Wednesday, March 18, 2009


Clarification on the last post


Hi, perhaps it's the way I wrote the last post that my emphasis was misread. I was actually emphasizing on the part that we shouldn't base our clinical decisions on subjective opinion, rather than the part on who to choose to operate on first. The example I gave was just a lead into the later part that I was trying to make a point about.

(Fortunately) In real life, we seldom face "artificial" dilemmas like this. Patients seldom arrive at the same second and seldom have "identical" vital signs. Even if they arrive at the same time, they would usually present with differing problems, and one would probably require more urgent attention from the other. Besides, there would definitely be more than one operating theater available (unless we are talking about major disasters).

My point is that we should not judge our patients (at least not as a reflex). We should not label them as being "deserving" or "undeserving" to live or to receive treatment. True, the guy may have committed suicide. On the surface, he might seem to value his own life less than the other guy, thus leading to the conclusion that he is less "deserving" of another chance at life. But is it really that simple?

Have we asked why?

Why did he commit suicide? The answer is almost inevitably "multifactorial". Ignorance? Financial? Social? Family? Medical? There is no single answer. You may say that he chose to end his life, by his own freewill, but is it that "free"? I would say that it is rather a choice shaped by circumstances, circumstances that might be out of his control, that might not be of his own doing. It might help to take a step back and be reminded that not everyone has the fortune of being highly educated like us. Not everyone has a complete family. Not everyone has a stable financial status.

There are a myriad of things, infinite permutations and possibilities. And almost definitely, these factors are influenced both by this individual's own actions and external contributors, some not directly "correctable" by him himself. And the interplay of these factors have cumulated in his act of self-destruction. True, he is accountable for his actions, but given all the above, is he deserving of his current circumstances? How do you define "deserving"? Who defines whether someone is "deserving"? I am pretty sure it is not us.

On the other hand, how much is the other guy free from "accountability"? Why was he involved in the accident? (eg. did not wear seat belts; did not wear safety harness/helmet; working/driving under influence of drugs/alcohol etc etc) Again, both intrinsic and extrinsic factors play a role, both directly influenced by the individual's actions and totally uncontrolled by him. How much role did his individual actions play? We do not know. Again, we do not know.

Before I leave this part of the discussion, I want to remind everyone of a medical condition called "depression". This patient likely has depression. In fact, it is likely that the majority of suicidal patients have depression. Depression is a medical condition, not so different from a flu, a pneumonia or a cancer. It merely affects a different part of the human body. I do not think anyone chooses to be depressed, same thing as nobody chooses to have a pneumonia or a cancer. That said, how "accountable" is this patient for his act of self-destruction committed under the influence of his illness? I will not elaborate, for this opens up another can of worms (in fact patients with COPD can be said to be "undeserving" of treatment because they chose to smoke; patients have cancer because they chose to lead an unhealthy lifestyle.. where do you draw the line??)

Hence I shall summarise my points as follows
  1. We do not have sufficient information to judge the actions of our patients
  2. There is no clear definition of who is "deserving", based on the actions of our patients
  3. It is not our job to judge the actions of our patients
  4. We do not give/withhold treatment based on what perceived right and wrongs of the actions of our patients.
When faced with the artificial situation above, true, we may have no choice but to choose one (oxymoron) to save. But I would base it on objective measures: who's vitals are more unstable, thus requiring more urgent attention etc. I hope I made my point. My point was not about who to choose, but rather a discussion against making a judgment based on the actions of patients. Thanks for reading.. =)

posted by nwxiang at 11:13 PM |


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