By Dora Abbi and Shruthi Guru
As fresh wide-eyed new medical graduates ascend the stage to receive their hard-earned diplomas after years of tests, revision and struggles they vow the famous words: “I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wronging any man by it.” Hippocratic Oath (c. 400 BC)
At first glance, the premise of this vow seems simple enough - do no harm, do not use your power for wrong, care for the sick; but as these excited new graduates enter the field of medicine, their dreams of saving lives crash into granite-hard reality. What does it mean to cause no harm? If it were interpreted in a literal sense, then no surgeries would occur, no blood withdrawals or vaccine injections. After all, each of these actions would cause some level of harm to the patient. Rather, ‘do no harm’ is a careful balance between cost and reward, optimism and realism.
Neurosurgery sparks some of the most poignant questions about whether surgery is worth the risk. The intricate network of glistening veins and pulsing arteries, nerves with electric impulses zapping through, and soft fragile tissue, makes up only 2% of the body’s matter. Yet, as a scalpel goes in to take out a vile tumour, it passes through memory, character and thought - the entire being that makes up a person. A person could be tumour-free but in a lifelong coma hooked onto a ventilator or living with debilitating deficits. Henry Marsh’s book: ‘Do No Harm’ provides an unforgettable insight into the realities of neurosurgery through some of his most memorable cases.
In one case, he is faced with a pregnant lady with a meningioma, a tumour in the meninges, the membrane which encases the spinal cord and brain. It pressed into the optic nerve, which had already caused vision deficits and would progress into blindness if nothing was done. In such a case, what would you choose? Total certainty of future blindness and a drawn out death, or a chance of sight and a normal life at the risk of blindness, a coma or death. Though the surgery nor tumour had any direct risk to the unborn child, how would possible risks be weighed here?
In this case, the operation was agreed on. An army of neurosurgeons, obstetricians and paediatricians stood at the OR for this multi-step procedure. After gruelling hours hacking at the tumour, the baby was safe and laid on a cot. The mother, unfortunately, laid on the surgical mat with blown out pupils. Unconscious, mute and unresponsive. She had no response to light. No response to sound. She had gone into a coma, after a postoperative intracerebral haemorrhage [1] - a rare but recognised risk. At this point, we would say the cost exceeded the benefit and would ask why we would even attempt such a surgery in the first place. Why risk it when she could have lived a long life even if she were blind? The only relief Marsh expressed was that in a way the patient had gotten her wish - for a quick, peaceful death rather than an otherwise drawn-out one. But even so, did this operation cause more harm than good? If it did then should we never attempt such a thing again?
Fortunately, by some twist of fate, the patient did wake up. Rare but somehow possible, she woke to see her family and her new child and would continue to see for the rest of her life until age and the customary blurry vision kicked in. She was free to live her life without constantly being under the looming shadow of the tumour and its ticking deadline. Now, did the harm outweigh the good or was the risk worth it? How is it possible to make the initial decision without this foreknowledge?
Later on in his book, Marsh encounters a schoolteacher in his late fifties with shockingly large petro-clival tumours [2] growing at the base of his skull. This tumour stretched over all of his brainstem and his cranial nerves – affecting the nerves for his hearing, movement, swallowing, talking and sensation of his face. The sheer size of this tumour leaves Marsh unsure on what to do or say. The question in this case is whether this tumour should or could be removed.
Leaving the tumour alone results in the schoolteacher’s gradual deterioration- losing his hearing, his ability to walk and eventually leading to his death. However, removal surgery could result in worse, like facial paralysis, deafness or major stroke. After the family of the schoolteacher sought a second opinion from an older, more experienced neurosurgeon, they returned to Marsh and followed on with the surgery which could either change the schoolteacher’s life for better or for worse. This operation began with a festive and celebratory ambience as the first few hours progressed almost perfectly. Every couple of hours Marsh would stop to get a snack or drink and the OR would have music continuously playing. After 15 tedious hours of removing this benign tumour, most of the tumour was gone with zero damage to the cranial nerves. Marsh remarks that he should have stopped here but he wanted to be able to say it was all gone and continued unaware of what would happen next. Brain surgery can be compared to defusing a bomb - completely unpredictable and terrifying and in this instance, Marsh is faced with a blown up disaster. As he continues with removing the final parts of the tumour Marsh tears a small perforating branch off the basilar artery [3]. Although the blood loss was trivial, the damage to the bloodstream was irreparable, meaning the schoolteacher never regained consciousness and his life was changed for the worse.
In both cases we could consult the 4 pillars of medical ethics: benevolence, non-maleficence, autonomy and justice. On one hand, the entire argument of whether to carry out the surgery rested on the principle of non–maleficence. Either option may result in harm and the question becomes how heavily to weigh each side. Both options seemed to be the benevolent option if the surgery went forward without problems by enabling both patients a chance of a life free from deterioration, but much like the previous pillar, the answer is not clear cut. Many would argue that the benevolent option or the option that would do the most good to their quality of life would be doing nothing and allowing them to enjoy the time they have. On the other hand, as neither benevolence or non-maleficence supports one side of the argument completely, the principle of autonomy must be used to make the decision. By providing all the information, risks and benefits to both sides and allowing the patient to form an informed choice. The principle of justice is not the most significant in this situation but it could be argued in the first example, that it would be unfair to deliver the baby early and cause possible complications, in order to operate on the mother. Despite this, ultimately, we would argue that autonomy is the most important factor in both of these situations. In the first example, as the possible benefits and risks are weighted differently by different individuals, and the risk to the baby was declared as minimal, the choice rests on the patient’s opinion. Similarly in the second case, the patient consulted a second opinion and made an informed choice.
Medicine, more than surgery or prescriptions, is about making difficult choices. We would expect the life or death decisions to be the most difficult , except, often the hardest decisions are deciding if a life with deficits or memory loss or in a coma is better than death. Whether the harm of surgery outweighs the harm of doing nothing. We would argue that ‘do no harm’ is a gross underestimate of the true complexity of the decisions that must be made. After all, if all possible decisions may cause some degree of harm, which one do you choose?
Key Terms:
[1] postoperative intracerebral haemorrhage: bleeding in the brain caused by the rupture of a damaged blood vessel in the head.
[2] large petro-clival tumours: slow growing tumour in the meninges deep within the skull base . Meninges is tissue that covers the outer part of the brain and provides protection - any tumour in this tissue is known as a Meningioma
[3] basilar artery: a blood vessel at the back of your brain
Robert H. Shmerling, M. (2020) First, do no harm, Harvard Health. Available at: https://www.health.harvard.edu/blog/first-do-no-harm-201510138421 (Accessed: 10 September 2023).
The four pillars of medical ethics - A quick overview (2023) Medic Mind. Available at: https://www.medicmind.co.uk/medicine-ucas-guide/the-four-pillars-of-medical-ethics-a-quick-overview/ (Accessed: 10 September 2023).
Comments