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Case By Case
A new medical ethics book gives case scenarios, with the understanding
that there are lots of answers.
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t stands out like a fiddler at a
symphony. On one of the first
pages of this otherwise seri-
ous book about medical ethics
is a two-line dedication from the
editor:
"To my daughter Hannah,
who makes it all clear."
Lois Snyder laughs. She's a
lawyer, a medical ethicist and a
mother. After a day filled with
dilemmas, she goes home to a 3 -
year-old child who gives new
meaning to the word "clarity."
M.N. Ozdaglar, M.D., F.I.C.S.
Senior Member Of America
Phlebology Society
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"I think we- can learn a lot
about the world from viewing it
through the eyes of a child," Sny-
der says.
"I think, to be blunt, children
have a way of cutting through the
crap and identifying the issues
at hand - and seeing the world in
a purer way. Untainted. With a
sharpened vision. They don't rely
so much on rationalization."
Snyder is the counsel for ethics
and legal affairs for the Ameri-
can College of Physicians, the
country's largest medical-spe-
cialty society, representing 89,000
internists and other doctors. She
also is the editor of a new book,
Ethical Choices: Case Studies for
Medical Practice.
In this book, which was pub-
lished by her organization, ethi-
cists, medical professors and
health-policy experts present sce-
narios of problems that doctors
face in their daily practice, and
then provide
commentaries
on how to han-
dle them.
A doctor no-
tices a senior
colleague drink-
ing too much at
a party and
then being
paged for med-
ical advice. Sub-
sequently, she
learns that he
has a drinking
problem. What
should she do?
She should con-
front him, and
if that doesn't
work, she
should continue
to pursue it -
maybe even re-
port him to the
state medical
society.
A patient
wants to be re-
ferred to a neu-
rologist,
orthopedic sur-
geon and der-
matologist for
problems that
his doctor
doesn't believe
warrant special
intervention.
What does she
do? She should tell him the truth,
firmly and patiently.
The how-to emphasis of Ethi-
cal Choices is by design.
"We want to make it clear that
ethics isn't just a matter of per-
sonal conscience, that the physi-
cian doesn't just decide, 'I'll do
whatever I think is right or
wrong,"' explains Snyder from
her office in Philadelphia.
"There are objective principles
at work here. There are ways of
reaching answers, instead of just
sort of throwing up your hands
and letting actions take a course."
But even the most specific of
the case commentaries in this
book are hedged with "shoulds"
rather than "musts." Some are
even more vague, focusing on
pros and cons, rather than solu-
tions.
Both cases surrounding physi-
cian-assisted suicide, for exam-
ple, raise issues rather than
make judgments.
In one case, an elderly woman
who is terminally ill persuades
her doctor to prescribe her a suf-
ficient number of barbiturates to
commit suicide. In another case,
a doctor struggles with a request
from a dying ma-n for a lethal
dose of morphine.
Snyder said the commentators
"sought to devote attention to
end-of-life care and how to do that
better. In those cases, in partic-
ular, you are not going to see
mandates on how to carry out
physician-assisted suicide or even
if it's right or wrong."
Ethicists generally argue that
the process of arriving at the an-
swer is as important as the an-
swer itself.
"Readers do not want answers
but rather tools or ways to think
through problems," according to
Arthur Caplan, director of the
University of Pennsylvania Cen-
ter for Bioethics.
Caplan, who co-wrote the fore-
word in Ethical Choices, likes the
idea of commentaries without ab-
solutes. "Hard-and-fast advice is
not what folks look for in case-
books," he says.
Or, as Snyder puts it: "There
is no one-size-fits-all in ethics."
Snyder says this volume will
be followed up with others as
more case studies are collected.
"A lot of what's out there on
ethics tends to be rather theo-
retical, based on an exposition of
principles," she says. "We really
think a case-study format is a
good way to reach practicing
physicians and medical students
and residents, all of whom are
people who have limited time and
lots of demands on that time."
Do physicians read these kinds
of books?
'The real answer to that is no,"
concedes Dr. Ralph Ocampo, a