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A case-based approach that provides the advice and
skills medical practitioners need to help patients
and overcome ethical challenges.

“Helping and not harming, keeping secrets, truth telling, and much more—Doing Right
is a wise, highly readable, and practical guide towards being the kind of doctor or nurse
every patient hopes to have.”
—Priscilla Alderson, PhD, Professor Emerita, University College, London, UK

“For over twenty years Doing Right has been regarded as the premier resource in Canada
for teaching clinical ethics to health care professionals. This revised and expanded 4th A Practical Guide to Ethics
edition ensures it will maintain that status for years to come.”
—Daryl Pullman, PhD, Professor of Medical Ethics, Memorial University
for Medical Trainees
“The foundational text in Canadian medical ethics has added engaging new material, while
and Physicians
retaining its clarity and focus on practical decision-making. Everyone from undergraduate
students to practicing clinicians will find this book instructive and inspiring.”
—Dr Merril Pauls CCFP(EM), MHSc, Professor & Co-director of Professionalism teaching, University of Manitoba

“This fourth edition of Doing Right provides an excellent overview of the ethical questions
most frequently encountered in contemporary medical practice. Grounded in a diverse
array of real-life cases, it will serve as an outstanding resource for ethics educators in
Canada.”
—Dr Mona Gupta, Associate Clinical Professor, Université de Montréal
and Chair of the Ethics Committee of the RCPSC

Highlights
• A case-based approach highlights real-life examples and encourages
readers to actively explore difficult decisions healthcare professionals have
to make.
• New chapters on Social Media, Medical Assistance in Dying, and the Ethical
Regulation of Research provide cutting-edge coverage of the ethical
dilemmas involved in medical science and research.
• Accessible and jargon-free, this new edition uses clear language and
straightforward explanations to guide readers through ethical dilemmas.
• Cases for discussion at the end of each chapter help readers analyze
ethical problems and brainstorm possible solutions.

PHILIP C. HÉBERT is emeritus professor of family medicine in the Department of Family

and Community Medicine at the University of Toronto. WAYNE ROSEN is a clinical assistant
professor in the department of surgery at the University of Calgary.

Philip C. Hébert
www.oupcanada.com Wayne Rosen
 Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries.

Published in Canada by
Oxford University Press
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www.oupcanada.com
Copyright © Oxford University Press Canada 2020
The moral rights of the author have been asserted
Database right Oxford University Press (maker)

First Edition published in 1996

Second Edition published in 2009
Third Edition published in 2014

All rights reserved. No part of this publication may be reproduced, stored in

a retrieval system, or transmitted, in any form or by any means, without the
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or through the following url: www.oupcanada.com/permission/permission_request.php

Every effort has been made to determine and contact copyright holders.
In the case of any omissions, the publisher will be pleased to make
suitable acknowledgement in future editions.

Library and Archives Canada Cataloguing in Publication

Title: Doing right : a practical guide to ethics for medical trainees and physicians / Philip C.
Hébert and Wayne Rosen.
Names: Hébert, Philip C., author. | Rosen, Wayne, 1961- author.
Description: Fourth edition. | Includes bibliographical references and index.
Identifiers: Canadiana (print) 20190051833 | Canadiana (ebook) 20190062037 |
ISBN 9780199031337(softcover) | ISBN 9780199034734 (loose-leaf) |
ISBN 9780199031344 (EPUB)
Subjects: LCSH: Medical ethics.
Classification: LCC R724 .H39 2019 | DDC 174.2—dc23

Cover image: Caiaimage/Robert Daly/OJO+/Getty Images

Cover design: Laurie McGregor
Interior design: Sherill Chapman

Oxford University Press is committed to our environment.

This book is printed on Forest Stewardship Council® certified paper
and comes from responsible sources.

