THE DOCTOR'S DILEMMA

Certain dilemmas of the personal conscience are more of a problem to highly effective people than to many others. I love to read medical blogs, not just the Googley medical advice, but the personal testimonies and questions. I find people among MD bloggers who are certifiably skillful, valued, and effective, as professionals are presumed to be, but also self-scrutinizing and disclosive on blogs far beyond what we are used to in people at this level. For instance, one doctor has shared on his blog (and I’m not going to link, because he has built a supportive community and I don’t want to mess that up) a situation that many of us will never face and honestly reported the emotional consequences to himself.

This man is a surgeon, especially skillful and successful with female problems, like breast cancer. He just gets better results with them and has had a rewarding practice. But he is a multi-skilled person and decided that he would retire a little early so he could pursue and develop other interests. A woman of his acquaintance (well, all right, friendship, but I’d guess that he ever met a woman he didn’t like in a protective and delighted way) needed a surgery of the kind he used to perform, but since he was retired, the operation was done by another surgeon who lost her on the operating table. More plainly, she died.

Now “our” doctor is left with a huge confused avalanche of feelings: did he have a right to retire when other doctors were not as skillful? If he had stepped out of retirement (which no one asked him to do) and had done that operation, wouldn’t he almost surely have brought her through successfully? But isn’t he obligated by professional duty and common sense to support the unfortunate doctor who “let her die,” if indeed there wasn’t some other detail of her case that wouldn’t have allowed “our” doctor to succeed either?

Where can he put his grief to keep it from turning into rage or self-accusation that has no hope of redemption? The next post after the one explaining the situation was of a just-snuffed red candle. To me it was a plain signal of suicidal thoughts. When challenged, the doctor referred us to the Wikipedia entry on ambiguity. So -- moral ambiguity. A very painful condition only alleviated by the removal of the conscience, which may cause the death of what? The soul?

I used to have a poster that advised one never to make comparisons between oneself and others, because others will always be either better than you (which might be discouraging) or worse than you (which encourages sneering). Rarely is anyone ever of equal competence, wisdom, and foresight. Anyway, how would you know? Who’s the judge?

Beyond that, when I was training for the ministry and talked about not being able to stop someone from bad behavior or save someone from making a bad decision, the excellent therapist I had at the time would bring me to a halt in a hurry. “How grandiose!” she said. “You’re the minister, NOT the God! You are not inerrant -- since you’re not Catholic, you can’t even claim to be the inerrant Pope and I expect you’ve noticed that he makes an error now and then. What makes you think that people’s lives are all about YOU and the help you give them?”

This doctor’s guilt came partly from him claiming an early retirement -- it seemed to him that the limit he set drew a line that excluded his friend from his care. If he’d known she’d need him, he might not have retired? What about the next friend? And the next one after that? Retirement might have slipped away entirely, so that he finally died slumped over one last person who absolutely could not be operated on by anyone else. And since he’s been retired a while, maybe his skills have gotten a bit rusty. Maybe he, too, would have lost the patient. No way to know.

Some people suggest that the concept of an all-knowing, inerrant, and limitless God came from our own craving to be that way. We can at least have a “Big Friend” in the sky who has the qualities we believe it. It’s easier than facing the idea that everyone makes mistakes, even us. I had a friend in the Marines in Vietnam who was sent to officer school. He said they taught him about “combat decisions:” when you decide something in the very moment of most intense dilemmas and then turn out to be right, which is quickly forgotten as the situation changes, or wrong, which is bound to happen. To hang on to those wrong decisions, beyond re-thinking and learning from them, is to corrode your ability to act and disempower yourself as a commanding officer. Professional effectiveness doesn’t come from never making a mistake, but from facing mistakes (if indeed that’s what they turn out to be in the end) and accepting the burden of having made them. When they are deadly, it hurts.

But this doctor didn’t make any mistakes. He didn’t even refuse a request to come out of retirement for the sake of a friend -- and there is a point of view that forbids doctors to operate on friends and relatives anyway, for fear of emotion clouding their judgment. His problem is not one of action or inaction, but of managing his own feelings about his friend and his skills. He might have heard of a friend lost in a small sailing ship and have had the feeling that since he was a much better sailor, if he had been on the trip, he could have saved the lost man -- but he had given up sailing in order to do something else, maybe become a pianist. There’s no sin to expiate, no bad decision to repent, just the terrific pressure of sorrow plus the corrosive game of “what if.”

I think attention in this situation is best paid to the terrific courage of this doctor in telling us what he felt as a human being. Maybe he was reaching out for comforting comments -- if so, he got them. The more Puritan might say that the duty of a professional is to NOT expose lay people to the anguish of those who deal in life and death. I disagree. We’ve heard enough about venal, over-proud, too-prosperous, self-serving doctors. It’s time to let us see that it’s not just the education, the salary, the social prestige that set doctors apart. It is the constant battle for clarity and effectiveness.