Do No Harm

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https://commons.wikimedia.org/wiki/File:Triage_Site_US_Army.jpg

“Prinum Non Nocere”; Medical School Students say these lines in the Hippocratic Oath, pledging to do no harm.  Traditionally this promise is made with the notion that physicians will do everything in their power to cure ailing patients.  Yet, complications arise when doctors make decisions on who, and what to prioritize when they must provide treatment selectively when vital resources are limited. When people are dying and you can only save some, how do you choose?

Examples illuminate the dilemma at hand: consider a story outlined in the Journal for Medical Ethics.  A physician recalls when four patients arrived in respiratory distress when  she was working in a hospital in Port-au-Prince, Haiti, after the 2010 earthquake (1).  No ventilators were available and she only had access to one oxygen tank.

One patient was a 15-year-old female with curable pneumonia and minor neurological issues. Another was a forty year old woman with tuberculosis and HIV, and three young children pleading for help at her bedside. Another was a 25-year-old nurse practitioner with a pulmonary embolism complication arising from a recent surgery for a bowel syndrome. The fourth patient was an 18-year-old female with serious heart failure and dyspnea (2).

The doctor chose to help the the nurse, although the 15-year-old with treatable pneumonia was the most immediately curable. The physician expands on her decision, “Did I make a medical judgment based on a co-morbidity or a value judgment based on my own latent biases? I am honestly not sure.”

Most hospitals use specific protocol when triage is necessary. They rank patients into three categories of priority : (1) those who will die even if treated, (2) those who will live even if not treated and (3) those who will live if treated but die if they are not (3).Those in the third category are priority for treatment. Yet, in the instance of life or death decisions, is it possible to be systematic?

Perhaps the physician in this story made decisions based on who’s life was inherently worthy of saving.  It is difficult for such an emotional decision to be unbiased and objective. Thus, the fate of four individuals lied in the value-judgements of one physician.   This predicament demonstrates that the balancing act between harms and benefits is not solely based on medical school training and clinical protocol, but interpersonal beliefs and values. This dilemma is exemplary of the complexities surrounding the pledge to “do no harm.” Triaging patients often elicits emotional biases and instinctive reactions, leading some to be subjected to harm indirectly.

This dilemma extends to other instances of disaster: Hurricane Katrina in 2005. New York Times reporter Sheri Fink describes troubling instances of triage at Uptown New Orleans’ Memorial Medical Center in her article, “The Deadly Choices at Memorial.” Nearly four years after tragedy struck the city, investigations continued into a well respected physician and two nurse practitioners who were charged with injecting lethal doses of drugs to hasten the death of  patients who were unsavable. Fink writes, “The physician, Anna Pou, defended herself on national television, saying her role was to “help” patients “through their pain,” a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.”

Anna Pou continues to defend her position today, and argues that physicians should be granted amnesty in situations of mass casualty. She describes her decision as a “mercy killing” and not a “murder.” She maintains that her decisions were made based on her values and better judgement (4).

While these examples are taken from mass tragedy, these ethical impasses characterize many emergency healthcare providers’ experiences. While uncomfortable, stories like these are important to analyze as we continue to link medical ethics with medical treatment. In a career field differentiated by personal connection, trust and care, medical students should understand the responsibility they are about to take on.

Edited by: Nikhil Karavattuveetil




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