Printed and bound in the United States of America

1  2  3  4 — 22  21  20  19
Contents
Cases ix
Preface xii
Acknowledgements xiv
Introduction: A Revolution in Learning xvi

1 Ethics Matters 1
I. Great Expectations: Healthcare Professionals and Ethics 1
II. Four Ethical Principles and Questions 2
III. The Principles and Ethical Reasoning in Medicine 5
IV. Beyond Principles 9
V. The Hidden Curriculum 10
VI. Overcoming Obstacles to Ethics 12

2 Broadening the Horizon: What Law

and Ethics Say 15
I. What the Law Says 16
II. W
 hat Ethics Says: Virtues, Rules, and Consequences in
Medicine 17
III. Expanding the Horizons of Ethics 23
IV. Professional Ethics 28

3 Managing Medical Morality 33

I. Managing Ethical Dilemmas 33
II. Really Hard Choices Are Not Always about Ethics 34
III. “Doing Right”: A Process for Managing Ethical Choice 37
IV. The Ethics Process in a Little More Detail 38
V. Applying the Ethics Process 43

4 The Times are Changing: Autonomy and

­Patient-Based Care 50
I. The Autonomy Principle 51
II. Autonomy as the Patient’s Preference 54
III. The Case of Ms Malette and Dr Shulman 56
IV. Choices: The Good, the Bad, and the Ugly 58

5 Reasonable Persons: The Legal Roots of

­Informed Consent 69
I. Medical Consent 69
II. Informed Consent: A Brief Legal History 71
III. Informed Consent: The Canadian Context 74
IV. S ignificance of Reibl v Hughes: The Modified Objective
Standard 79
vi ✦ Contents

6 Informed Choice and Truthtelling:

The Centrality of Truth and Trust 85
I. Disclosure and Truthtelling 85
II. The Elements of Informed Choice 89
III. Consent as Trust 95
IV. Other Special Circumstances 97
V. Special Circumstances and Limits on Truthtelling 101

7 Keeping Secrets: Confidentiality and

Privacy in the Electronic Age 108
I. Confidentiality and Privacy 108
II. Privacy, confidentiality, and Trust 110
III. New Risks to Privacy 115
IV. Limits to Confidentiality 121
V. To Warn and Protect 128

8 The Waning and Waxing Self: Capacity and

Incapacity in Medical Care 131
I. Incapacity and Its Discontents 131
II. Assessing Capacity 134
III. Capacity and Consent 136
IV. Treating and Protecting the Vulnerable 137
V. Substitute and Assisted Decision-Making 139
VI. Mental Illness and the Right to Refuse 142
VII. Children’s Right to Refuse 145

9 Helping and Not Harming: Beneficence and

Nonmaleficence 151
I. The Principles of Beneficence and Nonmaleficence 151
II. A Duty to Attend? 156
III. Risks to the Professional 158
IV. Endangering One’s Self 160
V. Parental Refusals of Treatment 165
VI. Parental Requests for Treatment 169

10 Conduct Becoming: Medical

Professionalism 175
I. Maintaining the Connection 175
II. A New Professionalism 177
III. Conflicts of Interest 181
IV. Professionals and Industry 183
V. Boundaries Large and Small 186
VI. Fitness to Practise Medicine 191
 Contents ✦ vii

11 The End of Forgetting: Ethical and Professional

Issues with Social Media 197
I. Friends, Boundaries, and Privacy in the Age of Social Media 197
II. The Personal and the Private 201
III. Patients Using Social Media 204
IV. Photographs and Patient Privacy 206
V. Internet Etiquette and Telling Others’ Stories 209

12 The Error of Our Ways: Managing

Medical Error 214
I. Medical Error 214
II. Error and Being Responsive to Patients 222
III. How to Disclose Error 223
IV. Apologies 224
V. Large-Scale Adverse Events 225

13 Beyond the Patient: Doing Justice to

Justice 230
I. Justice in Everyday Medicine 230
II. A System of Mutual Recognition 234
III. Distributive Justice 239
IV. Squeezing the Balloon 242
V. Guidelines and Rationing 245
VI. Justice for All? 247

14 Labour Pains: Ethics and New Life 254

I. Birthing and Reproductive Choice 254
II. Termination and Choice 260
III. The New Age of Reproduction 262
IV. Desperately Seeking Stem Cells 272

