Medical Tuesday Blog
Letter to an aspiring Doctor Continued from August By Theodore Dalrymple
Let me give you a concrete example of the dangers of not thinking critically. In 1980, a letter was published in the New England Journal of Medicine pointing out that patients in hospital who were prescribed strong opiates for post-operative, heart attack, or cancer pain never became addicted to the drug they were given. At the time, doctors withheld opiates from patients who would have benefitted from them because they, the doctors, were afraid that they might addict their patients to them.
Later, when synthetic opioids became available that were just as dangerous and addictive as the natural opiates, the letter in the NEJM was cited both by the drug companies that manufactured them and medical evangelists of pain relief as evidence that they might be prescribed to patients with any kind of pain whatever. Many doctors threw caution to the wind and began to prescribe these opioids with abandon to patients with various kinds of chronic pain, usually of ill-defined or uncertain pathology that was much more related to what might be called their situation in life than to any definable illness. They continued to prescribe these drugs despite abundant evidence that they were not effective in relieving the type of pain for which they were prescribed.
This, then, was the start of an epidemic of addiction to opioids that is now causing tens of thousands of deaths yearly by overdose in the United States. The epidemic would have been avoidable if doctors as a whole had adopted a more critical and thoughtful approach from the first to the supposed arguments for prescribing these drugs. It should have been obvious to any doctor of minimal experience that the two types of patient, those with acute or cancer pain and those with chronic pain of vague and uncertain origin, are very different. Proper treatment of one group of patients cannot automatically be applied to another, quite different group.
In extenuation of the doctors who unwittingly started the epidemic—not a few, incidentally—it can be said that they had been targeted by intense commercial propaganda and reassured by supposed leaders in the field of pain relief that their prescriptions were right and proper. This brings to light a contradiction with which you will have to wrestle for the whole of your career: the contradiction between the authority of others and your own personal responsibility.
You cannot dodge your personal responsibility by hiding behind the authority of others or the consensus of the profession. But at the same time, you will be expected to do as other doctors do. Early in your career, you will necessarily be subordinated to the authority of more experienced doctors. With luck (and in most cases), those doctors will instruct you to do the right thing, both technically and morally, but there is always the possibility that they will not. Later in your career, you will find yourself subject to an ever-increasing number of rules and regulations, many of which will appear to you as absurd at best and contrary to the interests of patients at worst. But you will have to obey them as a condition of continuing in practice.
As the technical possibilities of medicine advance, especially in genetic engineering, so will ethical dilemmas increase in number and gravity. But even now storm clouds are brewing; indeed, they have already brewed. I will give you a simple example. Medically assisted suicide is increasingly claimed as a right: A man, according to this line of thought, has the right to choose the hour and manner of his death in order to avoid suffering. From this, our age deduces that a doctor has the duty to administer the lethal means to exercising that right. That doctor may well be you. You went into medicine to save life, and you will end up by (in effect) killing.
There is no reason why assisted suicide should be confined to the dying. Why should those suffering from taedium vitae be denied the soothing final injection? There is nowadays a tendency for rights to spread, like ink through blotting paper. Abortion was originally intended to be performed in limited circumstances only, but now has become an inalienable right in any circumstances whatever—into which, indeed, it is impermissible to inquire. A right, after all, is a right; in our times, any limitation is treated as an illicit abrogation of that right.
Moreover, though we pay lip service as a society to diversity and tolerance, we increasingly demand uniformity. A recent article in the New England Journal of Medicine argued that doctors should not be permitted to opt out of performing procedures that they considered unethical on the grounds of conscientious objection. Once the profession, guided by ethicists, had decided as a whole that something was ethically permissible, no doctor should be allowed to go against the consensus. This, of course, would have the corollary that mass murder by doctors would in theory be permissible, or even obligatory. Never mind: It can’t happen here. But what was once unthinkable can become thinkable very quickly.
At what point you rebel, and how you rebel, against a prevailing ethical consensus will always be a matter of judgment, since it is a fact of human existence that no one can live only and exclusively according to his own lights but must always compromise. In all of this, you will have the responsibility to treat your patients according to the best methods and evidence possible.
Here, too, you will have to exercise your judgment. For example, patients will often ask your advice, despite having searched everything on the Internet in advance. But information on the Internet, apart from sometimes being mistaken, is raw information, and you will be looked to for wisdom and experience as much as for information. Moreover, to many questions there is no indubitably correct answer.
The open-ended character of medical judgment has increased a great deal because the very nature of medicine has changed. It used to be that patients went to doctors when they were ill and hoped for a cure, either surgical or pharmacological. (This is probably the picture of medicine as a profession that you have in your mind.) The transaction in those days was, at least conceptually, straightforward: diagnosis, course of treatment, results. Now doctors spend much of their time treating not illnesses, but risk factors for illnesses. For example, the higher a person’s blood pressure, the greater his risk of heart attack or stroke, but high blood pressure is (except in its most extreme form) symptomless. You don’t know you have it until you experience one of its complications.
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