Medical Ethics And The Blurred Boundaries Of 'Do No Harm'

I feel in over my head.

I am sitting at a table in a conference room of the Countway Library of Harvard Medical School, with an esteemed and brilliant ethicist to my immediate left, a man I know to be a strong proponent of assisted dying in Massachusetts, and to my right a woman who is both physician and Catholic nun.

The lunchtime educational session is presented by the Harvard Ethics Leadership Group, and before beginning the case presentation, they go around the room for introductions. The names come with titles: intensive care doctors and nurses, ethicists, clergy, palliative care specialists, social workers, hospital department heads. A co-chair of the Massachusetts Expert Panel on End of Life Care introduces himself. The honorifics build on one other like a wave.

The doctor/nun introduces herself, then turns to me. "I'm Paul McLean," I say. Instead of "I so do not belong here," I add, "of Community Voices in Medical Ethics."

The physician's anguish as she relives the story, before a crowded conference room, is hard to watch and impossible to look away from.

And then the esteemed ethicist introduces himself and seems not to notice how red I’ve become, or to question my place at the table.

There is a limit to what a medical professional knows. There is professional interest in what a diverse community believes. Community Voices, my organization, exists in that space.

We came to hear a story. I like stories. Sometimes I write them. Today's story is true, told without names, about a young woman dying of a cancer and making choices that test the bounds of autonomous choice and "do no harm."

The dying mother, in merciless agony, is not telling her children what is transpiring. They are too young to understand and see her like this, she insists, and keeps them at a distance with her shell-shocked husband’s dutiful help. And so two young girls' mother will die, and they will hear about this and attend the funeral and somehow cope with it over time and maybe grow up to be mothers themselves, but they will not be with their own mother as she is dying or even know what is taking place. They will be kept away from the harsh truth of mortality, ostensibly "for their own good."

Dad will have some explaining to do. Hopefully, he’ll listen, too. Perhaps parents might also take an oath to "do no harm."

The story is told by an extended care team, but most central is the attending physician. In caring for the dying woman, this doctor is tasked with determining the right dose of pain-killing medicine. The doctor is a mother herself. And though she doesn't go into detail, religious beliefs shape her personal values. The doctor knows quite precisely the dose that will alleviate her patient's agony, and knows that this amount also is likely to induce apnea. That is, it will challenge the breathing of a patient whose breaths already are numbered, perhaps to the point of hastening her death.

The dose will effectively treat the pain, and the physician dearly wishes to help her patient in this way. That the dose also might also take a mother from her children sooner than the disease would have strains the physician's own moral and ethical code.

A priest has helped the patient find a measure of peace with her wish to sufficiently treat her pain and the potential unintended consequences of that choice, what is known as the "double effect." This is of some solace to the physician, as well. But what about the children? What are the physician's obligations to them?

The physician's anguish as she relives the story, before a crowded conference room, is hard to watch and impossible to look away from. It is an act of such courage and generosity.

As is typical of these lunchtime educational sessions, an expert analyst has studied this case beforehand, hears the story retold and the questions asked and answered, and then offers perspective. The dialogue around the room is powerful. And though it is clear throughout the story who is the patient, my sense of the physician’s responsibilities, and to whom, have blurred.

Something ancient and ritualistic took place. Something sacred. I felt witness to absolution.

The analysis, by a physician-ethicist, is sensitive, understanding, compassionate and deeply human. It is ambiguous in places, but also wise, enlightening and considerate of medical, moral and ethical codes. This is what I have come to hear. This is what I have expected.

What I did not expect, and will never forget, was the physician-ethicist's deft touch, in a room full of medical intellectuals and modern opinions, in treating the attending physician's unresolved grief. Something ancient and ritualistic took place. Something sacred. I felt witness to absolution.

I would expect this in a sanctuary. I did not expect it in a conference room of a library at Harvard Medical School. Then again, it hadn't occurred to me before that day that both physician and nun might exist within the same person.

I left wondering what came of the children.

Related: