Probably every physician can think of one patient who affected him more than any other. The patient who has haunted me through the years was a child that I saw for only a little time at the very beginning of my career. I was an intern at a Catholic institution. I mention that because it seems to me relevant to the ethical considerations that swirled about the care of this infant. When this child was born, the obstetrician looking at it was horrified. It was a “monster.” That was the medical term used to describe a grossly misshapen baby. The doctor was concerned, then, first of all, about the effect on its mother of seeing the child. Therefore, he told the parents that it was born dead; and that the body had been disposed of. But the child was alive. This particular “monster” had deformities that were not consistent with it living for any length of time. The obstetrician must have recognized that immediately and chose to spare the parents the special anguish of looking at and knowing about this abnormal birth. But did he have the right to tell them a lie about such a critical matter? I’m not sure that there is a law to deal with such a strange situation, but I am sure the obstetrician violated medical canons. He short-circuited the parents’ wishes and concerns. Plainly, they had the right to know the truth. If a medical malpractice action had been instituted, the doctor would have been liable. By telling this lie, he was risking his career. The other people in the delivery suite were also complicit and also liable. As far as I was concerned, however, he had done the right thing.
There are ethical rules that govern our behavior. Sometimes, they are unspoken. They go without saying. Thou shalt not lie. Thou shalt not murder. Even those peoples who have not heard of the Ten Commandments know these rules. But there are not just ten rules or commandments. As social situations change and develop, so do these rules. There are rules, sometimes codified, sometimes not, that govern how we deal with fellow-workers, elderly parents, strangers, people we communicate with over the internet, and so on. In an important sense, all the rules of courtesy are ethical rules. They grow out of a fundamental idea: that we are responsible for and answerable to other people. There are some, of course, who regard these rules as God-given and embodied in various religious texts such as the Bible or the Koran. But even those who have no religious beliefs would find themselves usually in agreement with the ethical rules embodied in these texts. Not without exception, but for the most part.
In my opinion, these ethical rules sum to one principle: unethical behavior is behavior that hurts, or has the potential to hurt, other people. There is only one good: kindness, and one evil, cruelty. Ordinarily one does not lie, for instance, but might ethically do so if it served the purpose of helping someone, rather than hurting someone as it usually does. By this admittedly vague criterion any particular act, thievery, deceit, even murder, could be ethical. There are extraordinary circumstances when rules break down, and even the rules that govern when it is proper to break other rules, break down. At such times, an ethically driven person might entertain the idea of doing something that in almost all circumstances is forbidden. He does it usually by himself. He presumes to act even though he knows other people might condemn his actions. Doctors confront these situations sometimes. For instance, a different obstetrician, finding himself delivering a baby such as the one described above, might smother the baby before anyone had the chance to see it. Such things happen. They are not publicized because it is important to keep the rules in place. No woman wants to deliver a child thinking that the obstetrician, on his own initiative, might choose to kill the child. Most people like to think that there are no exceptions to these rules, but they are people who have not had to confront these choices themselves. It suits them to be definite. They think, what’s to stop some arrogant and idiotic person from taking it upon himself to do awful things? In that respect, they are right. I like to think that there are some who have the courage to make wise and selfless decisions, but there are others who take it upon themselves to violate these rules for no reason at all.
For instance, earlier that same year I was making evening rounds and discovered that one woman, who was 70 years old, had not eaten or been given fluids for two days. I had a pleasant conversation with her, and then I started an I.V. The woman was a private patient of one of the attending physicians. He called me in a huff the following morning.
“Why did you give that woman fluids? I hadn’t ordered anything.”
“She hadn’t had anything in two days.”
“She’s 70 years old, for God’s sake. It’s time for her to go!”
I knew, of course, of doctors who hastened the demise of painfully, and fatally, ill patients; but this woman was not suffering. She was not senile, and she didn’t even have a fatal illness. This guy decided for whatever reason that she was old enough to die!
When I was in medical school, the medical service at Bellevue Hospital would fill up with elderly patients who could not, for one reason or another, be placed in nursing homes promptly. They took up space that sicker patients, and more instructive patients, could be using. Mondays, following weekends when a particular resident was on call, it was sometimes discovered that one or more of these patients had died. The medical staff joked that this resident had conducted “death rounds,” meaning that he had killed them. I have no reason to believe that was so, but the fact that it could be the subject of a joke indicated that no one thought it was impossible.
But, these situations, thankfully, are rare. How to handle them cannot be squeezed into a comfortable formula. These are situations when the conventional thing is to do one thing, and the morally correct thing is to do something different. I can tell you from personal experience that at such times the person deciding these matters feels he is the wise and enlightened person described above, and not the arbitrary and arrogant person that someone else might be.
