Tuesday, March 22, 2005

Do No Harm

Certainly words to live by, especially for doctors. Like all simple concepts, we doctors even have an expensive word, non-malfeasance, which is generally accepted as our first ethical priority. First do no harm and no harm can come of that.

When this was said to me, it was said by a Chess Master who seemed to believe it was a point of crushing force and considerable thought. And it is.

TS is in PVS. No cure, no further recovery is possible. The natural history of this disease process is death. As early as 50 years ago, she would have died. As of now, our medical abilities have progressed to the point where we can only prolong her life. This is done primarily by feedings through a tube inserted into her stomach, but also includes prevention and treatment of infections, prevention of ulcers (an impossible task, Christopher Reeves died of an infected ulcer, despite the best medical care), and prevention of blood clot formation in the legs.

Modern medicine can do these things, but we can do nothing for her underlying condition. There is nothing we can do to heal the neurons which died as a result of hypoxia. It is likely that our grandchildren will be unable to cure such a devastating condition, unless stem cells, or another new therapy, supersede their great promise.

These are facts: her diagnosis, our abilities, and our present limitations. The Chess Masters would like to ignore these, and where ignoring them is impossible, they fall to discrediting. And failing that, they just distract the argument away from these simple, undeniable facts. You can see that happening every time they talk about what a bad person Mr. S is. This is more comfortable ground for them.

They would like to distract us all from another fact: her wishes. Although she never wrote them down (how many people in their 20’s or 30’s write down living wills?), her wishes are known. Her next of kin, her present husband, a man who refused blood money from the Chess Masters to give up this responsibility (totalling over 11 million), states that her wishes in this situation would be this: no more medical therapy.

On a personal note, I can understand this. I would choose a death rather than live in PVS. This is a personal choice to make. Anyone else may choose differently. As a doctor I have seen and respected decisions that I would not make for myself or for my loved ones. Patients are free to prolong their life through whatever means are available. Before this case they were also free to rfuse medical therapies at any time, including chemotherapy, radiation, surgery, medicines, and artificial tube feedings.


TS choose not to prolong her life in this manner. TS is a person, much as the Chess Masters would like her to be their wooden pawn. She had wishes, desires, and a will. Her wish was for no artificial means to maintain her life in her present state. Some would respect these wishes, others would trample on them.

Do no harm.

What is harm? Given the facts of this case, forcing a feeding tube into the stomach of an unwilling person is more than harm. It is assault and battery. It is also the utter and complete disrespect of another human being. A living, breathing person, not a wooden pawn, pushed at the will of others to occupy a stratigic square.


Inserting a tube into TS is shameful. It is also battery. I would also call it malpractice. It is most certainly harmful.

The congressional and executive Chess Masters who would legislate the decisions already made by TS, and thus assume power over her wishes, go beyond a case of assault and battery. Words cannot capture the immorality of such an act. It is only slightly comparible to rape and slavery, but goes further than that. It is the complete subjugation of an innocent and defenseless person for personal political gain.

Those who voted for Terry’s Act rightly assume their place next to tyrants through history. Tyrants who assumed power over the defenseless, made decisions regarding their life and death. They also find their place next to slave owners, who thought nothing of selling slaves for money and political favor. What can one say of those who think of other humans as property, to be used to advance their own power?

I would start by saying what I already have.

19 Comments:

Blogger echrai said...

Well said. I'd like to also state for the record that it drives me to distraction how completely and utterly futile living wills are in most states. They should be honored, they should be binding, and they're not. I understand it's difficult for any doctor in a given hospital to know about the existence of one at the time when it's most necessary. Many methods have been tried and most of them have failed. I understand that to let a patient die can and may constitute malpractice on the part of the successors, living will or no, which only exacerbates the already foul situation between lawyers, doctors, and insurance companies. Still, just as everyone has a right to live a free and happy life, don't we also have a right to die with minimal suffering within a reasonable period of time? I wish I had a brilliant idea to make it feasible and functional for living wills to be accessible at need and honored by doctors and hospitals, family members, and the law. Then again, if I could come up with that solution, I'd have no need for law school and be a much richer person. And with the current state of affairs in our government, I don't see that solution coming from another source any time soon.

10:55 AM  
Anonymous Jesse said...

I guess the only real issue I have with your comments are the tone of them. Because, as much as I disagree with your opinions, I believe wholeheartedly in your right to express them. However, when you use hate filled language to describe those with whom you disagree, it muddies the water of the issue. And that, in itself is a distraction from the issue. If your point is to "go off" on those with whom you disagree, then, well, I guess that's in line with your words. However, if your objective is to inform, or interact, then your words aren't conducive to that goal.
Why is it that there must be "Chessmasters" at work here, and not people who feel every bit as passionately as you do about the issue--just on the opposite side of it?
Many of the things you list as facts, are in dispute by TS's parents. What the congress has done in passing this law is not to usurp a patient's individual rights, but to merely give family members a standing in the courts. Standing is a legal term which means simply that you have a right be heard. It does not guarantee any particular outcome, but that those family members have the same rights of review afforded to others in different circumstances.
Are there politicians who are mugging for the cameras on this?--Unfortunately, we can never know the true motive of one's heart. We can only go by the behaviors they exhibit. So yes, there are plenty of questionable people on the TV these days. However, in judging the behavior of those people, we must also look at the behavior of the husband. And again we must admit, that no, we do not know the true motives of his heart either. We can only go on the behavior he exhibits. And by the same measuring stick one applies to the politicians, we can raise eyebrows about MS.

