosclerosis, the ordinary form of high blood pressure, many diseases affecting the joints, and dozens of other common conditions are incurable diseases! And yet doctors spend most of their time treating such patients, relieving their symptoms, and trying to prolong their lives. Do you really want to bar these 'incurables' from receiving such assistance? Then you can abolish medicine altogether!"
The story sounds funny but isn't. People equally versed in medical problems as the members of that committee have drafted living wills, hospital regulations, and important pieces of legislation. (1)
At the opening of the international conference (2) organized in Prague, Czechoslovakia, by the Hastings Center, an important American institute of bioethics, a middle-aged man rose from his seat and exposed the primary failing of medicine: Medical specialists, he said, sought vain glory in spectacular interventions publicized in the media, but nobody paid attention to the average patient. "What about me?" asked the speaker, "what if I suffer from some common, unglamourous disease like arthritis or diabetes? Don't I deserve the attention of the high priests of medical science?" A large part of the audience applauded the speech.
I thought the speaker was some embittered patient attending the conference, a suffering person whose grievances against medicine deserved understanding, and who was under no obligation to know more about the subject. To my surprise, I learned the next day that he was Professor B, chair of the department of bioethics at the University of Pecs, Hungary.
Let's consider in some detail the professor's allegations. Diabetes mellitus and the diseases of the joints are two fields that for many decades have attracted brilliant researchers and particularly devoted medical practitioners. Owing to their efforts, we are now able to correctly diagnose degenerative joint disease (osteoarthritis), rheumatoid arthritis, gout, the involvement of joints in acute rheumatic fever, in collagen diseases, in sarcoidosis, and some fifty other diseases afflicting the joints. Treatments have been worked out for many of these. The pharmacological treatment of arthritis has developed from basic salicylates to steroids, the whole range of non-steroid anti-inflammatory drugs, and immuno-suppressive therapy. It is supplemented by elaborate physical therapy, surgical arthroplasty and total hip and knee replacements.
One hundred and fifty years of research for the causes of diabetes has led from the discovery of the role of pancreas, identification of insulin-producing islets, to the isolation of insulin, and later to the crucial distinction between insulin-dependent and the adult-onset types of diabetes, and the introduction of oral anti-diabetic drugs; to the studies of diabetic ketoacidosis, and to all consecutive improvements in the treatment of diabetic coma. The discoveries of Somogyi taught us to avoid excessive dosage of insulin. Followed the discovery of non-ketotic, hyperosmolar coma, which is due to dehydration and must be treated not with insulin, but with water; the introduction of dozens of insulin preparations to match various blood sugar rhythms; the studies of insulin resistance, the finding of insulin antibodies, and the introduction of "human" insulin, obtained by manipulation of bacterial metabolism. These achievements have resulted in keeping millions of arthritis patients mobile and millions of diabetic patients alive.
Many medical graduates train in diabetology or pursue several years of study to specialize in rheumatology, and devote themselves entirely to treating patients with diabetes or diseases of the joints. Specialized hospital departments and even specialty hospitals, outpatient clinics, revalidation centers, specialized nurses, dieticians, and physiotherapists help these patients. Doctors have encouraged and helped the arthritic and diabetic patients' associations, the designing and manufacturing of equipment to assist people with impaired limb mobility, the training of diabetics and their families in self-controlling the blood glucose levels, in the technique of insulin injections, in recognizing and combating episodes of hypoglycemia. Instructions, pamphlets, books, and journals are distributed among patients with diabetes and arthritis. Plays have been written and staged featuring Princess Insulin in order to make the treatment more attractive to diabetic children, and Dr. Joslin awarded gold medals to patients who for twenty-five years strictly adhered to their diet, thereby effectively preventing the complications of...