Reflections on Playing God Engendered by a Chat with L.

REFLECTIONS ON PLAYING GOD ENGENDERED BY A CHAT WITH L. JOSEPH HERMAN* One of the pleasures of belonging to the medical profession is the opportunity it affords to be one who "learns from all men," something the ancient maxim equates with being wise [I]. When I entered medical school 33 years ago, I owned an early edition of Harrisons Principles of Internal Medicine, complete with underlinings by a cousin senior to me in the calling from whom the tome was a hand-me-down. Just past the title page, there was a dedication which I am forced to quote from memory since it has, alas, disappeared from more recent issues. Written by the editors, the greatest names in medicine and neurology of their day, it read: "To our younger colleagues who continue to inspire and teach us." I was proud to be joining a vocation where such democratic ideas prevailed and, were I to be asked to rewrite the dedication with the benefit of a whole generation's hindsight, I would leave most of it in place. However, I would substitute "patients" for "younger colleagues," subject to the reservation that learning usually has more to do with questions than with answers! My most recent teacher has been L., a 63-year-old exact scientist, who came to see me with chest pain having all the hallmarks of angina pectoris . Six years earlier, he had undergone coronary bypass for a critical stenosis of the left main artery found in the course of an investigation of stable ischemic heart disease. He told me that the operation took a full year out of his life because the sternotomy wound became infected, leading to septicemia and diabetic ketoacidosis. At the end of two months' hospitalization, he required follow-up by a plastic surgeon for a sacral pressure sore that developed while he was comatose and the doctors despaired of his life. Later, a sinus tract leading outward from *Department of Family Medicine, Faculty of the Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Correspondence address: 42 Harav Uzziel Street, Bayit V'gan 96424, Jerusalem, Israel.© 1994 by The University of Chicago. All rights reserved. 003 1-5982/93/3604-0822$0 1 .00 592 Joseph Herman ¦ On Playing God the sternum was diagnosed and additional surgery required for removal of the wires holding the two halves of the bone together. L. had never questioned the need for bypass since every physician who reviewed his medical record came to the same conclusion; he would live only a short time without one. On the present occasion, too, although the pain responded well to conservative therapy, L.'s cardiologist wanted to investigate it thoroughly , and the patient thought he had better go along with the idea. He was engaged in research on an esoteric aspect of his field of study and had made progress that gained him the beginnings of international recognition. He wished to assure himself of sufficient longevity to bring his work to fruition so that, in effect, he wanted an operation not because the quality of life was poor but because it was good! In medicine, when we speak of "playing God," we generally refer to matters like the rationing of scarce resources in underserved areas, or to difficult decisions taken with regard to organ transplants, or the switching off of a respirator. My contact with L. suggested more common ways in which we play God, and they may be understood against the background of a saying nearly two millennia old. It was pronounced by Rabbi Akiva and defined the workings of Deity among men as: "Everything is foreseen, yet freedom of choice is given" [2]. I submit that the most frequent way in which we play God is dispensing advice with the implication that everything is foreseen. Regarding disease of the left main coronary artery, the truth is that the majority of people in anatomic circumstances similar to those in which L. found himself six years ago are walking around undiagnosed. Furthermore, according to Gibbons and Miller, . . . the most important issue is whether mildly symptomatic patients with three vessel or left main disease . . . would benefit prognostically from revascularization . . . The prognosis...