12:17 PM  
Blogger Doc NOS said...

Jesse,

My words do not even begin to express my absolute disgust with the people who would use TS as a pawn in their political games. I do not recant.

"What the congress has done in passing this law is not to usurp a patient's individual rights, but to merely give family members a standing in the courts."

No. This is wrong. TS has been before numerous courts (19, now 20). What congress did was to make a state issue a federal issue. The verdicts have been given in the TS case. That's it. Case closed.

You would like to make it sound like TS has been denied due process, wouldn't you? But the fact is that she's been given more trials, more due process in the last 7 years than many convicted of capital crimes! Each fact of this case has been pored over with a microscope. One more court date does nothing, except advance the political cause of people like DeLay.

12:31 PM  
Blogger marybishop said...

echrai says: I understand it's difficult for any doctor in a given hospital to know about the existence of one at the time when it's most necessary.

So true. My father also died of cancer..healthy as an ox then a funny feeling in his stomach..visit to the doc and a 3 months-left-to-live diagnosis.

He lived 3 months and two weeks...he had a no resuscitation order but when he went into cardiac arrest the doc on call did what he thought was best and brought him back to live those last two weeks.

We never complained although his last two weeks were painful with a black arm and a clot in his carotid...point being it's hard to get a doctor to do the opposite of what he or she is trained to do which is to save lives. I would nor did ever fault the young doctor who "saved" him.

You bring up a seminal point echrai -- maybe not in TS's case but in general...something to think about indeed.

And, Jesse, I like Doc Nos' tone quite a bit.

12:55 PM  
Blogger Doc NOS said...

Another excellent point about the legality (perverted legality, but legality nonetheless) of what is happening TS can be found at:

http://erikgrow.blogspot.com/

The legal expert he quotes: well, I wouldn't entirely trust him to interpret the constitution, but he makes an interesting point, one I happen to agree with.

2:23 PM  
Anonymous Jesse said...

"You would like to make it sound like TS has been denied due process, wouldn't you? But the fact is that she's been given more trials, more due process in the last 7 years than many convicted of capital crimes!"

The one big difference, here, DocNOS, is that TS is not, in fact, a criminal. With her standing to receive death allowed by the courts, it is not too much to have another look by a higher court.

2:24 PM  
Anonymous Jesse said...

Again, to marybishop and others who may find the Doc's tone "just fine": I only object to the tone if the intent is to dialog. If it is to rant in anger then it seems in line with that goal. A point to be made though, is that ranting in anger is rarely successful in moving an issue forward.

2:29 PM  
Anonymous Jesse said...

"TS has been before numerous courts (19, now 20). What congress did was to make a state issue a federal issue. The verdicts have been given in the TS case. That's it. Case closed."

Well, not quite. In none of those trials was representation afforded to TS. She did, however, have a guardian ad litem (GAL) appointed for her, and the GAL's report recommended that the tube NOT be removed. This was what happened with the first attempt, and why the governor of Florida initially became involved. Later, when the supreme court of Florida found the law signed by Gov. Bush to be unconstitutional under Florida law, the whole process began again. So, although the case has a lengthy history in the courts, there are still many issues that the "microscope" has missed.

2:38 PM  
Blogger Anne said...

Jesse makes a good point: "I only object to the tone if the intent is to dialog. If it is to rant in anger then it seems in line with that goal. A point to be made though, is that ranting in anger is rarely successful in moving an issue forward."

People object to people like Michael Savage because of his often angry tone, and they tune out the message.I know that I sure do. I don't know of anytime I've ever been persuaded by someone who was venting, ranting, yelling, or insulting me or the people or values I hold dear. Tone is quite important if you really care about people actually listening to what you have to say.

Dialog in this case is most helpful. I, for one, hope that it continues.

3:04 PM  
Blogger Erik Grow said...

Thank you for the link Doc! I just read it for the first time, and have found your blog to be very insightful. It is refreshing that a doctor has time for a blog, and the will to speak out about what is happening. As for the Scalia quote, yes the irony of the messenger was certainly intended! As for the substance of the TS issue, there's already plenty of my view on it in my blog, so I won't add to it here right now. Time for lighter fare! I already have an idea percolating. Check back soon. Thanks again!
-Erik

3:29 PM  
Blogger marybishop said...

