Cesto ovde diskutujemo o tome. Evo jednog putovanja kroz medicinsku etiku od 60tih do danas iz pera Stephena Shaleta.
The ‘black spot' is a fictional literary device invented by Robert Louis Stevenson for his novel Treasure Island. In the book, a pirate is presented with a ‘black spot' to officially pronounce judgment - a verdict of guilty. It was a source of much fear because it meant that the pirate would die imminently. In Treasure Island, Billy Bones is so frightened by it that he suffers a stroke and dies - thus fulfilling the prediction.
Now, in the London teaching hospital at which I trained, we had our own version of the black spot. He was known as the Professor of Pathology or, rather unaffectionately, as the Grim Reaper. Tall, lean and ascetic-looking with taut, cadaveric facial features, one of his research interests concerned the clinical ability to estimate splenic size in life. To provide further data on this topic, he regularly visited patients, whom, he had reliably been informed, were expected soon to exit this world, on the evening before their expected demise. At his visit he would percuss and palpate the abdomen to estimate splenic size and then compare the findings with splenic weight and dimensions at autopsy. On the ward, his appearance elicited a fear that was palpable, the silent prayer almost audible from the patients' facial expressions: ‘please don't let him stop at my bed!'.
Leaving aside the question of the value of his research, his interests raised ethical and moral dilemmas for the Grim Reaper. Should he explain to the patient the reason for his visit? What explanation could avoid inducing further anxiety? Many such questions are raised by clinical practice as well as research protocols.
A few years ago I was flying home from the USA after a family holiday. On my return I had to fly off again on
the very same day to Spain to speak at an endocrine meeting. The timetable just allowed me enough time to go home, unpack, repack, and return to the airport for the flight to Spain. Unfortunately, however, a female fellow passenger became ill on the flight from the USA. Over the tannoy there was a request for a doctor and, before I had time to consider the request, I was volunteered by ‘she who must be obeyed' - presumably because she was anxious to secure further seat space.
So, off I went to seat 27B, where Mrs X was slumped with the obligatory oxygen mask over her face. Mr X told me about his wife's heart condition - and her three large gin and tonics and very full lunch. At this point, the steward whispered in my ear, ‘You need to make a decision. If she is seriously ill we will have to turn back, but, if this is not too serious, then the flight can continue to the UK.'
Now, people say that I am indecisive but I don't know about that. On this occasion, I was desperate for the flight to continue without a pause. However, whilst I was reassuring the steward that Mrs X would be fine (at the same time laying her flat on the floor), it dawned on me that this may not be the case. What if she died one hour further into the flight? How would I feel about that and how would I explain things to her husband?
I decided that, if that were the outcome, I could reassure Mr X that his wife had died in a good cause - my lecture! It was a cracker and even contained new data! I felt confident that the husband would understand that the loss of his wife for the sake of medical education was a sacrifice of which he could be proud. Having sorted out the morals and ethics in my own mind, it was almost disappointing when Mrs X sat bolt upright after 20 minutes, pronouncing that she felt fine.
I wandered back to my seat so deep in thought that I failed to notice Mr X standing over me. He was full of compliments about my care for his wife and shook my hand with a grip like a steel clamp. I was certain that he had broken two of my fingers. Had he read my mind? Did he know my plans? It didn't matter; there was no way the lecture could be ruined - I could use the laser pointer with either hand.
This episode reminded me of an occasion when, as a first year clinical student, I was allowed, on the understanding that I was not to speak, to accompany the senior surgeon on his working ward round. On this round, he decided which patients could be discharged home, and when.
We stopped at the bedside of a small, elderly lady with very thick-rimmed glasses and a hearing aid. Given the timing of the round, it was soon apparent that she had mistaken our surgical entourage for the tea ladies and their trolley. The boss whispered to his juniors, ‘Why is she here?' The registrar whispered back, ‘Gangrene of all toes of the left foot, sir. We are waiting for the line of demarcation and then we plan to take her to theatre to remove them.' ‘Let me look,' he said.
Having done so, he gently grasped the dead toes in his right hand and snapped them off. The whole procedure lasted less than 10 seconds and had been clearly painless. Nonetheless, I was stunned - and even more so when he approached her, proffered the black digits towards her face and pronounced, ‘Madam, your toes.'
No conversation, no consent form but, at the same time, no anaesthetic and no post-operative complications. My head was spinning and I recovered my composure only when I heard her reply, ‘Toast is fine but I like my cup of tea at the same time.'