More information about text formats
As a surgeon my attention was caught by the opening question "What
should we say to the man who has lost an arm in a farming accident", in
Savelescu, Foddy and Rogers' article on the clinical ethics of "What
should we say?" 1 Having read their article I believe the authors failed
to address the practicality of ethical difficulties in this and other
By introducing thei...
By introducing their own personal experiences as example, I think
that they immediately fell into the ethical trap which they were trying
to expose. That is the clinician viewing an illness and the ethics of
clinical practice in terms of their own, personal context as opposed to
the patient’s personal context
Furthermore, I believe the authors’ related negative experiences
have biased the article.
It is of course difficult to know what to say to a patient at times,
and as a clinician I have heard many of the quoted statements made by
family and physician, and indeed the patient themselves, as a means to
address and understand a set of circumstance, be it a broken arm or
The primary goal of the physician who is unsure what to say following
trauma or any illness is very simple. One must restore control of the
situation to the patient. There are no “best treatments” in medicine. He
or she must be told what the problem is, and how it can be addressed.
Knowing what the treatments are, and the consequences of no treatment, the
individual is allowed to make an informed choice, choosing which
treatment is best for his set of circumstances. While knowledge of these
circumstance is informative, it should not prejudice the clinician.
The context of the patient’s diagnosis is vital to any relationship
with them. A soldier on the battlefield with a minor shrapnel wound to
face, it is likely that to be relieved to have survived, a Vogue® model
with a similar injury would more likely be devastated. The skill as a
physician is in recognising the patients own present fears, and future
aspirations, expectations, and worries. While we can restore control of
the immediate situation to a degree, we must educate patients of the
expected progress of an injury, or illness, including whether full
restoration of function is likely, the timeframe for recovery, and future
adverse possibilities. In so doing a patient experiences not complications
but consequences. What is a “gaping hole” in a calf may be viewed in
context as a healed wound. Albeit one which may require revision. In many
ways it is not how we say it but what we say.
Lance Armstrong was an athlete at 25 years of age when he developed
advanced cancer, Initially given a dismal chance of survival, even with
treatment, he nonetheless chose to undergo resection of brain metastasis,
chemotherapy; and subsequently has become one of the greatest athletes
alive. Having made dramatic recovery, and “rebuilding” his physique he
stated, "my ability to suffer a lot of pain and suffering helped me a
Happ was the Middle English word for chance, or fortune, from which
are derived words like happens, happenstance, hapless, but also happiness.
If more good things happen to us in life, than bad, then we may consider
ourselves happy 3. Clinical practice is similar. The patient who perceives
that good decisions have been made during treatment, and who knows to
expect possible adverse effects is more likely to be happy with their
treatment, even if the course of that treatment is not always smooth.
The perceived ability to have influence on one’s fate may restore
confidence and happiness to our patients.
In answer to the question posed by the authors; "What should we say?"
I believe that it is our duty as clinicians to establish a relationship
with the patient, determine what has happened, and then explain the nature
of what has happened to the patient, in terms that are clear and
understandable, with the advantages and disadvantages of any treatment.
Any comment or statement made before assessing the patient will ring
When explaining to the patient following injury, a phrase I commonly
"You are unfortunate to have X injury, but fortunately we can offer
I agree that illness may create a communication gap between patient
and clinician. It is the duty of a clinician to recognise such a gap and
ensure that the patient remains enabled in the decision making process.
Where there is difficulty in establishing such a clear relationship or
when the patient is incapable, through physical or mental illness then
ethical consideration must be as to who is best able to help the patient
in the decision making process. Simply establishing the competence of some
patients decision making ability is often incredibly difficult. In
particular when they present acutely with others whose opinion may be
biased. This is a very difficult area for the practicing clinician
involved in acute care. While I appreciate that theirs is an abstract
paper I believe the focus must ultimately be practical.
Absolute statements in general should be avoided. There will always
be patients who disprove the rule. For this reason I disagree completely
with their statement;
"A sick person will struggle to express the extent of their suffering
when we say, as was said to John "You are looking well"".
While at times a patient may correctly perceive the clinician who
says this to be completely dishonest, and disinterested in exploring real
concerns of the patient, for others, who have an established relationship
of trust with the clinician, this statement may restore true hope in the
Returning to the scenario introduced by Savulescu et al, the patient
who has had an arm cut off in a farming accident, is unfortunate to have
had the accident, but fortunate to arrive in a timely fashion to a
microsurgical unit. Appropriately counselled, he may chose to have his arm
reattached and accept stiffness, numbness, scarring , risk of sepsis,
reduced function and need for future operations, or, may accept
disability , simply have the stump sutured, and return sooner to his work.
1. Savulescu J, Foddy B, Rogers. What should we say?
J.J Med Ethics. 2006 Jan;32(1):7-12.
2.Martin Cannellakis Director, The Science of Lance Armstrong,2005
3.Lancaster J Pursuing Happiness, New Yorker. 2006 February 27;74(42):40,