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Eyewitness in Erewhon Academic Hospital
  1. I de Beaufort,
  2. F Meulenberg
  1. Erasmus MC/University Medical Center, Department of Medical Ethics and Philosophy of Medicine, Rotterdam, The Netherlands
  1. Inez de Beaufort, Erasmus MC/University Medical Center, Department of Medical Ethics and Philosophy of Medicine, PO Box 2040, NL - 3000 CA Rotterdam, The Netherlands; i.debeaufort{at}erasmusmc.nl

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PART 1: THE DOORS OF ETHICAL PERCEPTION

Mrs Robinson, if you don’t mind my saying so, this conversation is getting a little strange. (From The Graduate)

Every hospital department is a transit house. This one as well. Higher than the handsomest hotel, the lucent womb of Erewhon Academic Hospital shows up for miles. At the end of the corridor the swinging doors rattle incessantly. “The doors of perception,” as ethicist Sven Kremer calls them. People walk in and out daily; only one or two go directly to the right at the south exit. Nobody does that voluntarily. It is the small passage to the mortuary. Crack … the door almost falls off its hinges. Two power-lifters carry their load down the corridor. The two have been selected with care: nurse Steven is an amateur boxer and nurse Richard was—albeit in his younger days—champion weightlifter of Nutopiah North-North-West. Their freight breathes heavily. It is a human being. To be more precise: a woman.

Gwen Loyd, a 52-year-old nurse who has recently taken up her old profession again, whispers, “Gross…”.

Her male colleague, Jake Cummings, smiles: “What do you mean? Do I hear an unprofessional judgement of a discriminatory nature?”

“Well, haven’t you seen how fat she is. No wonder her gallbladder was overworked. How did they get her through the door? She must weigh 10 times as much as I do.”

“But you’re anorexic. A very lovely anorexic if I may say so.”

“Again, do I hear an unprofessional judgement of a discriminatory nature?”, with feigned indignation. Nobody, not even she, can escape Jake’s charm.

Jake: “Touché.”

A cynical Gwen, with her pale lips at their smallest: “Who is going to visit the whale? Is there a vet in the house?”

“I will. I feel sorry for her. I suppose she actually feels quite miserable, with her more or less fatal weight … And you? You should watch your emotional levels.”

“Deep under the layers of fat, a sad soul is sheltering … You’re a nurse, not a psychologist. And she refused to see the psychologist.”

Laughing, she walks away, almost bumping into Sarah Walters, senior consultant, who only just avoids her and gives her an annoyed glance.

“Haha, that was a near-fatal collision with do-not-touch-me-Sarah,” Jake comments. Stunning redhead Sarah doesn’t hear it. She is on her way to an emergency staff meeting. Two patients urgently need a liver transplant. Tonight, there will probably be one liver available from a brain-dead patient in intensive care. She draws up to the table, mumbles “sorry” and is immediately immersed in all kinds of arguments, to which she silently listens.

“One is younger than the other and will profit longer from the transplant.”

“Yes, but the other has young children, the younger one is single. Shouldn’t that count?”

“Let’s stick to the medical facts, the personal context will only obscure the issue.”

“But you disregard the lifestyle of the patients. One enjoyed his liquor quite a lot, the other is a teetotaller. So …”

Sarah hasn’t said a word. She feels as if she is riding on the merry-go-round of arguments she has all heard before, though in different forms. This will get us nowhere, she thinks. Why not toss a coin and go for the justice of arbitrariness? “I propose we call Gordon McIntyre.” Just mentioning the name of the ethicist silences those present. But does silence mean agreement?

McIntyre and his colleague Sven Kremer head the Advisory Board on Medical Ethics. Where McIntyre is an almost godsend ethicist—especially in his own view—Kremer is quite the opposite. Do opposites attract? One will never know for sure. McIntyre hasn’t even heard of the word doubt. Poor Sven … He is still working on what is to become The medical ethics bible. Ten years and three sabbaticals have been devoted to the book already, and probably at least 10 more to go. Sven is a pro-and-con-person. You think you understand what he advises and then he goes and undermines all his own arguments and turns them upside down. Confusion is his main product. “Thank heavens he is not a doctor,” a doctor once whispered during a lecture. “He’d be paralysed when it comes to deciding.”

