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Where's the Evidence?Debates in Modern Medicine$

William A. Silverman

Print publication date: 1999

Print ISBN-13: 9780192630889

Published to Oxford Scholarship Online: September 2009

DOI: 10.1093/acprof:oso/9780192630889.001.0001

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Lifesavers

Lifesavers

Chapter:
(p.85) 21 Lifesavers
Source:
Where's the Evidence?
Author(s):

William A. Silverman

Publisher:
Oxford University Press
DOI:10.1093/acprof:oso/9780192630889.003.0021

Abstract and Keywords

This chapter presents a 1992 commentary on neonatal pediatricians' dedication to their patients. The ‘never say die’ attitude is more common pediatricians than in other medical specialities, possibly because the practice itself is the least concerned with death, and the close ties doctors form with their patients and families.

Keywords:   neonatal care, neonates, medical care, medical practice

Medicine is the [profession] most likely to attract people with high personal anxieties about dying.

S.B. Nuland1

Thought is the prisoner of language, and thoughtful action is influenced heavily by the choice of words. For example, physicians often conjure up rescue fantasies and talk of ‘saving lives’ when they employ heroic measures to prolong the lives of patients who are deathly ill. The doctors understand, of course, that the time and the place of a rescued person’s demise have merely been changed by an act of medical heroism. It is impossible to ‘save a life,’ as an evangelist ‘saves a soul,’ for an eternity. Earthly existence can only be prolonged for varying finite periods. We pay a certain price for using the ‘save-a-life’ metaphor when this mental-set guides medical interventions.

In the adventurous new field of neonatal medicine, onlookers are often puzzled when they hear doctors talk about ‘saving’ seriously compromised babies by aggressive interventions. For example, a journalist and a hospital chaplain have written a very perceptive account2 of the attitudes and behaviours of caretakers observed in a prestigious American special care baby unit over a period of 18 months. They found that the young doctors (neonatal medicine is a young person’s game) who endured the exhausting physical and emotional demands of complicated high-tech treatments, seemed to view the intensive care nursery as a war zone—an arena where special forces and armaments were deployed against death and disability. Interns and other trainees spoke of being ‘on the front lines’ or ‘in the trenches’. As in other highly demanding, dangerous enterprises, the protagonists found it necessary to develop smooth working teams. Doctors and nurses came to know one another well, the reporters observed, they help one another in crises, they hold together against the rest of the world, knowing that nobody who has not shared their experience can fully understand. They develop their own special ways of seeing and doing things, their own special language (p.86) and humour. In effect,’ the observers concluded, ‘they become a separate small society…with its [own] unique culture.’

A professor of political science became interested in the new phenomenon of rescuing previously doomed neonates born extremely early or with serious biological imperfections. He arranged to spend four months observing the social structure, the outlook, and the technical operations of personnel in an American neonatal unit. He wrote,3

This place is like a magnet to me. I can’t pull myself away. Why? Because it is like going in the best magic room at a state fair with all the latest lights and equipment and magicians performing fantastic tricks with the highest-priced prizes at stake—health [and] life….

He observed that the hardworking young staff was coping, as competent persons tend to do in tense situations, by joking to stay relaxed and to reduce the unrelenting pressures of life-and-death decision-making. After answering a phone call to the nursery, a doctor shouted, ‘MASH unit! Incoming wounded!’ The team members seemed to be supremely confident of their technical power to ‘save lives.’ In an interview, a resident said, ‘[we] can bring a peach back from the dead, with the skills [we] have developed.’ (In another setting,4 a nurse asked an intern, ‘Who gets saved?’ ‘[A]lmost anything,’ was the reply, ‘We’d resuscitate a Big Mac if we could.’) When initiating heroic action in a life-threatening emergency, the medical team often took the position that parents were too distraught to make rational decisions about interventions for their babies. The political scientist concluded that the special care nursery was ‘a place where decent and dedicated people do and think terrible things….[T]he conditions of the place make them what they are, whatever they are.’

Two sociologists conducted a field enquiry by ‘entering the life’ of an American newborn intensive care unit for a period of six months; and, over an eight-month period, they followed a consecutive series of seriously-ill babies admitted to the facility.5 They also found a preoccupation with ‘saving the lives’ of compromised neonates. The director noted,

We have made a real difference here, not just in mortality rates in the city, but over an entire region, even into [an adjoining state in the US]. There are infants who wouldn’t be alive now if we hadn’t started this unit.

