The Return of Paternalism?

Paternalism is the notion of doctors unilaterally acting on the patient's behalf. It follows in that "Father Knows Best"-type of tradition (hence, the word). In recent years though, medical ethics has veered away from the traditional paternal role of the physician towards one of neutral advisor. This new ethic placed patient's autonomy as the paramount ideal. Patients were supposed to make decisions for their own care after being presented with the options in an unbiased manner by their physicians. The physician-as-agent was supposed to merely standby and execute the patient's decision. They could offer advice if asked, but had to be careful not to advocate too forcefully, lest they violate the norm of autonomy.

Of course, most patients who are not well-versed in the issues involved still rely on their doctor's assistance in making that ultimate decision. New research in psychology and behavioral economic shows that perhaps patients do in some cases need this "nudge" in the right direction. However, as the article notes, if one cannot trust the public to act in their own interests after even a "nudge," why not do more?

Many of the suggestions in “Nudge” seem like good ideas, and even, as with “Save More Tomorrow,” practical ones. The whole project, though, as Thaler and Sunstein acknowledge, raises some pretty awkward questions. If the “nudgee” can’t be depended on to recognize his own best interests, why stop at a nudge? Why not offer a “push,” or perhaps even a “shove”? And if people can’t be trusted to make the right choices for themselves how can they possibly be trusted to make the right decisions for the rest of us?

But, therein lies the problem: if doctors push, we risk the pendulum swinging too far back towards paternalism. It seems that there is a real dilemma brewing between the necessity of paternalism and the ideal of autonomy. Modern medicine so far does not seem to have a palatable answer.

The Perils of Organ Donation

Organ donation is clearly an area fraught with ethical dilemmas. A recent story has shed more light on the differing incentives various actors face in the organ donation decision. The story concerns a surgeon who has been accused of inappropriately prescribing medications in order to hasten a donor's death so that the organs harvested would be more viable. At first glance, it seems that the surgeon prescribed medications to ease the man's suffering as he was removed from a ventilator. However, the article goes on to note that the transplant surgeon's presence in the room violated protocol, and that while administering the medications...

According to a police interview with Jennifer Endsley, a nurse, the transplant team, including Dr. Roozrokh, stayed in the room during the removal of the ventilator and gave orders for medication, something that would violate donation protocol. Ms. Endsley, who stayed to watch because she had never participated in this type of procedure, also told the police that Dr. Roozrokh asked an intensive care nurse to administer more “candy” — meaning drugs — after Mr. Navarro did not die immediately after his ventilator was removed.

Sadly, I am more inclined to believe the nurse's version of events. It's sometimes sad to think how technology has given us this great power to save human lives, yet somehow, the entire process almost ends up being almost dehumanizing. I remember observing a liver transplant procedure and being in awe that I was seeing the inside of someone's body with this giant cavity where the liver once was, yet simultaneously, somehow detaching this from the person that lay beneath the drapes. Actually, viewing a harvest was more striking. When we first met the donor, she was in the neuro ICU, brain dead, but her heart was still beating. We went into the OR, draped her, prepped, and soon made an incision and began the harvest. Only after about an hour into it did I realize her heart had stopped beating. A necessary step, yet it seems strange that no one really gave much pause to acknowledge this event. I do not claim that all transplant surgeons / staff are like this, but I do recall having this distinct feeling as I watched the procedures and how the transplant team functioned. I think the rigors of being involved in transplant surgery forces one to compartmentalize and focus so narrowly on the harvest and transplant that one may lose sight of the humanity underneath it all.


Think there's a better way? Read about some more views on organ donation.

Psychiatry or Sigh-chiatry?

My first full day on my psychiatry rotation was a minor revelation. Although each specialty has its own unique culture, I think in some ways, psychiatry is, um, "uniquer." This is not meant as a criticism or derogatory in any way; I just find it very intriguing since the approach to the patient and the manner in which they are discussed seems very different to me.

So, why do I say sigh-chiatry? Even though my one day of experience is hardly enough to draw any definitive conclusions, I did observe more sighing today than I feel I've seen in any other rotation. While medical specialties tend to always believe they are "more sinned against than sinning," the psychiatry team definitely bought into this to a higher degree. This is not to say that they do not provide quality care and a valuable service to their patients, or that they somehow infringe upon other services to a greater degree. In fact, to a certain extent, I agree with their claim that other services dump on them.

Yet, I feel there is more to the sighs than merely a sense of injustice. My sense is that, unlike most other specialties, psychiatry deals with the abstract, the gray areas, the parts of medicine that make most doctors uncomfortable. Doctors must acts with a presumption of infallibility to be effective. To do this, they are bolstered by hard science and objective fact. Psychiatry strives for this, but due to the complex nature of the problems they face, they are at a disadvantage. This vagueness is both a boon and a burden. It benefits psychiatry by forcing the doctors to treat their patients more holistically, but limits psychiatry's ability to offer definitive answers. The patients' frustrations to some degree become the doctors', if only due to human nature. As our attending was discussing today, the psychiatrist must integrate not only objective clinical data but also subjective emotional data. He described how humans have 'mirror neurons,' which are special neurons that respond to images of suffering (or any other emotion) by triggering an empathetic response in the viewer (think of a guy cringing when he sees another guy kicked in the groin). Furthering this idea, the human response of the doctor to the patient and his troubles is of course primarily empathy, but one cannot help share their exasperation as well.

Sigh.