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Not so long ago in the BMJ I quipped that most professional medical ethicists could not distinguish their “gluteus maximus from their lateral epicondyle” and suggested that such ethicists should undergo a short clinical attachment (BMJ 2006, 333:1226 doi: 10.1136/bmj.39055.658762.59).
Soon after publication, a nephrologist kindly invited me to observe a ward round at his hospital. It proved to be a puzzling experience, not because the blood gases, creatinine levels, diagnostic tests, and myriad statistics recited by a junior doctor sounded like one of Mallarmé's incomprehensible poems, but because, as the afternoon progressed, I noticed the patient-as-person fading behind this shroud of science. I felt comfortable with my consultant, my team with their dangling stethoscopes, the all-knowing computer wheeled by the bedside, and the timid patient, dwarfed by our confident crowd. Ethics seemed a million miles away.
This absence of ethics was most puzzling of all. I spend my days thinking, teaching, and writing about medical ethics, but there, in a group of doctors and with the patient before me, the subject seemed alien. “Think,” I urged myself, “what are the ethical issues here?”
My reverie would soon be interrupted: “Urine output . . . raised creatinine levels . . . metabolic acidosis . . . abdominal x ray.” Even in cases that I knew had obvious ethical dimensions, such as those involving futility and end-of-life decisions, I felt powerless to use ethical reasoning since I could not perceive the ethical issues with any clarity. It reminded me of a time when, intent on discovering a card magician's method for a trick, I got so engrossed in his patter, in Sam Spade and the evil kings (a dramatic reference to the ace of spades and the four kings), that I forgot to observe the subtle movements of the conjurer's hands and body. Magicians, like doctors, are well aware that language can disguise reality, distracting the mind from the disappointing truth ahead, be it a palmed card or a grim prognosis.
My proximity to the patient, instead of highlighting the ethical components, obscured them. The incantation of scientific jargon, the outward confidence of the consultant and his team, the austere clinical environment, and the meekness of the patient all combined to give an air of certainty to the ritual. Ethics, this antithesis of science, had no place in this assured display. I could now see why some doctors and medical students found it so hard to appreciate the relevance of ethics to clinical practice. “Ethics and medicine are inseparable,” we tell our students, but up close the link is not so obvious. It may be easy enough to identify ethical issues in the classroom, but at a crowded bedside the task takes on added complexity and requires practice.
More recently, I attempted to fill the gaping holes in my medical knowledge by spending five weeks in a southern Indian hospital, observing the work of a rural surgeon. Again, I initially struggled to perceive the ethical elements. I was enthralled by the medicine, the ritual of surgery, the mesh, the corkscrew, and other instruments, the different kinds of suture material, the mattress and subcuticular stitches, the smells and sounds and techniques. But as the days went by, as I saw more surgeries, it became easier. I learnt to zoom out of the medical and focus on the social and ethical dimensions. These more uncertain, fuzzy elements of the healing endeavour began to emerge from the mass of clinical information.
As my ethical gaze slowly sharpened, I reflected on the surgeon's kind hearted paternalism and the submissiveness of patients; the considerable influence of relatives in decision making; the prevalence of disclosures that were “economical with the truth”; the limited importance of confidentiality in this communal setting; the perfunctory nature of obtaining consent; the ethical implications of treating illiterate and medically unsophisticated patients; the financial and emotional costs of surgery to poor families; the responsibilities of sleep deprived surgeons and anaesthetists towards their patients, their colleagues, and themselves; the difference a few words of comfort can make in times of pre-operative fear; the role of humour and camaraderie in the theatre; the wisdom of using mobile phones when operating; the extreme difficulty of speaking your mind when offence may result; the proper relationship between culture and ethical norms; and many other issues that were initially as invisible to me as the card magician's sleights. I was not merely thinking about clinical ethics, but actually “doing ethics,” in real time with flesh-and-blood patients.
The first step to moral action is moral perception, since an ethical problem can seldom be resolved if not first spotted. For teachers of medical ethics, developing this skill in students should be a priority and the most critical place to do so is at the bedside. Suturing an orange in a lab and suturing a uterus in a casesarean section are quite different activities. The same holds true with studying ethics in the lecture hall and “doing ethics” on the wards. The aseptic first is a poor approximation of the messy second.
My proximity to the patient, instead of highlighting the ethical components, obscured them