15 A Dark Wood: End-of-Life Decisions 276

I. Allowing Death: Refusals by Patients 276
II. Competent Decisions, Living Wills, and Advance Directives 281
III. Decisions to Withhold or Withdraw Life-Sustaining Treatment 284
IV. Persistent Vegetative States and Prognostic Error 287
V. Unilateral Decisions Regarding Life-Sustaining Treatment 289
VI. Palliative Sedation 292

16 Medical Assistance in Dying: The Triumph of

Autonomy 296
I. Assisted Death: Terminology and Other Jurisdictions 298
II. Medically Assisted Death in Canada: A Brief History 300
III. Legislating Medical Assistance in Dying: Bill C-14 302
viii ✦ Contents

IV. MAID: Minors, Advance Requests, and Mental Illness 304

V. MAID and Issues of Conscience 313

17 Nature and Culture: Of Genes and Memes 319

I. All in the Genome? 319
II. Cultural Connections 327
III. Worlds Apart? 331
IV. Culture and Defying Death 332
V. Transcending Culture 335

18 The Ethical Regulation of Research 340

I. Medicine’s Legacy 340
II. The Purpose of Research 341
III. Consent for Research 344
IV. The Tissue Issue 347
V. Some Questions and Answers Regarding Research 350

Conclusion: Setting our Sights 358

Notes 362
Index 406
 Cases ✦ ix

Cases
1.1 To Prescribe or Not to Prescribe (resource allocation, justice,
professionalism) 2
1.2 “I’m Not Ready to Die!” (resource allocation, respect for autonomy) 8
1.3 A Risky Teaching Tool (professionalism, moral distress) 11
2.1 “You Have No Right to Touch Me!” (capacity, autonomy) 16
2.2 Silent Witness (confidentiality, beneficence, nonmaleficence) 19
2.3 The Worrier (beneficence, truthtelling, medical error, autonomy) 22
2.4 “Don’t Tell!” (confidentiality, truthtelling) 27
3.1 Hidden Trauma (confidentiality, truthtelling, cultural issues) 33
3.2 To Feed or Not to Feed? (autonomy, capacity, end of life, consent) 43
4.1 More Surgery Wanted! (autonomy, beneficence, cultural issues) 51
4.2 A Man Who Would Live on Eggs Alone (autonomy, beneficence) 54
4.3 Ligation Litigation (autonomy, consent, reproductive ethics) 58
4.4 “Don’t Touch My Arm!” (autonomy, consent, beneficence) 60
4.5 Tranquillizer Trap (autonomy, beneficence) 62
4.6 This Lady’s Not for Turning (autonomy, nonmaleficence) 64
5.1 A Simple Question (consent) 70
5.2 New Grads and Small Centres (consent, truthtelling) 74
5.3 How Not to Get Informed Consent (consent, autonomy) 77
5.4 “You’ll Be Back to Work in No Time!” (consent, autonomy) 80
5.5 What You Don’t Know Won’t Hurt You (consent, truthtelling) 81
6.1 A Dark Secret (truthtelling, consent) 87
6.2 “If I Had Only Understood” (consent, autonomy) 89
6.3 “Thanks but No Thanks!” (consent, capacity) 92
6.4 Ratcheting up the Rhetoric (consent, coercion) 94
6.5 “I Trust Ya, Doc” (consent, disclosure, autonomy) 98
6.6 “Stop the Test!” (consent, capacity, autonomy) 100
6.7 A Reflex Response (truthtelling, nonmaleficence) 105
7.1 The Shame of It All! (confidentiality, privacy) 108
7.2 Mum’s the Word (confidentiality, privacy, minors, autonomy) 110
7.3 A Favour, Please (confidentiality, privacy, professionalism) 112
7.4 “Just Email Me, Doc” (confidentiality, privacy) 115
7.5 For the Record (confidentiality, privacy) 118
7.6 A Pain in the Butt (confidentiality, privacy, limits of confidentiality) 125
8.1 “Talk to Me, Not My Daughter!” (autonomy, capacity) 131
8.2 A Questionable Consent (autonomy, capacity) 134
8.3 Whose Life Is It Anyway? (autonomy, capacity, withdrawal of
care, SDM) 140
8.4 An Odiferous Condition (autonomy, capacity, consent) 142
9.1 No Surgery Wanted (autonomy, beneficence, consent) 152
9.2 A Rush of Blood to the Head (autonomy, beneficence, consent) 154
9.3 Is There a Doctor in the House? (beneficence, professionalism) 157
x ✦ Cases

