How doctors really decide who lives and who dies | Matt McCarthy | Big Think

How doctors really decide who lives and who dies
----------------------------------------------------------------------------------
Our health care system right now prizes efficiency, rather than embedding an ethics committee throughout a patient's treatment.

The challenge of being a medical ethicist is bringing "airy" concepts into clinical practice.

Sometimes the solutions to ethical issues become established via legal precedent.
----------------------------------------------------------------------------------
MATT MCCARTHY

Matt McCarthy, MD, graduated from Harvard Medical School and went on to complete his internal medicine residency at Columbia University Medical Center. He is the author of two national bestsellers, "The Real Doctor Will See You Shortly" and "Odd Man Out." His newest book, "Superbugs," is on-sale now.

McCarthy is also an assistant professor of medicine at Weill Cornell and a staff physician at New York-Presbyterian Hospital.
----------------------------------------------------------------------------------
TRANSCRIPT:

MATT MCCARTHY: When I graduated from residency training, I had finished four years in medical school, three years of internal medicine residency, and three years of subspecialty training in infectious diseases. I took a job as a staff physician at a hospital in Manhattan. And it was a teaching hospital. And I suddenly found myself surrounded by every morning on rounds medical students, interns, residents, a pharmacist, a social worker, all of these people who are turning to me to make medical decisions, which I felt reasonably comfortable with.

But it was a patient who I met who challenged me with an ethical issue that made me recognize how out of my own depth I was at handling these things. And that patient was a 24-year-old woman. I'll call her Sarah. And she had end stage anorexia nervosa. And she weighed 35--she was 24 years old, and she weighed 35 kilograms. She was the size of a fifth grader. And her heart was barely pumping, and her electrolytes were a mess. And there were all of these issues that were essentially just on the verge of death. And when I went to see her with my medical team, she said to me,"I have just one request. I would like a palliative care consult. I want you to help me die."

And as I was standing before her, I said, "No, no, no. There's a lot of things we can do for you. But that's not one of them. We're going to get you through this." In fact, that's a phrase that I say to a lot of patients-- we're going to get you through this. And as I was saying these words, I felt the glare of the medical students and residents around me. And I recognized I wasn't being my best self, my best doctor self that I had dreamed of being. It just didn't feel right that I was telling this woman, "No." And I ended up reaching out to our ethics committee. And that started a long and winding process of me getting involved in medical ethics where I learned just how many ethical issues doctors were facing. And it led to a clinical research career where what I study now are the ethical issues doctors face where they don't ask for help or they don't ask for an ethicist.

Part of that is because our health care system right now prizes efficiency. And itis often inefficient to say, time out, we need to talk to a clinical ethicist and make the right decision. ButI've come to recognize how important that can be. When you join the world of medical ethics, you learn about a whole new vocabulary of terms that were never exposed to medical students like me, things like beneficence and non-maleficence and autonomy and justice. And they're very theoretical and airy concepts. And the challenge of being an ethicist is to bring those concepts into clinical practice. And so the first thing you do, if you're going to be a medical ethicist, when you're called in for a case, when I goto see an ethics consultation, is you figure out, what are the facts. And there is a saying in our hospital that good facts make for good ethics.

And often that is the big stumbling point. Doctors may be disagreeing about something or a patient and a doctor or disagreeing, and that leads to an ethics consultation. And in a third of the cases at least, we find out that there is a fundamental disagreement on the facts of the case. The other thing that's very helpful to know are legal precedents. So a hypothetical would be a 12-year-old boy needs surgery for a tumor in his liver, and he's going to require a blood transfusion during that surgery. But his parents are Jehovah's Witnesses. And they say, "No blood transfusion!" And the surgeon says, "I'm not taking this kid to the ER unless I can transfuse him bec...

[adtc]

Feel like he was rushed to wrap up and he didn't get enough time to finish what he was trying to say

[imatsoup]

As somebody who deals with chronic illness and has for most of my life, I know what its like to argue with doctors over treatments. A big point of contention is the money issue. Personally, if money weren't a problem and my insurance ACTUALLY insurerd me; I'd ask a lot less questions and be a lot more open to anything that doctor's put on the table. If it's a financial reason, the ethical thing to do is not to put the person in even more debt that they leave behind for their family to worry about.