The neonatal team ascribed the highest importance to ‘technological truths:’ in hospital care, ‘technology was the sole pragmatic means to the end of curing.’ The approach inspired the belief that technology ‘fosters a progressive, rational order.’

What stands out in the reports of these and other interested (non-medical) bystanders is their amazement to find that dedicated, intense (p.87) young doctors seemed to view every death of a marginal baby as a personal failure. Next time, the dauntless young ‘warriors’ seemed to say: next time, with a little more knowledge, a little more technical ingenuity, a little more effort, we will be successful in overcoming death—the enemy.

How do doctors come to hold such narrowly-focused death-defying views? Why is proficient action so much more highly prized than inactive reflection? The questions interested a group of health educators;6 they postulated that the degree of activism in treating neonates with severe defects might be related to the level of development of a young doctor’s moral reasoning. (The thesis was based on the work of Kohlberg7 and Rest:8 ‘the differences among people in the ways they construe and evaluate complex moral problems are determined largely by their concepts of fairness,…more adequate and complex concepts of fairness develop from less adequate simple ones.’ Individual moral judgement matures and becomes less arbitrary, Kohlberg and Rest argue, with an increase in the amount and in the complexity of social experience.) From the results of a survey of American paediatricians, the health educators concluded that doctors whose moral reasoning is relatively high (e.g. mature consideration is given to a balance of interests) can be expected to be sensitive to characteristics of each situation and to vary their treatment accordingly (e.g. to be less aggressive in their treatment of neonatal defects in instances where the family requests such limits). ‘Low [relatively immature] moral reasoners seem to treat cases more uniformly,’ the survey team found.

John Emery points out that a ‘never-say-die’ attitude is seen more often among paediatricians than in other medical specialities.9 ‘Paediatrics is probably the speciality that is least concerned with death,’ he writes, ‘and to some extent is the anti-death phase of medicine.’ The veteran paediatric pathologist notes that paediatricians become so closely involved with patients and their families that ‘When a child dies [in an intensive care unit, the young] doctor is often emotionally exhausted.’ Emery pleads ‘that paediatricians need considerably more help in dealing with themselves’ [when children under their care die] than they or most of their colleagues realise.’

Perhaps there would be some improvement in the way neonatal paediatricians cope with their ‘defeats’, if they would give some thought to a change in the language used to describe their ‘victories.’ Instead of talking about ‘number of lives saved,’ the young warriors might adopt the phrase, ‘number of lives prolonged’ to describe their miraculous results. The word ‘prolonged’ does not slip off a doctor’s tongue quite as familiarly as the word ‘saved’; and the suggested terminology does not have the connotation of completeness or of finality. But that is just the point!

Clergymen, it should be noted, choose their words carefully when they discuss the notion of saving a life. For example, Lord Soper once said, ‘It is (p.88) ludicrous that people who confess to the most ardent desire to get to heaven, use the most scrupulous precautions to keep themselves here on earth. What right has any of us to prevent anybody from beginning his journey home?’

(1997)

As Nuland, a perceptive surgeon, has noticed,1 many doctors are attracted to a career in medicine because of their own heightened anxieties about dying. Given the vaunted image of doctors’ God-like power over life and death, the lure is not too surprising. For example, the rescuer’s personal stake in staving off death was revealed in an interview of a famous anaesthesiologist.2 She told the reporter that she always carried a small surgical knife and a length of tubing in her purse to create an artificial airway in an emergency. ‘Sixteen times I used it—successfully,’ she said. ‘Nobody, but nobody, is going to stop breathing on me.’

The predilection of doctors, even early in their training, to see the battle against death in personal terms, was bared in a dramatic episode played out on an emergency ward some years ago. A medical student had just started to examine a very old, unconscious man newly admitted to the ward, when the patient stopped breathing. The student called for help, a CPR team responded, resuscitative efforts were initiated quickly and extensively, all to no avail. The team left, leaving the budding doctor alone with the dead patient. The student was so disturbed by this unexpected disaster he lost all self-control, and began to beat on the dead man’s chest while shouting, ‘Goddamn it, you can’t do this to me!’

Notes:

(1.) Nuland, 1994.

(2.) Gustaitis and Young, 1986.

(3.) Frohock, 1986.

(4.) Shepard, 1990.

(5.) Guillemin and Holmstrom, 1986.

(6.) Candee et al., 1982.

(7.) Kohlberg, 1976.

(8.) Rest, 1979.

(9.) Emery, 1990.

(1.) Nuland, 1994.

(2.) Skolnick, 1996.