Autonomy

If a woman is diagnosed breast cancer and decides not to undergo treatment, we would persuade her but would accept her final decision. This is respect of autonomy and is one of the cornerstones of modern medical ethics.

In January 2013, a premature baby was born at a hospital in Hong Kong. Because of a complication of brain infection, the doctors recommended surgery. The father refused. That night, the hospital applied for guardianship and performed the brain surgery against the family’s wish. In April, the team operated on the baby’s eye, again despite the father’s protest. Last month, the baby was finally stable enough to enjoy a weekend at home. This time, however, the father refused to bring his son back to the hospital. The hospital obtained another court order and took the baby back.

Was autonomy being violated in this case? The doctors would argue that the father was after all not the baby himself. In the consent process, healthcare professionals were not asking what the guardian wished but what the baby would want should he have the ability to choose. When the father’s decision did not appear to be in the best interest of the baby, the team overrode his choice based on beneficence (to do good).

This story drew my attention as our team was involved in the care of two old ladies with bile duct obstruction and infection recently. Both ladies were in their nineties and suffered from multiple illnesses. Without intervention, the infection could be lethal. On the other hand, to clear the obstruction, we had to perform endoscopy, which was also very risky given their background. In face of such dilemmas, we used the standard tactics – explain everything to the families and let them choose. Ironically, the family of the sicker lady, who even depended on mechanical ventilation at night, insisted on aggressive treatment. She underwent two endoscopic procedures. More is yet to come.

In difficult situations like this, letting family members make the decision is the safest approach if the primary aim is to avoid complaints. Come to think of it, however, seldom do we ask what the patient herself really wants.

Deadline

Last week, my friend AC invited me to write a review with him. At the end, he sheepishly added, “We expect the work in two weeks. The deadline has already passed.”

I sighed. Although I know many people who miss deadlines all the time, I have never done it before and find it hard to understand.

When I mentioned this to GW, she was most understanding. “It is quite natural. After you have missed the first deadline, everything else is postponed and will not be finished on time.”

“But then at least you should turn down new requests when you know you can’t meet the deadline?”

“When that becomes a habit, it does not matter anymore.”

What really surprises me, however, is that punctuality has little correlation with success. One of the best clinical researchers I know is notorious for being late. He would not even start working until he has received the first reminder. Yet people continue to beg him for help the next time. In a way, being good is more important than being punctual.

Monopoly

Last weekend, our team attended a research workshop. That evening, my teammates taught me to play Monopoly Deal. I must say I have not formulated any winning strategy yet. Everything I put on the table was snatched by the other players.

At one point, SW charged me 5 million. I protested, “But I have no money. Why don’t you collect money from richer people?”

“Because I want your land,” SW explained. After a while, he added, “This is what happens in real life.”

How very true.

Photos

On the next day, AL showed me a set of photos she took during our medical grand round. I was wondering why she took photos of us, but alas, it was not us.

That was a student bored to death by our talk. The gentleman first took off his sandals, and then rubbed his toes one by one with his fingers. He turned on his laptop and flipped between Facebook and Yahoo. Despite all these, we speakers seemed not aware of his annoyance. He finally gave up and slept with his mouth wide open.

After seeing the photos, I was first quite defensive. “But we didn’t initiate that. The external examiners made us run that talk.” On second thoughts, I owed that student an apology.

That said, while we were waiting for the grand round to start, Szeto and I actually discussed what we would rather talk about. I suggested detective stories.

“Nah,” Szeto sneered, “that is beyond your expertise. If you talk about Mozart, I would have to discuss Beethoven.”

That would be interesting. One of the theories is that Mozart died of poststreptococcal glomerulonephritis (Ann Intern Med 2009;151:274-8). Perfect for a renal grand round.

Strategy

Yesterday, I had the pleasure of conducting the first medical grand round of the academic year with Szeto. I have always dreamed of doing a grand round with the walking Harrison. The intellectual exchange must be profound. Unfortunately, we took up a rather dull topic – introduction of the practical examination system.