[stevesayewich]

I am a 73yr man. I am presently reading the book, "Being Mortal, " by Atul Gawande which covers, "Medicine and What Matters in the End."
My belief is that, all things being equal, which they're not, the patient should have more say about the end of Their Life.

[greatwhiteshark]

how can doctors decide what the patient wants .If that woman wanted to die that's her decision .Doctor should not make decision for her.

[tgooding]

People should be able to get what they want out of life with the assistance of the medical profession; not in spite of the medical profession. If you are mentally able to make this decision you should be able to choose for YOURSELF whether or not to take treatment.

[Icecoldhard]

Personally there is too much religious mumbo jumbo involved in these discussions

[flowergrowersmith]

A very interesting talk indeed. Thanks Dr McCarthy and Big Think.

[cxa]

I thought I might want to be a doctor at one time, but I felt like these were exactly the type of decisions I wouldn't want to be responsible for making.

[rolandwoltman]

As someone who has tortured many a Grandma to death, keeping them just barely alive for them to be here one more day, I find the main ethical issue that is unaddressed is the physician (or facility) not educating the patient/family on just how much torture they/their family member will endure to often, just live that one more day...

Some questions I'd have for the informative and deep thinking Doctor McCarthy:
1) If ICU patients were prisoners of war... how long would you have to work in the ICU before you went to prison?
2) If a patient cannot speak for themselves, why are they not defaulted to DNR? What if they are older then the average age of human death? What if they have a terminal condition (beyond being human)?
3) If studies show palliative care can lead to the patient sometimes (far too often) living longer, while not being tortured to death... Why are physicians not forced to do continuing education about this? Or to inform the families about this...

Anyone else have questions for the Dr McCarthy to do a future Big Think about?

I recently watched an ER physician tonight with a dying patients son. Make an informed, brave and obviously correct in this case. The decision to let the Father of that man go on to whatever is next. The physician was brilliant and caring. But I have, in my decades of experience, seen far too many times where that conversation never happens...

[Blitznstitch]

Only fact that matters, Do you have health insurance? No? Then you don't get the full range of care that you need to get better, instead you'll get whatever is needed to live until you get close to death again

[ItsLoriK]

Life isn't a gift for everyone. To realize & accept this by letting (emotionally healthy) people decide the outcome for themselves is a sign of a humane, respectful, & progressive society.

[MrAdryan]

Wow, that was super fascinating! I have been wondering about the answers to these questions for a very long time. That was rad, thank you!

[cjinpa]

Would have enjoyed hearing the rest of the story of the anorexic. Feel like we got the beginning to a few things here but not the rest of the story. Give me more please.

[youtube-critic]

I really liked this talk. I had never heard of Ethicists in my small town. Speaking from my own perspective, I felt that the issue with medicine was not a priority of autonamy but rather a priority of avoidance. Avoiding death. There's nothing wrong with that, except when we work so hard to do it that we lose our ability to empathize with someone who feels differently in the context of their situation.
This video definitely gave me a different perspective to consider.

[dreamlife]

In this time of Covid, we need to address ethical issues again. The anti-vaccinated that are crowding our hospitals versus the vaccinated that needs intubation, etc etc etc.

[enatp]

It baffles me that the medical system would expect the public to have complete confidence in only one path to healing. Medical practitioners need to know how to integrate other principles of healing into treatment but it is an arrogant system.

[pjukas]

Good facts = good he is broke, nothing we can do

[Angelo-uogj]

I have my doctorate in physical therapy and I am interested in medical ethics. I didn’t know there were jobs for this but can I go this route as a DPT? Where do I start?

[DrRamy-bbfw]

So happy to see the field of Bio-Ethics/Clinical Ethics expanding! Awesome topic, thank you!

[gorhamcj]

Very interesting topic. I would listen to an in depth video on this if you would consider it. I work in healthcare also.