9.4 No Fools Allowed (autonomy, beneficence) 160

9.5 An Acceptable Request? (autonomy, beneficence, consent,
capacity) 162
9.6 The Pillow Angel (autonomy, beneficence, consent,
capacity, minor) 171
10.1 An Unexpected Death (beneficence, professionalism) 175
10.2 Show a Little Respect! (professionalism) 179
10.3 Who’s Helping Whom? (professionalism, conflict of interest,
boundaries) 182
10.4 Supping with the Devil (professionalism, conflict of interest) 183
10.5 Drug Redux (professionalism, conflict of interest) 185
10.6 An Uncomfortable Revelation (professionalism, boundaries) 188
10.7 Too Far from Away (professionalism, boundaries) 189
10.8 An Unfair Rating (professionalism) 191
11.1 To Friend or Not to Friend (professionalism, boundaries) 197
11.2 More Than Just a Friend (professionalism, boundaries,
confidentiality) 200
11.3 My Personal Life Is My Business! (professionalism, boundaries,
privacy) 201
11.4 A Google Dilemma (professionalism, boundaries, privacy) 204
11.5 Whose Wound Is It Anyway? (professionalism, boundaries, privacy) 206
11.6 A Soldier’s Story (professionalism, confidentiality, privacy) 209
12.1 “I’m Just So Tired!” (medical error, truthtelling) 214
12.2 A Lapse in Care (medical error, truthtelling) 219
12.3 The Newfoundland Breast Hormone Assay Inquiry (medical error,
truthtelling) 225
13.1 Time Well Spent? (justice, beneficence) 230
13.2 Misfortune Begetting Injustice (justice, advocacy) 232
13.3 Should He Wait or Should He Go? (justice, resource allocation,
beneficence) 237
13.4 Terms of Entitlement (justice, resource allocation, autonomy) 240
13.5 A Transplant Tourist (justice, resource allocation, beneficence) 249
14.1 A Trivial Matter? (reproductive, abortion, autonomy) 254
14.2 A Right to Be Tested? (reproductive, abortion, professionalism) 255
14.3 Whose Baby Is It Anyway? (reproductive, beneficence) 270
14.4 The Saviour Child (reproductive, minors, genetics) 273
15.1 The Story of Nancy B (autonomy, end of life, withdrawal/withholding) 277
15.2 No Crap, No CPR (autonomy, end of life, withdrawal/withholding) 280
15.3 Don’t Leave Home without It! (autonomy, end of life, withdrawal/
withholding) 282
15.4 “She’s Not Dying!” (autonomy, end of life, withdrawal/withholding) 284
16.1 An End Foretold (MAID, autonomy) 297
16.2 A Minor Problem (MAID, minor, autonomy) 305
16.3 Advance Notice (MAID, autonomy) 307
16.4 A Depressing Condition (MAID, autonomy) 310
 Cases ✦ xi

16.5 A Conscientious Objection (MAID, autonomy, professionalism) 314

17.1 A CRISPR View (consent, genetics) 319
17.2 All in the Family? (genetics, consent) 323
17.3 A Cultural Gap (culture) 327
17.4 A Dispute over Death (culture, end of life, withdrawal/withholding) 333
17.5 A Wound Too Terrible (culture, end of life, withdrawal/withholding) 335
18.1 A Reversal of Fortune (research ethics) 341
18.2 Poles Apart (research ethics) 344
18.3 An Unexpected Association (research ethics, genetics) 347
18.4 Are You Coming Home Soon, Dad? (research ethics, privacy) 353
18.5 An Unfair Trial (research ethics, justice) 354
Preface
The future ain’t what it used to be.
Colloquialism, but attributed to New York Yankees’
catcher and manager Yogi Berra 1

Why is there a need for a new edition of a textbook on ethics? Isn’t ethics con-
stant and enduring? The answer to this is, simply, no. Our attitudes to numerous
practices common in the past—such as slavery, racism, the sexual harassment of
women, 100-hour work weeks for medical interns, discrimination against gay and
transgender people, the untreated suffering of the terminally ill—have changed
dramatically 2.
In the 20 years since the first edition of Doing Right, medical ethics has con-
tinued to change and many questionable practices have withered away 3. This book
is intended to contribute in a small way to the ongoing evolution towards more
ethical medical practice.
Doing Right has been updated to include recent developments in bioethics and
jurisprudence. It represents the most comprehensive revision of the book to date.
In addition to new chapters on topics such as assisted dying and social media,
there have been substantial revisions made to other chapters as well.
All who work in healthcare must face difficult ethical issues, so we have in-
cluded cases affecting not only physicians but also other healthcare professionals
such as nurse practitioners, nurses, social workers, and trainees. Interprofessional
practice has become the new norm for healthcare. With that in mind, this text
has been written from the perspective of the well-intentioned healthcare profes-
sional, the good clinician, regardless of their focus. Although different healthcare
professionals will have different degrees of agency and responsibility for handling
dilemmas in clinical practice, the “right way” of doing so should reflect a common
professional point of view, as seen from those with an abiding commitment to the
healing enterprise. This is best arrived at by consensus and through critical inter-
professional discussion.
When a troublesome issue must be addressed, consider following three simple
steps:

• Look to the wisdom of others. Don’t try to make hard decisions alone.
• Be humble and admit you don’t know when you don’t know. Consider your
limitations and be open about them. No one can do or know everything.
• Turn to your best resource, the patient beside you. They may know more
than you realize.
 Preface ✦ xiii

Remember that medicine, although a difficult enterprise, need not be a lonely one.
Dialogue and progress in ethical matters, as in medicine and society gener-
ally, may not require a common language. However, they do require allegiance to
the core and pre-eminent values requisite for all professions: a respect for human
dignity and a dedication to critical thought. Thus, the work to abolish—within
and across cultures—human bondage, female degradation, and child labour, as
well as the achievement of medical milestones, such as the eradication of smallpox
and soon polio and other viral plagues, are definitive indicators of progress. They
also result from recognition of our shared humanity and our ability to change.
This book will explore the commitment to these values and their implications for
medicine and society.
Ethics taps into the human penchant for regulation to transform and in-
creasingly moralize aspects of social life, such as healthcare. “Ethical rules are
‘­advantage-reducing’ rules” 4, claims the less powerful can make against those with
more authority. They can reduce unfair advantages of the more powerful. At the
same time, they can enhance the position of the less well-situated, such as patients
and the public generally, giving voice to those heard less often and speaking truth
to power.
Ethical rules are well suited to challenging existing hierarchical or authori-
tarian systems. Rules and attitudes of showing respect for others, seeking consent,
abiding by confidentiality, and being honest attempt to level out what is an uneven
playing field. Together, ethics and the new information technologies, with their
emphasis on patient self-determination, transcend the secretive and paternalistic
Hippocratic ethos. They also give rise to new expectations of healthcare when the
old institutions are revealed to be inadequate to the tasks at hand. The point is
not to build an exceptionless ethical system—all ethical systems have fault lines
and limitations—but to better understand and more fully respond to the new and
emerging capacities made possible by healthcare. Advances in ethics, as in medi-
cine, are achieved by seeing the miscalculations and errors in our ways.
A final word about words. We shy away from thinking of “patients” as “con-
sumers,” “customers,” or “clients” of healthcare and instead think of them as
“partners” or “participants” in care. In our view, these “p-words” better capture
what healthcare is all about. Those we serve and try to help are unwell and vul-
nerable. They deserve protection as well as promotion. When travelling through
the unfamiliar country of illness, people do not want or need to feel boondoggled
and cajoled as if in a commercial marketplace. On the contrary, they need to feel
respected, cared for, and heard, not treated as a commodity.
Finally, morality is used interchangeably with ethics, although many would
use morality to refer to the local custom and ethos and ethics to refer to the critical
reflection on diverse practices. Medicine is used interchangeably with healthcare,
although the latter implies a broader scope of care.
xiv ✦ Preface

Acknowledgements
Unlike the previous editions, the fourth edition of Doing Right is the result of
a rich and fruitful collaboration between the original author (PCH) and Wayne
Rosen, a surgeon based at the University of Calgary. Both of us had our starts in
Philosophy at Queen’s University, clearly a department with a propensity for turn-
ing out medically minded philosophers (or philosophically minded physicians)!
Philip would like to express his gratitude to Wayne for his wisdom, hard work,
and patience. This edition would never have been completed without him. Wayne
would similarly like to express his gratitude to Philip. It has been an honour to
work with him on this project.
We both would like to express our extra special thanks to our editors at OUP
(Canada) and to Nancy Carroll of WordReach whose excellent editing hands
helped us navigate treacherous waters.
Insightful feedback and help came from a tremendous number of know-
ledgeable and supportive family, friends, colleagues, and students who read and
commented on portions of Doing Right. Thanks must go to Erika Abner, Pris-
cilla Alderson, Lisa Alexander, Peter Allatt, Sharone Bar-David, Cécile Bensimon,
Lenny Berlin, Carrie Bernard, Anne Berndl, Wendell Block, Ivy Cheng, Sara
Cohen, Eoin Connolly, Kristine Connidis, Chip Doig, Neda Ghiam, Rocco Gerace,
Mona Gupta, Janice Hébert, Paul Hébert, Jonathan Hellmann, Yiwei Hu, Ian
Jarvie, Hanna Jones-Eriksson, Kelly Jordan, Michael Kaufman, John Kingdom,
Eva Knifed, Peter Landstreet, Winnie Lem, Mary Rose MacDonald, Maria Mc-
Donald, Martin McKneally, Chryssa McAlister, Sue MacRae, Cliodhna McMul-
lin, Eric Meyer, Brian Murray, David Naimark, Florin Padeanu, Kathy Pritchard,
Daryl Pullman, Melanie Randall, Deb Selby, Norman Siebrasse, Laura Sky, Gavin
Smith, Robert Storey, Frank Wagner, Dick Wells, Shawn Winsor, Hilary Young,
and Rhonda Zwingerman. The errors and limitations of this book remain ours.
Wayne would like to also express his sincere appreciation to a number of
people at the University of Calgary who made his work on this project possible.
Sean Grondin and Elijah Dixon of the Department of Surgery supported and en-
abled a somewhat atypical sabbatical for a surgeon. Ron Bridges and the Univer-
sity of Calgary Medical Group provided much-appreciated financial support for
Wayne’s sabbatical. Wayne could also not have carried out this work without the
generous support of his surgical colleagues at the Peter Lougheed Centre in Cal-
gary, who took care of his patients and picked up the extra work while he was away.
It is a privilege to work with this special group of surgeons.
Not surprisingly, the biggest debts of gratitude we owe are to our spouses—
Victoria (herself a tireless editor and fierce grammarian) and Laurie—and to our
children—Neil and Raven, Ben and Sam. You have instructed us in more ways
than you can know and we can count. To paraphrase Marx, the educators must
themselves be educated 1, and we have been re-educated by your welcome critical
 Preface ✦ xv

reflections and by your lessons from life. This has been not just an education of the
intellect, but also an education of our emotions—or our “sentiments,” as they were
once known 2. Without your unwavering support, forbearance, and suggestions,
this edition of Doing Right would not have been possible. We are indeed blessed
and fortunate to have you in our lives.
Philip C. Hébert, MD, PhD, FCFPC

Professor Emeritus
Department of Family and Community Medicine
University of Toronto
Toronto, Ontario, Canada
philip.hebert@sunnybrook.ca

Wayne Rosen, MD, MSc, FRCS(C)

Clinical Assistant Professor

Department of Surgery
University of Calgary
Calgary, Alberta, Canada
wrosen@ucalgary.ca

Winter 2019
Introduction
A Revolution in Learning

You talk and I’ll listen.