Let me describe the Cyclops child. It had a single fused eye in the middle of its forehead. The irises pointed to the sides. There seemed to be four lids surrounding the eye like a box. It was blind, of course. A large part of the brain and head were missing. There was no nose. On investigation, it turned out that the baby’s esophagus and trachea had not separated, so that feeding the child was impossible. The food would go directly into the lungs. Also, the child had extra fingers. It did not look like a baby. It did not even look like a doll. It was unworldly. Alien. It was, someone said, “one of God’s little jokes.”
As an intern, I was very busy; but I looked in briefly to see this very unusual child before it died, Everyone expected its death to be imminent. In the meantime it existed in some kind of legal limbo, no name, no family. As far as the hospital went, it did not exist. But there it was.
I rotated onto pediatrics a few days later, and the baby was still there. Still alive. Because it did not look like a human being, most of the time no one was disturbed by it; until it cried! Then it sounded like any other baby. It was hungry, and it could not be fed. Picking it up would not stop the crying. After a while, the staff spent as much time as possible on the other end of the ward. It was agonizing to me. Human beings are not constructed to listen to a crying baby and do nothing. And I felt sorry for the nurses and the rest of the staff. As the days went by without the baby dying, I began to wonder, just how long can a baby live without being fed? I did not know. Every day, when I went to the ward I hoped the baby would be dead, but it lived on.
The resident told me during rounds that he wanted me to treat the baby’s extra fingers.
“Why?” I said. “The baby is going to die.”
“Well, you might as well use this opportunity as a learning experience.”
That sort of made sense to me. I was planning to be a psychiatrist, and I did not envision ever having to treat someone’s extra fingers; but much of what I did as an intern had very little to do with psychiatry.
The way you treat a baby’s extra fingers is to tie a ligature, a string, as tight as you can around the base of the finger. The blood supply is cut off, and after a while the finger falls off.
When I went over to the baby, it was lying quietly in its bed. It did not object when I picked up its hand. But when I tied the ligature around its finger and pulled tightly, it screamed.
My God, what was I doing, I suddenly thought. My hands began to shake. The kid was in pain. It could feel pain. I should have realized that, but somehow I did not. It was because the baby did not really look like a baby, I thought. I put the child down and retreated out of earshot.
Later that day, I went to the library to look up this particular kind of birth defect. To my surprise, a number of cases had been reported previously. Most of them died within a relatively short period of time, but one Cyclops child lived for a year! I knew this baby wasn’t going to live for a year without being fed; but it was possible somebody might decide to pass a stomach tube, for the same reason I was asked to amputate its finger, for the experience. I found myself suddenly in a rage. What was the point of taking care of this baby? There was a price to be paid. Dying though it might be, the staff still had to tend to it, to change it, to clean it, to hold it in repeated attempts to comfort it. The baby was suffering, and so was everyone else. Earlier, I had caught an aide crying. A couple of nurses had stayed home that day. It was at that point that I began to think about killing the baby.
I realized right away that there were some problems involved in killing someone, some practical problems and some psychological problems. The practical problems, in this case, involved finding a way to be alone with the child. It lay in some kind of crib off to one side on the ward, where visiting parents were not likely to see it. But it was always in plain view of the nursing station. Some of the nurses were nuns. I thought they might object on principle to my killing one of the patients. My best opportunity would have been when I was amputating his finger, but the thought did not occur to me then.
The psychological difficulties were obvious. I did not know how anyone managed to kill anyone else. I was always afraid of hurting my patients. For that reason, I had trouble drawing blood or passing tubes. The only way I could imagine killing this baby was by putting my hand over its mouth and smothering it. Could I possibly do that? Besides, smothering leaves tell-tall signs, small petechial hemorrhages on the skin and ruptured blood vessels in the eyes, or eye. I could not imagine anyone doing a pathological examination on this baby; but I definitely did not want to put myself at risk to save the staff from having a bad time for another indeterminate period of time. Still, they were having a really bad time.
I went to the ward that night even though I was feeling a little sick and discovered that the baby had died. It was gone. Someone had beat me to it, I thought. But that was unlikely. Probably the baby starved to death, like it was supposed to.
The next few days, I found myself thinking obsessively about how I would have placed my hand on the baby’s mouth. Could I have really done that? Probably not. But maybe. The scene played out in my mind over and over.
Over all the years that followed, I found myself thinking from time to time of that picture, my hand over the baby’s mouth. I knew then, and I still think now, that the right thing to do would have been to kill that baby. It wasn’t really a baby; it just sounded like a baby—that's what I tell myself. But I would like to stop thinking about it. After all, the whole thing happened over fifty years ago.(c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog