Chapter I. Bioethics versus Medicine

Article excerpt

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 I 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. …