Whatever Happened to a Responsibility to the Patient?
Late last year, in a conference room of a major New York hospital, a team of surgeons fretted over their concerns with their plans to perform the first U.S. human-hand transplant. The hard part was finding a handless patient who would consent to the risky procedure. The first prospective patient, it turned out, had lost his hand building a bomb. What would the press write, these doctors worried, if they chose as their first patient a clumsy terrorist?
But while they combed city streets for more suitable patients, a group of Louisville, Ky., surgeons beat them to the punch in January, when they performed the first hand transplant in the United States. Resigned to the fact that there was no point if they would not be the first to perform the daring procedure, the New York doctors called it quits.
What makes this medical drama disturbing is the dubious medical nature of transplanting hands between nonrelated individuals and the intense international competition that ensued between rival surgical teams bent on being the first to perform this procedure. While the rival surgeons should have been motivated by the best of intentions, the rash manner in which they set out to be the first makes clear that one of their primary concerns was achieving fame, and one of their key motivations was perhaps greed.
The Louisville surgeons themselves were bested by a group of French doctors, who, last September, became the first to successfully attach a right hand to the arm of an Australian man who lost his hand in a jailhouse carpentry accident. The French doctors had disbanded their tedious research, which might have solved many of the problems now faced by the transplant recipients, and scurried to find any suitable patient when they realized American surgeons were ahead of them. It has always been true that being the first with breakthrough operations is an excellent way to earn research grants, as well as a place in the annals of medical history. Coming in second tends to be a confirmation of someone else’s work. The surgeons, no doubt aware of this, were willing to rush their research and settle for less-than-ideal patients.
Unfortunately, now both transplant recipients possess poorly functioning hands, at the cost of needing a lifelong regimen of antirejection drugs that suppress the immune system and leave them vulnerable to infection and cancer. Citing these dangers, and the fact that the risk-to-benefit ratio for experimental hand transplants “has yet to be convincingly established,” the American Society for Surgery of the Hand has joined dozens of medical critics of these doctors’ actions.
The argument for encouraging such operations is that they foster other advances. Doctors’ blithe rejection of sound judgment, after all, has led to countless treatments and cures. For example, in 1885, Louis Pasteur created vaccines against anthrax and rabies, which he planned to test on himself. His colleagues, however, fearing the loss of a great scientific mind, deterred him and instead inoculated themselves with the vaccines, which proved effective.
The difference, however, is that Pasteur and the scientists of an earlier generation practiced according to the spirit of Hippocrates, considered the father of medical science. Hippocrates preached humility, cooperation among physicians, social responsibility and, above all, commitment to the patient. He urged physicians to seek out new remedies but be skeptical. In other words, fame, when it rarely happened upon a diligent researcher such as those chronicled in Paul de Kruif’s now classic “Microbe Hunters,” was to be taken as a byproduct of providing good patient care.
Today, there are two contrasting systems, two distinct cultural traditions, for providing health-care services in this country: the commercial and the professional. The line separating a doctor’s commercial interests from his patients’ medical interests is increasingly blurred. As word of medical milestones flashes across the evening news, it is often harder and harder to tell whether a doctor truly had the best interests of the patient in mind.
This is also reflected in the growing number of physicians now using public-relations agencies to goad an unwary public into seeking sometimes unnecessary medical interventions. An Encino-based PR firm that represents more than 200 doctor groups put it this way in a recent article published by the American Medical Assn.: “With the decrease in revenues from insurance companies and government, doctors are being forced to become more and more like any other business person.” On any subway car in New York, it’s impossible to make it to work without being assaulted by the smiling face of Dr. Zizmore, who promises acne-free living for the masses.
In medical school, we were taught that “good surgeons know how to operate, better ones when to operate and the best when not to operate.” But when you’re a hammer, the whole world looks like nails. It takes wisdom, restraint and humility not to operate when that is what you have been trained to do.
In some quarters, the tradition of medical professionalism has been overtaken by the commercial ethic. In an era in which doctors are forced to fight for every health-care dollar, performing splashy operations like hand transplants is a way to compete for patients, but is not always in the patient’s best interest. For some doctors, the drive for fame and financial reward appears to be getting out of hand.*
