Monday, January 03, 2005

Ring or finger?

In a New Year's Day conversation I had with relatives, someone mentioned the story of an American soldier who was injured in the Iraq war. He had injuries to his hand and the doctors wanted to remove his wedding ring to save his finger. However, the soldier refused and told them to save the ring and sacrifice his finger instead. They did as he requested, but somehow the wedding ring was lost anyways. Fortunately for him, his wife was (eventually) supportive, and his story has generated some donations from sympathetic people.

While it is a romantic notion to choose to save a wedding ring over a finger, everyone in our discussion agreed that this was a foolish thing to choose since a ring can always be remade, but a finger cannot. Other people seem to agree, claims of heroism notwithstanding.

(To me this seems like a metaphor for America's involvement in the Iraqi War. What are we fighting for in Iraq? Democracy or the people of Iraq? Are we trying to save the ring and sacrificing the finger, only to lose both?)

Of course, we don't have all the facts, but I wonder what his doctors were thinking. Doctors let patient make bad medical decisions for themselves all the time, since patients have that right. Someone with acute chest discomfort who refuses to go to the hospital. A patient with severe allergies who refuses to get rid of a beloved cat. The out of control diabetic who refuses to start insulin because he can't stand the thought of injecting himself. The woman who chooses alternative therapy for her breast cancer because she doesn't want to lose a breast. But should doctors perform a surgery they believe isn't in the patient's best interest? Was it in the patient's best interest?

Luckily, I don't operate, but tonight I visited with an 80-something year old woman at her son's home. She has a compression fracture in her lumbar spine, has been hobbling around with a walker and feels she is perfectly capable of going back home and taking care of herself. On top of this, she has a mild dementia which prevents her from recognizing how limited she really is. Her family really wants her to either stay with them or get a live-in helper, but she just wants to maintain her independence.

Like the soldier, this woman values something so strongly that she would risk her health to keep it. I'm afraid that if she gets her way, like the soldier, she will lose both. Sometimes, doctors have to NOT do what patients want them to do, in order to do the right thing. This is a kind of thinking I would never have considered a few years ago, being accustomed to always abide by the patient's wishes.

I told her relatives they had a choice, to either respect her wishes and let her resume her life alone and suffer the consequences. Or they could keep her with them, constantly delaying her return home, a "permanent vacation" for the rest of her life. It isn't totally honest, but it would be far safer for her and give her family some peace of mind. Her dementia would probably keep her from realizing just how long she is actually staying with her son. And since she is arguably mentally incompetent, this isn't a violation of ethical principles. At least, not mine.