“Do no harm” is causing problems.
Somehow, “do no harm” came to mean “keep every patient alive for as long as possible.” It’s a problem creeping around the edges of the healthcare debate, but one with devastating consequences. The mindset seeps into doctors offices and hospital rooms, affecting everything doctors do when they treat patients, changing patients’ lives and the lives of their families.
Sometimes patients don’t want to be kept alive. Sometimes keeping them alive is the harm. Is it doing harm to preserve the mind of a man whose body is nearly completely destroyed? Is it doing harm to preserve the body of a man whose mind is gone?
I know. Deep.
Seriously though, it’s a topic that needs to be reported and discussed delicately–how do you explain the human cost of keeping someone alive, a nuanced cost facts and statistics overlook?
In “Casualties of War,” Gawande explains how doctors working in war zones have come up with ingenius ways of saving injured soldiers, driving down the death toll for both the wars in Iraq and Afghanistan.
“But,” writes Gawande, “if mortality is low, the human cost remains high.” He takes the example of an airman who suffered a mortar attack outside Balad Airbase in Iraq.
“The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question.”
“His abdominal injuries prevented him from being able to lift himself out of bed or into a wheelchair. With only one hand, he could not manage his colostomy. We have never faced having to rehabilitate people with such extensive wounds. We are only beginning to learn what to do to make a life worth living possible for them.”
The airman might seem a dramatic example, but the problem is very everyday.
As Katy Butler skillful recounts in her recent piece for The New York Times Magazine, “What Broke My Father’s Heart,” or “How Putting in a Pacemaker Wrecked My Family’s Life,” elderly people’s bodies are being kept alive for longer than they can actually live.
In Butler’s story, her father is implanted with a pacemaker so he can undergo surgery to repair a painful hernia. The cost to her family is devastating, particularly to her mother. Before the hernia surgery, her father had already suffered a severe stoke that left him nearly speechless and needing constant care, most of which fell to Butler’s mother.
After the pacemaker and the surgery, Butler’s father degenerated even further. His mind went blank, he became incontinent, but his heart kept beating, forcing her mother to continue to care for him, to the detriment of her own health.
Butler uses the story to point out the many flaws in the health system that contributed to her families situation. The specialists were making decisions and recommendations independently of the trusted and like-minded family physician. Doctors are largely paid per procedure, leaving no incentive for doctors to choose “no further treatment” as the best course of action. Pacemakers, once used as an emergency stop-gap, have become more prevalent as biotech companies work to expand the markets for their products.
It’s a big mess of problems, but it’s important to see what happens when different branches of healthcare all interact. In this case, they worked together to create a terrible end to Butler’s father’s life, and a heartbreaking situation for her entire family.
After Butler’s father’s death, her mother went to see a heart surgeon to discuss her options–she had two leaking heart valves. When she showed the doctor her “do not resuscitate” bracelet, Butler writes that the doctor “recoiled,” refusing to operate on her mother if he could not resuscitate.
This to me is the most important part of Butler’s story. Butler’s mother’s doctor was taking “do no harm” as an invitation to replace his own judgement for her mother’s. He doesn’t want a patient to die on his operating table. That is understandable. But all of the little choices to keep a patient alive, to always assume life is the most desirable outcome, can lead to years of misery for patients and their caregivers.
To change that problem would mean altering the perspective of an entire profession, a hefty goal, but maybe not an impossible one. The hippocratic oath, to which the phrase “do no harm” is usually attributed (it’s actually not in the oath, but whatever), has undergone several re-writes. One such rewrite, by Louis Lasagna in 1964, puts avoiding over-treatment right in the second paragraph.
So, problem solved! Now we just need to fix billions of dollars of medical care machinery working in the disservice of patients who wish to die peacefully and with dignity.