Neat ethical principles have nothing to say to doctors like me, faced with the brutal, bloody compromises of hospital life

by Ronald W Dworkin  BIO

Photo by JC Gellidon/Unsplash

practised anaesthesiology in a large medical centre for 30 years. He is a fellow at the Institute for Advanced Studies in Culture at the University of Virginia, United States. His most recent book is Medical Catastrophe: Confessions of an Anesthesiologist (2017), and his other writings can be found at RonaldWDworkin.com. He lives in Maryland, US.

Edited byPam Weintraub

I suffered from a bad conscience before the case even began. My patient was in his late 70s, partially blind from narrow-angle glaucoma. He had undergone a colonoscopy a few days before and now needed emergency abdominal surgery for a perforated bowel. Before his colonoscopy, he’d had a slight fever, which the surgical team – including myself, the anaesthesiologist – had dismissed, but which later proved to be an early sign of sepsis. Two voices now vied for supremacy in my head. The first asked: Why did you overlook his fever? The second replied: How could I have foreseen what would happen? The first shot back: A smart doctor is only a smart doctor if he does foresee things. It doesn’t take a smart doctor not to foresee things. Anyone can do that.

The man was on several intravenous drugs called ‘vasopressors’, which cause the heart to eject more blood and the small arteries to squeeze down, thereby raising blood pressure. Without the drugs the man would die.

I told the man my plan was to place a breathing tube in his windpipe while he was still awake, as the sedation normally used to put patients to sleep would cause his blood pressure to crash. He offered no response. His eyes sitting in his grey, haggard face were remote and sad, as though overflowing with all the mute loneliness that preys upon a solitary individual close to death inside a hospital.

I numbed his throat with local anaesthetic. His sorrowful glance was filled with entreaty as I inserted the flexible scope into his mouth. When I manoeuvred the scope past his throat, he jerked his head from side to side. As I went deeper, he bucked with a pained expression on his face, squinting his eyes and contorting his mouth, his illness having prevented me from numbing his windpipe beforehand.

Was my inflicting of pain unethical? The field of bioethics arose in the 1960s to answer such questions. But it had nothing new to say in my case. The philosophy of utilitarianism, which justifies inflicting pain on a sick, speechless patient to save that patient’s life, had conquered everyday medical practice long before bioethics came along.

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Bioethics has surprisingly little to offer practising physicians in general. Other than the principles of informed consent and patient confidentiality, the field has had no impact on my three-decade career, nor on the career of any other anaesthesiologist I know. Surgeons have told me something similar. We took the Hippocratic Oath upon graduating from medical school, but we already had a firm sense of right and wrong before then. My own code of ethics drew, cafeteria plan-like, from a variety of sources: a secularised version of Judeo-Christian teachings such as ‘respect human life’ and ‘be kind’, notions that undergird most civilisations; a strong belief in individual freedom and agency, courtesy of my southern California upbringing; an Aristotelian sensibility that perfect justice is an abstraction, without meaning in the real world; and the pragmatic view that ‘moderation in all things’ is a wise dictum to follow, when you can.

When my colleagues and I ran into moral dilemmas our own codes of conduct couldn’t resolve, it was often technology – not bioethics – that supplied the workaround. Special ‘holding’ bags could keep blood connected to the bloodstream and make emergency transfusions acceptable to Jehovah’s Witness patients. Translation apps, meanwhile, could spare me the prospect of urgently anaesthetising a non-English-speaking patient before I understood their medical history.

In fact, during all my years practising medicine, I never met a bioethicist at my hospital, even after the 1980s, when bioethics launched a specific focus on ‘clinical bioethics’ to advise doctors in their daily practices. In that first decade, only 1 per cent of US hospitals had a clinical bioethics committee; today, an estimated 97 per cent of US hospitals have one. Yet clinical bioethics, like general bioethics, which covers all the life sciences, tends to focus on obscure issues, such as human subject research or the appointment of healthcare proxies. Often, a bioethics committee sets broad policy for the hospital without focusing on any individual patient case.

Inflicting severe pain on a patient creates a kind of moral residue for a physician that begs for relief

Personnel accounts for some of bioethics’ irrelevance for practising physicians. The field has long been under the control of non-physicians who focus – understandably – more on patients’ rights than on doctors’ inner experience. A hospital bioethics committee, for instance, typically has a doctor on it, but other members might be nurses, lawyers, sociologists, clergymen or even just laypeople. In fact, anyone can call themselves a bioethicist; it is an unregulated field without formal certification for the title. Non-physician bioethicists tend to overlook doctors’ complaints of ‘burnout’ and their struggle to preserve their decision-making independence inside large companies.

As a result, bioethics tends to ignore the hospital rooms where a doctor’s bad conscience lives. Inflicting severe pain on a patient creates a kind of moral residue for a physician that begs for relief – something utilitarianism alone cannot supply. A routine intubation on an unconscious patient may prompt, at most, quiet professional satisfaction; a difficult one performed successfully can arouse in a doctor the feeling athletes experience when registering a sports record. An awake intubation is different. It means passing a breathing tube into a conscious person’s windpipe, a procedure that can mimic suffocation.........

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