Jesse et al -- listen to your own tone of superiority and smugness - I prefer doc's tone to that.

6:25 PM  
Blogger Doc NOS said...

"A point to be made though, is that ranting in anger is rarely successful in moving an issue forward."

Where do you think we are, in a fucking high school auditorium? We are not 'moving an issue forward.' At least, I hope we're not. We're talking about why it is pure evil to use the tyranny of the a government to interfer with the wishes of a defenseless woman.

8:29 PM  
Blogger Doc NOS said...

MB,

Thank you for sharing. Sometimes in the heat of the moment, when a heart or pulse stops when a patient is in the hospital, it is very difficult to adopt a sensible stance - especially when the information is incomplete. I'm very sorry your father was coded.

8:34 PM  
Blogger Doc NOS said...

"none of those trials was representation afforded to TS."

OK, I'll call you on this bias as well.

Guess who her representation is? That's right - the man she married, Mr. S. He is the one representing her legal interests in this case. Not DeLay, not her parents, and certainly not our tyrant of the week, Bush.

Oh yeah, today over 8,000 children will die of malaria. Tomorrow as well. Once again, that is EIGHT THOUSAND CHILDREN!!! Just thought I'd try to give some perspective. If Bush got up at 1 AM ever again, I hope it's to address a real issue, like a preventable disease that is killing kids. Not to prove what a Pawn Master he is. Not to assume tyranny over TS. Not to further erode what civil liberties we have.

Perhaps he should just stay in bed.

8:40 PM  
Blogger marybishop said...

Thanks Doc

Don't you love it how your "tone" is coming under scrutiny when Bush et al have crossed over a serious line usurping our personal choices and freedoms and that gives the tone-moaners no cause for concern.

I didn't realize that malaria was that pervasive and destructful. When I read that statistic it made my heart hurt.

3:57 AM  
Blogger laurenbove said...

I think it's excruciatingly difficult to exact a tone from a bunch of words on a page on a screen connected to a computer.

You really cannot judge one way or another exactly the intent of the writer what tone he or she would adopt if the words were to be spoken. For goodness sake! Think about the many ways (and intentions) one can say the word, fuck. Is it not best to er on the side of positivity?

Having said the above, it's a moot point to ponder. Additionally, why bother commenting upon a blogpersons tone? It's argumentative. Isn't that exactly what the commentor was just discouraging?

Good communication on blog or other similar medium is difficult. For the author (DOCNOS) to convey emotion, certain words must be used. It's a useful convention. Now, personal attacks regarding such are NOT useful conventions.

Let's stick with the subject matter and leave tone out of it. Blog Author Docnos: Keep on keeping on.
Everyone else: IF you don't like it. Click off!

Having said that: I agree completely with Echrai (as I usually do)MB and the good Doc. I'd write more but I've got to go get my living will tatooed on my ass.

8:42 AM  
Anonymous Jesse said...

One last point and I will indeed "click off". My point in even bringing up tone was to clarify the objective of those using an offensive tone. It was not to be smug, divert the discussion, or any other. I would ask that you take a moment and check your motivation on this exchange: are you in disagreement, and passionate about your opinions on this matter? Or are you filled with hate for me and anyone who dares not agree with you?
I apologize for being direct, but I am baffled to find any other way to clarify my clarifcations.

It is interesting, though, that tone can not be determined by DocNOS's typing, but can be determined by mine, don't you think?

9:45 AM  
Blogger laurenbove said...

Poor Doc: Sorry this has taken a turn for the negative.

No hate here! For me? I hold hate for child murderers anyone who'd be mean to my kids. That's about it.
I'm not into picking on tones but am trying to get off that topic. It's not the point.

I'm way more interested in the content of what's being said and a witicism here or there than how things are being said.

Don't focus on the tone issues. Just speak your peace. The more one replies in the negative and stays there, completely off topic, the more one defines one's own tone.

This is Docnos' blog. Docnos is a physician in the trenches. Personally, I tend to put a lot of stock in his experience. I'd like to hear it minus the sensitivity factor, that's all.

1:54 PM  
Blogger Doc NOS said...

Jesse,

I hate tyrants everywhere. You and yours are not the first humans who would be tyrants, not will you be the last. I hate you. I hate all tyrants. I hate those in the house who took it upon themselves to tyrannize a citizen. I hate Bush for the same.

What they are doing is so low, so evil, and so disgusting that hatred is the only emotion I have.

It's actually the sort of detached hatred you get when you hear about a man who raped and killed a child. Something that didn't affect you personally or directly, but you know you should feel something, and the best thing to call it is hatred.

Yes, Jesse, I hate you. You who would assume power over the defenseless. You who aid and feed this repulsive political game, which just so happens to involve a person, and which is so ill suited to it's legislative environment. But, again, it's sort of that detacted hatred where I also don't really wish you and yours any ill will. I just want you to see the error in your ways, shut up, and leave well enough alone.

Does that make sense?

10:33 PM  

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