‘Think of the patient as your own child – then clinical & ethical decisions come easily’
Love your patient, as you love yourself or your child.
This was the simple message that Prof. Benjamin Joseph from the Aster Medcity Hospital, Kochi, India, gave in a measured but compelling delivery straight from the heart, during the SLOA Oration 2019.
‘ The Hippocratic Oath, the Mosaic Law & the New Commandment’ was this eminent Consultant Paediatric Orthopaedic Surgeon’s intriguing theme, under which he underlined the need for clinical decision- making to be based on scientific evidence and ethical decision-making to be based on one’s conscience without commercial interests coming into play.
With regard to decision-making in clinical practice, Prof. Joseph asked how one should make the correct choice when there were several different ways to treat a condition. There should be a template for decision- making which includes: listing the problems to be addressed; listing the aims of treatment; listing the treatment options for each problem; listing the merits and de-merits of each treatment option; and listing the factors that need to be taken into consideration while planning treatment for a particular patient.
Taking up the case of an eightyear-old boy who presents with a recurrence of a deformity of the knee, he guided the audience on how a treatment plan could be formulated by using such a template, stressing that then “decision-making may not be too difficult even in complex situations”.
“Yet,” he lamented, “all too often we see that the choice has not been the right one.”
The reasons for the wrong choice in clinical practice, Prof. Joseph attributed to:
Hyposkillia – deficiency of clinical skills. Those afflicted are ill-equipped to render good patient care, cannot take an adequate medical history, cannot perform a reliable physical examination, cannot critically assess the information they gather and cannot create a sound management plan, have little reasoning power and communicate poorly.
Inadvertently following the
path dictated by market forces. Deliberate choice of the wrong treatment for commercial gain. (He had this point with a pair of hands reaching out to a heap of coins.)
He cited the instance of children who suffer a fracture of the clavicle, where many orthopaedic surgeons ignore evidence of the mainstay of management of such fractures in this age group being conservative management but resort to surgery due to industry dictates.
Just because a car is coated in gold, does it run better, asked Prof. Joseph.
Focusing on the Law of Moses ( Mosaic Law) and the Ten Commandments, he said they encompassed Commandments relating to God and those relating to fellow human beings. However, the New Commandment dealt with just two aspects – ‘Love the Lord your God with all your heart, soul and mind’ and ‘Love your neighbour as yourself’.
“All other commandments are superfluous because we all love ourselves and would never wilfully do anything that harms our own interests. If we love our neighbour as much as we love ourselves we could never harm their interests!” he said.
Next, Prof. Joseph put the Hippocratic Oath under the spotlight, pointing out that it integrates respect for the teacher; commitment to teaching; commitment to purity; commitment to honourable conduct; commitment to patient confidentiality; commitment to do no harm; and commitment to shun corrupt practices (“whatever houses I enter, I will go into them for the benefit of the sick and will abstain from every voluntary act of mischief and corruption”). The dictionary definition of corruption was dishonest or illegal behaviour especially by powerful people (such as government officials or police officers); inducement to wrong by improper or unlawful means (such as bribery); and a departure from the original or from what is pure or correct.
Modifying the Hippocratic Oath in the pattern of the New Commandment, Prof. Joseph said: “Treat every patient exactly how you (or your child or loved one) would like to be treated if you were in his/her situation. Ethical decision- making then becomes exceedingly simple.”
He concluded with a description of how he attended a symposium on paediatric femoral fractures. Different speakers had extolled the virtues of different treatments – plaster spica; traction; external fixator; intra-medullary nail; and plate & screw.
During the discussion, the audience had been told to give their preference and people had favoured one or the other, spread across all methods, mainly surgical options. The final question from the moderator had been which method they would choose if it was their child. One and all, without hesitancy, had raised their hand for plaster spica which was the conservative management method.
Even for the distinguished audience in Colombo last Thursday this simple revelation said it all.