Other people's lives: reflections on medicine, ethics, and euthanasia.

AuthorFenigsen, Richard

Part One: In Defense of Medicine

Chapter IX. On Therapy

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." 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 puncture, carries a sizable risk of infection. And only patients with hemophilia easily bleed into the joints; in all other people, a simple exudate is what one can expect under the circumstances. Why not try a non-steroid anti-inflammatory drug? In nine cases out of ten the traumatic swelling of a knee disappears within an hour after a single 100mg dose of diclophenac.

Another unreasonable course of action is to call the surgeon because the patient is not getting better with conservative therapy. This does not yet prove that he would get better with the surgery! Since there is no truly effective treatment of chronic bowel inflammation called Crohn's disease, in many cases surgical resection of the bowel was undertaken in an attempt to cure these patients. Unfortunately, in the majority of cases full-blown Crohn's disease recurred after surgery. (91) The patients sacrificed up to a yard of the bowel, they have been exposed to the risks of surgery, and the painful recovery, and gained only a short respite.

As a very young medical student I had a memorable conversation with my father. He was a trial lawyer and used to tell us about his court cases, omitting the names. One day he came home very satisfied with the verdict: the prosecutor demanded four years' imprisonment for his client, but the court sentenced the man to only one year and a half, and granted my father's request to set the defendant free pending appeal. "How can you be so happy about that," I exclaimed, "you told me he was innocent! And now you rejoice because he is sentenced to one year and a half in jail, and is, perhaps temporarily, released?" "My dear," my father answered "his innocence is a great thing. Let's hope it will be recognized. Meanwhile, it is good to have him out of that filthy jail, at home with his wife and children."

Medicine, too, is the art of the possible. The error of the "radical therapists" is not that they seek radical solutions, sometimes such solutions do exist, but that they reject other ways to help their patients. Mr. A, of Brookline, Massachusetts, a man in his early seventies known with adult-onset diabetes and narrowing and occlusions in the arteries of the legs, suffered his first two attacks of chest pain, one after a meal and one while lying in bed. His electrocardiogram remained normal and the heart enzymes were not raised in his blood, which showed that Mr. A had not suffered a myocardial infarction. A catheterization was immediately done: the catheter was introduced through an artery in the groin to the aorta, iodine dye was injected into the coronary arteries and the left ventricle of the heart, and films were made of these structures. This study showed narrowing of two major coronary arteries. The important anterior descending artery was not narrowed. According to the criteria based on large studies, (92) and accepted on both sides of the Atlantic, such patients should have coronary bypass surgery if attacks of chest pain persist in spite of adequate treatment with medicines. In other words, treatment with drugs (and diet etc., of course) should first be tried; and this was what two experienced cardiologists advised in Mr. A's case. The so-called beta-blockers are the drugs of choice. They do not make the coronary arteries any wider, but they reduce the work and the oxygen demand of the heart, allowing it to adapt to the diminished blood flow and oxygen supply. In a significant percentage of cases this treatment prevents chest pain, myocardial infarction, and death. (93)

But Mr. A's attending physician disdained "half-measures" and had not started any drug treatments. Within two weeks a new attack of chest pain occurred, and Mr. A was directly sent to the operating room. The patient's chest was opened, his heart stopped, extracorporeal circulation installed, and two bypasses were made, pieces of patient's veins that led blood from the aorta to two coronary arteries beyond the narrowing. Mr. A's recovery was uneventful. He continued his treatment for diabetes and his cholesterol-lowering diet. No beta-blockers were given; the problem was radically solved, wasn't it?

Nine months after the surgery Mr. A's attacks of chest pain recurred. A new catheterization showed that both bypasses were occluded by clots.

Therapeutic Nihilism. In the not so distant past when 95 percent of drugs listed in the pharmacopoeias produced no demonstrable effects, therapeutic nihilism was the usual attitude of intelligent physicians. "Apply drugs when they are new and still have the power to cure," wrote Trousseau, the great French clinician of XIXth century. When a colleague asked "after what" the patient improved, witty doctors used to answer: "After the 16th of October," or whatever the date might have been. As the Warsaw century-old medical legend had it, at the department of internal diseases led by professor Jozef Pawinski, there were three mixtures in use, one of which was white, the other green, and the third one brown. If the white did not work, Pawinski would try one of the other colors. Only the hospital's old pharmacist remembered what these mixtures contained. In an American hospital, I was told a similar anecdote about aspirin being available in three different colors.

The Cardinal Sin of Traditional Medicine. Nihilism notwithstanding, therapy, the need--and the duty!--to treat, very much preoccupied the physicians. Even when nothing sensible could be done, gestures were made, or medicines given, ut aliquid fieri videatur, to let it be seen that something was being...

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