By Lauren Rissman
A distraught, exhausted mother asked through her tears, “Doctor, what would you do?” The palliative care, neurology and pediatric intensive care team sat in silence in the cold glow of fluorescent light. At that moment, I felt a zap of pain to my heart. It was sharp, followed by a lingering ache. It was visceral and unforgettable.
The mother asked again. As a team, we discussed with her the uncertainties in prognostication. Sometimes kids get better, and sometimes they don’t. After a cardiac arrest, it can take weeks for kids to regain function, if at all. This question was not mine to answer, but rather use it as a stepping block to evaluate a family’s hopes and expectations for their child and their future, as a family.
“He loves The Lion King,” she explained. Though her son had a traumatic brain injury and was receiving multiple sedating medications, she thought it was important for The Lion King to be playing in the background, so her son could enjoy it. But, within 10 minutes of the opening credits, he had had another episode. She described the episode as arm stiffening, and then demonstrated what she had observed. One arm, over her right ear, reached for the sky. Her left arm hung down by her side, fingers pointing to the ground. She arched her back and turned her head. She paused and then began to cry. “I don’t want him to be in pain,” she explained.
At this moment, I was faced with the dichotomy of being both a caring human and a trained physician. Hippocrates teaches us to “Do no harm.” It’s the first promise we make in medical school, witnessed by family, friends, and faculty, as we solemnly drape ourselves in the stiff white, short coat of our apprenticeship. Am I inflicting harm if I do not withdraw potentially futile medical care? I understood my patient’s neurologic injury to be devastating—meaning he was unable to feel pain. But, clearly, he and his family were suffering. If I did not withdraw life- sustaining therapies, was I being unethical?
James Drane teaches us about the ethics of character. He argues that ethics is subjective, but assumes that there is uniformity in that one who has a good, ethical character values the same characteristics as another who also has a good, ethical character. And, here is where I feel torn: I am both human and physician and my ethical character is discordant, depending on the coat on my back.
When this mother artfully explained the dissonance she felt in her options, I too felt the same dissonance. With my medical training, I could explain to her that not enough time had passed to evaluate if her son would open his eyes again. I could provide intellectual honesty to try to convince her of this fact. This characteristic would help to classify me as an ethical physician on the basis of virtue, according to Drane.
Yet still, my human self—a daughter, wife, an aspiring mother— could equally argue against the prolongation of life-sustaining measures, because as humans, we are averse to suffering. And, both this patient and his mother were suffering. It was truly unbearable to watch. I could not fault this patient’s mother for asking the heavy question.
This compassion that I possess as a human is in direct conflict with the nondirectiveness I provide as a physician. This dichotomy provides insight into the thorny ethical complexities that exist within oneself, that of the physician and human. And as these two identities vie for attention, they are also able to merge to provide more comprehensive care as both a physician and being. This happens every day as I walk into the hospital and place the white coat on my shoulders. I feel the weight of the profession as I immediately transform into a listener, healer, and advocate. This is the art of medicine that cannot be taught in the classroom. You recognize it only as it approaches you, when a mother asks, “What would you do?” Honestly, I do not know.
Lauren Rissman, MD, is currently a pediatric intensive care unit (PICU) fellow at Ann and Robert H. Lurie Children’s Hospital of Chicago. She is a bioethics scholar as part of the Bioethics Scholars Program at McGaw Medical Center of Northwestern University. She studied neuroscience at the University of Southern California and completed her pediatrics residency at the Children’s Hospital of Los Angeles.