Inscription on a park bench, 2017

A new medical curriculum

Beside a peaceful pond in San Francisco’s Golden Gate Botanical Garden can be
found a bench with the following inscription: “You talk and I’ll listen.” Although
it’s not entirely clear what this really means, two doctors had dedicated it, so we’d
like to think it was meant for patients and doctors together: You [the patient] talk
and I [the doctor] will listen.
This is the starting point for the new journey any healthcare professional is
expected to take with patients. It begins with making the effort to understand the
patient’s world, an important instruction, given the number of studies suggesting
how time-constrained modern physicians are. At the bedside and in the office,
patients are given as little as 12 seconds to tell their story before physicians start
interrupting them 1. And then they keep on interrupting them . . . . No wonder
patients often feel they can’t get a word in edgewise (with the physician, anyway).
Traditionally, communication with nurses and other healthcare professionals has,
by contrast, been considered superior, but this may be changing—and not for the
better. Nurses too can be swamped with charting and computer work that can
erode their time with patients 2.
Our hurriedness undoubtedly contributes not only to the epidemic of error
but also to the dissatisfaction with modern medical care on the part of patients
and practitioners. (Of this, more later; see Chapter 10.) A partial remedy to this
problem has been suggested by one family doctor: “If there is one thing to learn, to
do really well as a physician, it is to listen. In the midst of the intensity of medicine,
the crises, the sadness and the everyday, and the wall of computer screens, always
listen to your patient. The patient will give you a better history if they see you are
listening” 3.
Good healthcare professionals have always known they need to learn a lot
more about their patients and their circumstances—their hopes, fears, dreams,
and nightmares—in order to most effectively help them. What has changed in
medical education is the more explicit emphasis on encouraging our ability to
elicit and respond to unique patient factors. In the midst of the hustle and bustle
of modern medical life, there is much to be said for paying attention—as well as
for self-reflection and for critical thought.
4 ✦ Doing Right

[to them] has increased worldwide over the past few decades.” 6 Therapies in
medicine, as we shall see in future chapters, all come at some cost to the wider
community.
Another important feature of this case is Mr M’s criticism of your expertise as
a clinician. The patient may have viewed you as uncaring, which does not augur
well for a therapeutic alliance. Rather than openly addressing the patient’s criti-
cism, the practitioner might be tempted to write him off as difficult and demand-
ing and ignore what are, from the patient’s perspective, legitimate concerns.

Listening to a patient does require humility and openness. As a general rule,

practitioners should provide only care likely to help their patients. Of course, the line
between helpful and useless care may not always be clear (and can be quite conten-
tious as we will see in this and in future chapters), but the overuse of drugs, especially
antibiotics, is an all too common occurrence in medicine. Each time clinicians give
in to inappropriate demands for tests or treatment, their ethical fibre is weakened,
making it less likely they will act properly in other situations and “hold the line.”
How can you prepare yourself, as a healthcare professional, to provide effective
and appropriate medical care? In considering what should be done, the practitioner
or trainee needs to step back from the situation at hand. A simple reflective exercise
can help you ensure that you have acted properly. Consider the following simple ques-
tions corresponding to the fundamental ethical principles of healthcare (see Box 1.2).

Box 1.2

These core questions correspond to fundamental ethical principles of healthcare:

1. What are the patient’s wishes and values? (Autonomy)

2. What can be done for the patient? What are the harms and benefits
of the options? (Beneficence/Nonmaleficence)
3. Is the patient being treated fairly? Given the competing claims of
others, how can the needs of all be best satisfied? (Justice)

Reflecting on ethics goes back thousands of years, but the most influential
modern theorizing about ethics began in the 1960s, the era of modern trans-
formative medicine. A number of high-level reports from American Presidential
Another random document with
no related content on Scribd:
 »Joutavia! Se oli mahdotonta. Sitäpaitsi he olivat Martignyn
vaikutuksen alaisina, ja luullakseni hän pystyi mihin rikokseen
hyvänsä.»

»Ehkä hän ajatteli, että satatuhatta olisi vain ensimmäinen suoritus

hänelle. Neiti Holladayn ollessa hänen vallassaan hän olisi kyllä
voinut toivoa saavansa lisää loppumattomiin. Ilman häntä —»

»Mitä ilman häntä?»

