- Ethics Class
In our medical school, we teach ethics during the first year. We try to make it interesting by bringing in clinicians to discuss cases. Medical students do not like theory. Like William Carlos Williams, they want no ideas but in things.
This year, I once again gave the lecture on truth-telling, or as I have started to call it, "disclosure dilemmas." I try to cover the waterfront and review all the situations in which doctors have information they might choose not to share. We talk about whether students should introduce themselves as "doctor," whether any doctor should tell the patient it is their first time doing something, whether informed consent should include general outcome statistics, or those of the institution, or those of the individual doctor. We get into mandatory reporting requirements and the tensions they place on confidentiality. And, of course, we talk about delivering bad news, about giving bleak prognoses. Each area has zones in which things seem relatively black and white, and zones in which there are shades of gray.
During this winter quarter, I was also attending on the wards. When I came on service, one of the patients was an eight-month-old who was unable to eat by mouth. An ex-preemie, she'd had some birth asphyxia and a moderate intraventricular hemorrhage. Each month, the doctors tried to convince her mother that she would need a G-tube—a feeding tube inserted into her stomach through the stomach wall. At each discussion, the mother adamantly refused. So the baby had a nasogastric tube in place instead. She got all her nutrition, but it didn't seem like the best long-term solution. I arranged to meet with the baby's mother.
I started the discussion by asking her what she understood about her baby's condition. She looked at me suspiciously, like she'd been down this road before, and like she wished I'd cut to the chase. But she was experienced enough, too, to know that she was going to have to humor me a little bit.
"My baby was a preemie and had some brain damage. They told me she might never see, hear, walk or talk. But she's been doing better, much better."
"That's great," I said, "Babies are always surprising us. What have you noticed, in particular, as signs of progress?"
"Well, she's more alert, she smiles a lot more when she sees me, she's breathing more off the vent. . . ."
"That's fabulous. I think we're up to eight hours per day off the vent now. If we keep that up, we should be have her home on just nighttime ventilation. That would make life a lot easier during the day."
"Yeah. . . ."
"What about her eating by mouth?"
"Well, she's doing okay with that."
Our speech therapists had recently evaluated her. They said her suck and swallow reflexes were totally uncoordinated. Since she wasn't aspirating what she had in her mouth, they were continuing to work with her, but they thought there was no chance that she would ever be able to eat by mouth.
"One of the things I wanted to talk about," I said, "is getting a G-tube. Our speech therapists think it'll be months or years before she is able to eat by mouth. They're worried that the NG-tube will just cause problems during that time. It is uncomfortable, it may increase her chance of getting pneumonia, and she is starting to learn how to pull it out. Have you thought anymore about a G-tube?"
Mom stared at the floor, and her body was tense. It felt as if the temperature was rising in the room.
"Look," she finally said, her voice now trembling with emotion, "After my baby was born, I thought she was going to die. When she was in the NICU, I took six months off work and I never left her bedside. I've been through everything with her. She had lines, she had chest tubes, she had surgery. . . . " She paused. She seemed to be on the verge of tears. "And now, she...