Hard Cases
Dr. Abigail Zuger on the everyday ethical issues doctors face.
The new chief executive of our clinic was gung-ho on its mission and purpose, so much so that he was prepared to put his insurer’s money where his mouth was. He announced at a staff meeting that he would be transferring his own medical care to one of the doctors on staff.
We exchanged glances. This pleasant-faced man knew none of us, and we didn’t know him. None of us were related to him, reported to him or socialized with him. We were linked by proximity alone, and separated by a reassuringly dense tangle of corporate tiers.
And yet in the blink of an eye, each of us reached the same conclusion: What an utterly dreadful idea. As removed as he was, he was still too close.
How many degrees of separation are needed between patient and doctor for effective medical care? The correct answer is “many,” or even “as many as possible,” a dictum so counterintuitive that everyone routinely violates it.
Surveys indicate that almost all doctors have been asked to provide some form of informal medical care to a close relative, and almost all of them have obliged, even though most hospitals and many professional organizations warn against it. Doctors often write prescriptions, sometimes supervise a hospital stay and occasionally perform surgery or provide continuing primary care.
Medical care supplied by a relative — or an old friend, or a trusted employee — just seems so logical. After all, who could care for you more? But that is just the problem, as Sir Thomas Percival, a British doctor wrote in 1803: “Solicitude obscures the judgment, and is accompanied with timidity and irresolution.”
Medicine is filled with difficult decisions, and even the most trivial action (you write a prescription) can explode in unanticipated ways (a horrific drug reaction ensues). These shoals are rocky enough without additional complicating relationships.
Granted, one of the time-honored ways doctors help patients make hard decisions is to ruminate out loud on what the doctor might personally choose. But that technique employs a kind of trompe-l’oeil perspective. When the hypothetical turns real, and the doctor’s own toddler is groaning on a stretcher with belly pain that needs to be explored surgically right that minute or left completely alone — that’s when an objective eye helps.
Pity those patients for whom no truly objective eye exists. They are the people we all know intimately, though they know us not at all: politicians, actors and other celebrities.
The “V.I.P. syndrome” was coined in the 1960s to describe the predictable misbehaviors of doctors who care for these famous patients. Doctors may bend over backward to spare the illustrious one discomfort, ignoring obvious problems. Or they may instead provide a showy display of doctorly activity, pursuing even tiny problems best left alone.
Whether from too little medicine or too much, the care becomes instantly substandard. Commentators have wondered if some of these considerations did not contribute to Joan Rivers’s recent death.
The team of Israeli doctors who cared for the prime minister Ariel Sharon in the first weeks of the stroke that was to kill him eight years later wrote in detail about their efforts to avoid the V.I.P. syndrome. Mr. Sharon’s complicated medical problems were almost dwarfed by this administrative challenge: His doctors had to deliver impeccable medical care, secure Mr. Sharon’s privacy while keeping the public reasonably well-informed of his condition, and also maintain a semblance of normalcy for all the other patients in their hospital.
The process required the tactical thinking of a military campaign. A single senior physician was deployed to coordinate a gigantic medical team, with all major medical decisions made by consensus. Disagreements were managed in a preprogrammed way, as were all interactions of junior and senior consultants. So many interested parties in the hospital and the news media tried to hack into the hospital computers that Mr. Sharon’s care had to be taken off-line, with handwritten notes in a paper chart and paper reports hand-delivered from the lab.
It doesn’t take an actual V.I.P. to set off a similar cascade. After all, every collection of humans generates small-scale celebrities: You have them at your workplace, we have them at ours. In a health care setting, the more beloved they are by their colleagues, the less objective their medical care there will be. If they are despised, the same applies in spades.
Roving eyes will take an interest in their private details. Doctors will begin to think tactics, not medicine. Far better for that very important patient to avoid the whole thing and become a big nobody somewhere else.