“I sort of like it,” says Sarah, “it makes you think for yourself, no pretence of ethical truth, helping you to sort things out by making it more difficult.”

One colleague objects: “I’d rather have … you know … a clear-cut utilitarian, or a clear-cut autonomy-adept, or a four-principles guru as far as I’m concerned. You know where they stand. This view from nowhere gets us nowhere.”

“Yes, but that doesn’t mean they’re right. And besides, I like the impartiality Sven tries to demonstrate, radiate.”

“Pff, well … I’m paid to know my medical developments, they’re paid to know their ethical stuff. I’d rather they tell me what to do, like I tell them what therapy they need.”

“It is a different kind of expertise my friend.” Pauses. “At least they say it is.”

A few rooms down the hall at least one liver is safe, deeply hidden under the paunch of …

“… Mrs Robinson, good morning. Do you want a cup of tea?”

Mrs Robinson reacts imperturbably: “I want a proper breakfast! Get me a plate, and make it a decent one: sausages, bacon and a lot of eggs.”

Jake: “I’m sorry, but you have just had surgery and you should be careful. I can get you a biscuit if you like.”

Angrily: “Young man, I want to eat. I’m hungry. This is my body. My choice. If I want to eat, I’ll eat …“

“Has the doctor spoken to you about the relation between overweight and your gall bladder problems? What did she say?”

Mrs Robinson: “She said I was supposed to lose at least 40 pounds and that I should start now, using the opportunity of the hospital stay. But I told her I’ve tried a thousand times to lose weight … name me a diet and I’ve tried it. I’ve decided that enough is enough. This is the way I am. My mother was like this, my sister is like this, probably my children will grow up like this. No use torturing yourself with a diet knowing you’ll gain weight again.”

Jake, sprightly: “Some manage …”

“Good for them. I don’t. The only thing I could do is bariatric surgery, and I don’t think that that is an option. It’s not that I enjoy my stay here so much that I’d volunteer for another operation.”

Jake, tenaciously: “Mrs Robinson, this conversation is getting a little strange. Has the doctor discussed the risks of obesity with you?”

“No need. The papers are full of them, diabetes, heart problems, I may be fat but I’m not stupid. My mother died of a heart attack when she was 56.”

“Surely you don’t want that …”

“Of course not, but I can’t eat carrots and apples for a year, and then gain weight again. It’s too depressing.”

“So is dying at 56 …”

Mrs Robinson, ending the discussion: “Get me some proper breakfast, will you. I’m starving. I came here to have my gallbladder cut out, not to be lectured.”

“This is a hospital, not a hotel. I’ll get you a nice cup of tea and a biscuit.”

When he has left the room, Mrs Robinson reaches for the grey hospital cupboard and takes out a big box of chocolates: “Emergency stock provisions.” She mimics Jake: “A nice cup of tea and a biscuit.”

“Do you want a chocolate?” she asks the occupant of the neighbouring bed. He’s a famous violinist, she’s been told, but is tied to a lot of tubes so doesn’t answer. “Chocolate is good for you. Well, for me anyway.”

None of the noises from the patient rooms and the meeting room reach the man who polishes the floor of the corridor with his machine, the earphones of his MP3 player glued to his head. His body moves to the sounds others do not hear—the silent pantomime of a mostly taciturn Pakistani man. “Call me Ishmael,” were the first words he spoke when he came to the department, and those were also his last. Listening to Simon and Garfunkel, he does not hear the telephone that cackles on the counter. Shaking her head, Gwen observes him and then answers the telephone herself. A few seconds of silence and then Gwen’s words evaporate.

“Oh my God …”

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