Incidentally, I came across a comment by our student shortly before our presentation (http://liralen.xanga.com/700427944/item/). She was referring to my old entry on examination tactics (http://vwswong.blogspot.hk/2009/04/examination.html). That was a quote from Sima Yi:

軍事大要有五：能戰當戰，不能戰當守，不能守當走，不能走當降，不能降當死耳

According to our student, it's a pity that there is no significant difference in terms of prognosis of the last 3 options. This cannot be farther from the truth.

Above all, the final year professional examination has the lowest failure rate compared to all other examinations our graduates will face in the future. History is full of examples of students talking nonsense throughout the examination and still becoming doctors. Just this year for example, I encountered a girl with impeccable English but undetectable knowledge. Almost every sentence she said was wrong, but she picked up our non-verbal cues and rephrased her statement immediately every time. Szeto also examined her and arrived at the same conclusion. To our utter astonishment, all ten examiners passed her.

Now, saying that the last three strategies make no difference would certainly disappoint Mr Sima. When you do not know the answer, you can try to talk about things you know first and work the way through, skillfully change the topic, or sincerely admit your deficiencies. All these tactics seldom lead to failure.

Sir Ferguson enjoys big wins, but also understands the importance of drawing a difficult game. Only the team that does not give up can win the league.

Mock

Not surprisingly, AL and K passed the College examination with flying colors. Shortly before the examination, they asked GW and me to conduct a mock examination for them. Personally I think such kind of exercise is quite useless. But as Prof RK said, when many useless things add up together, they may turn out useful. To go along this line, I asked a useless question that would never appear in the examination.

“A 38-year old man learned from the news that a rich man in town is dying from liver failure. He offers to donate part of his liver to him, but demands a compensation of $500,000 in return, which the family for sure is willing to pay. He argues that he owns his body and should have autonomy over its use. Besides, he believes that his request is reasonable given the sacrifice he is going to make. As a doctor, do you agree with his points?”

After thinking for a while, the candidate replied, “This is certainly not acceptable. Above all, doing no harm is the fundamental standard of medicine. We cannot risk his life to save a richer person.”

“Wait a second,” I interrupted. “Do you mean you are against living donor organ transplantation?”

Seeing it could not be right, the candidate changed strategy, “Not really. We also need to see if the patient had problems with alcohol and the reason for liver failure.”

“He does not drink alcohol. He had decompensated hepatitis B-related cirrhosis.”

“We should see whether the patient really requires liver transplantation and is fit for the procedure. Besides, we shouldn’t let someone jump the queue just because he can pay.”

“All right,” I said. “In other words, if the patient is at the top of the waiting list but a cadaveric liver is not available yet, you would find the proposal acceptable. In fact, you may argue that such a move would even shorten the waiting list for other patients.”

“No, no, no. Organ trading is illegal in Hong Kong.”

“That is true,” I said, “but what is the ethical basis of the policy?”

“I give up.”

At least we learned one thing that afternoon. Principles are not subject to conditions. There is no if or when. You cannot say the government should not run students over with tanks if they are protesting peacefully. They just shouldn’t.

Comments

We held the professional examination last month. After examining the first five students, Professor RY remarked on the standard of the class at the coffee break. Many of us were astonished. It took us at least several months to arrive at the same conclusion. “Of course this may be sampling bias. I will examine the rest of the students first,” he said when the next batch of students entered.

When I told my friends the story, they were not impressed. “He doesn’t pay attention during examinations,” HC said. “He even dozed at the last college exam.” I did not argue. However, after so many years, I am sure he does not need ten minutes to decide who is a competent doctor.

Once, a famous director was invited to the rehearsal of a play. A moment later, he fell asleep. The cast was very embarrassed but had to continue. After the first act, the producer could not tolerate any longer and woke the director up. “We are sincerely asking for your comments, and you simply dozed off!”

The director rubbed his eyes and mumbled, “That was my comment.”