Critical Decisions

The ins and outs of our medical decisions

How the Action Imperative Imperils Medical Care

When Aggressive Medical Care Was More Dangerous Than Assassin's Bullets

Dr. Smith Townsend knelt on the filthy train station floor, the patient lying in front of him with a bullet wound in his back.  The patient was clinically stable for the moment, so Townsend turned his attention to the wound, convinced a quick removal of the bullet would offer his patient the best chance of survival.  Fueled by an action imperative, Townsend took his index finger—ungloved, unsterilized, probably only moments earlier in direct contact with that filthy floor—and inserted it the wound, feeling around for the assassin’s bullet.

It was that finger, and dozens of other later wound probings, that transformed the gunshot wound from an injury into a death sentence.   President James Garfield would live for another two agonizing months, while the bacteria introduced by repeated wound probings spread throughout his body.  Well intentioned physicians, spurred on by a belief that inaction is the enemy, instead acted as unwilling accomplices in the death of our 20th president.

In deciding how aggressively to treat their patients, physicians need to remember that healing often begins within, and that the best medical care is sometimes to provide as little care as possible.

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I learned about Garfield’s horrendous medical care reading Candace Millard’s gripping book Destiny of the Republic.  Elected president in 1880, Garfield lived at a time when the medical profession was still largely unscientific.  Quacks abounded, touting pseudo-scientific cure-alls.  Antibiotics were more than a half century away from discovery.  The idea that microbes—tiny, living creatures—caused illness was being discussed by doctors in Europe, but most experts dismissed such talk.  Other causes of illness after all were so obvious—filthy air and evil humors—that it would be fantasy to blame disease on invisible living creatures.  There were voices arguing against this collective wisdom.  For instance, a surgeon in England named Joseph Lister had been trying to convince his colleagues that antiseptic measures would reduce post-operative infections.  Lister was largely dismissed.  It would be small consolation to him, I expect, to learn that 130 years later, millions of people would cleans their mouths everyday with Listerine.

Garfield was shot by a madman, likely spurred on to delusions of grandeur by schizophrenia.  The assassin shot Garfield from close range, but the bullet somehow managed to skirt his major organs and arteries.  It also helped that Garfield was a real physical specimen--young, strong and healthy--so even though the doctors who first rushed to his side were convinced that the wound would prove fatal, his strong constitution thought otherwise.  Left to his own devices, Garfield would probably have recovered from the injury.  Indeed, upon his death, an autopsy showed that the bullet had lodged itself behind Garfield’s pancreas, and had been safely entombed there by a fresh layer of connective tissue.  Garfield’s own body had, in effect, walled off the bullet to prevent it from causing further harm.

But Garfield’s own body was no match against a flurry of filthy fingers.  Because the autopsy, you see, also showed a long channel running from the entry wound alongside Garfield’s liver.  The bullet didn’t sit at the end of this channel.  Instead, the channel had been created by all those probing digits.  It was this channel, and the bacteria that physicians introduced into it, that killed Garfield.

Garfield’s doctors were responding to a primal human desire for action, a desire that continues to influence medical decision making today.

For example, a recent study in the New England Journal of Medicine demonstrated that for many patients with localized prostate cancer, less is more—a strategy of watchful waiting maintains high survival rates without exposing patients to miserable side effects like incontinence and impotence.  And yet it is so difficult for patients, or physicians for that matter, to “do nothing” (as many patients have described watchful waiting to me) when a tumor is growing inside their bodies.

Some of my own research sheds light on this “action imperative.” In one study, I asked people to imagine that they had a slow growing cancer with two possible treatments.  They could opt for watchful waiting, which carried only a 5% chance of death from the cancer.  Or they could choose surgery, which would cure the cancer, but which carried a 10% risk of death.  In this case, a substantial majority of people said they wanted the surgery, preferring death from activity to death from inactivity.  “Get it out of me,” they said. “Better to go out fighting than to wait for bad things to happen.”  The thought of untreated cancer bothered these people so much that they preferred taking action, even when that action was more likely to harm them.

Sometimes even artificial choices reveal fundamental truths about human nature.  In this case, people’s choices jibed with what I had seen so many times in real life.  Cancer, “the big C”, creates a powerful compulsion to act.  I have witnessed this phenomenon dozens of times among older men with localized prostate cancer for whom surgery has not been shown to yield any survival advantages, but who nevertheless opt for this treatment, willing to put up with impotence and incontinence just to know that they have done everything in their power to “kill the beast,” as one patient put it to me.

This action imperative is psychologically understandable.  But it is often clinically misguided.  The body has evolved with all kinds of creative ways of healing itself.  Some early cancers are kept in check by people’s immune systems.  Most infections are eradicated without the help of antibiotics.  Most wounds, if kept clean, heal on their own.

As we strive to improve the quality of medical care, and simultaneously curb rising healthcare costs, we need to keep the lessons of Garfield’s wound in mind.  Sometimes the best course of action is inaction.

 

**Previously posted on Forbes**

 

Peter Ubel, M.D., author of Critical Decisions and Free Market Madness, is a physician, behavioral scientist, and Professor of Business and Public Policy at Duke University.

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