»No, juoni kehittyy ja kehittyy kuta enemmän sitä ajatellaan.

Luulen sen kehittyneen silläkin aikaa, kun hän oli sitä
toteuttamaisillaan. En epäile, etteikö se lopuksi olisi kehittynyt niinkin
pitkälle, että hän olisi ottanut neiti Holladayn jollakin salaperäisellä
tavalla hengiltä ja sitten olisi antanut hänen sisarensa asettua sijalle.
Kukapa olisi saanut petoksesta selvän heidän oltuaan pari vuotta
ulkomailla? Ja sitten — niin, sitten olisi neiti Holladayn sisar voinut
mennä naimisiin Fajallensa kanssa jälleen ja ruveta lepäämään
rikkaudestaan nauttien. Ja Fajallesta olisi tullut huomattu mies —
hyvin huomattu mies. Hän olisi kohonnut ja kohonnut — korkealle.»

Seuralaiseni nyökäytti päätänsä.

»Touche!» huudahti hän.

Kumarsin kiitokseksi; tahdoin näet oppia ranskankieltä niin

sukkelaan kuin asianhaarat sallivat.

»Frances ei kai nähnyt enää äitiänsä eikä sisartansa?»

»Ei, hän halusi mieluimmin päästä heistä.»

»Entä rahat?»
 »Ne jätettiin arkkuun. Lähetin avaimen takaisin. Hän halusi niin.
Olihan äiti joka tapauksessa hänen äitinsä.»

»Tietysti; ehkäpä hän ei pohjaltaan ollut niinkään paha.»

»Sitä hän ei ollut», sanoin minä varmasti. »Mutta Martigny —»

»Oli nero. Melkein pahoittelen, että hän on kuollut.»

»Minusta on se enemmän kuin paha, se on vähentänyt elämäni

harrastuksia yhdellä.»

Olimme tulleet Austerlitzin sillalle ja pysähdyimme siinä

tahtomattamme. Allamme virtasi joki siltoineen, laivoineen, joiden
väki oli laitureilla; edessämme olevan kuvan keskellä kaukana
kohosi kirkon torni, ja kaiken tämän ylitse levisi lämmin kesäkuun
aurinko. Nojauduimme kaidetta vasten ja katselimme kaikkea sitä
ihanuutta.

»Ja nyt on arvoitus ratkaistu», sanoi hän, »ja prinssi ja prinsessa

ovat naimisissa, aivankuin saduissa, joita kuulimme
lapsuudessamme. Se on hyvä loppu.»

»Kaikkiin tarinoihin», lisäsin minä.

Hän käänsi päätänsä ja katsoi kysyvästi minuun.

»On olemassa muitakin tarinoita», selitin. »Heidän tarinansa ei ole

ainoa.»

»Eikö?»

Pariisin henki — taikka ehkä se oli kesäkuun auringonpaiste — oli

mennyt vereeni, joka virtasi yhä nopeammassa tahdissa eikä ottanut
tyyntyäkseen.

»Ei, varmasti ei! Esimerkiksi toinen voisi olla se, jossa te ja minä
olisimme päähenkilöt.»

En uskaltanut katsoa häneen; voin vain tuijottaa eteeni veteen.

Hän ei liikahtanut. Muutamia silmänräpäyksiä kului.

»Se on mahdollisuus», sanoin epätoivoisena. »Mutta on olemassa

syvä juopa mahdollisen ja todellisen välillä.»

Ei mitään merkkiä vielä; olin saattanut hänet tyytymättömäksi —

minun olisi pitänyt ymmärtää se!

Mutta sittenkin rohkaisin mieleni ja loin häneen salaisen

silmäyksen.

Hän seisoi katsoen alas veteen; hymy leikki hänen huulillaan, ja

hänen silmissänsä oli tavaton loiste.

»Ei aina», kuiskasi hän. »Ei aina!»

 *** END OF THE PROJECT GUTENBERG EBOOK HOLLADAYN
JUTTU ***

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