TY - JOUR
AU - Nelson, Nicholas M.
AB - Imagine you are a physician, distraught over the paths that your profession and the "clients" you serve have been channeled into for some time, and you come across the following: It feels a little dirty to be participating in the malpractice system at all since I don't like the system, think the world would be better off without it, see the lawyers as parasites, and saw myself, then, as a parasite on a parasite. And, further, this: "Until quite recently it was widely inferred that it was the doctor's moral obligation to decide what was best for the patient." You might well conclude that you had found an empathetic landsman, a true mensch. Ah, but what about this: " . . . the jury system . . . functions more like a lottery in many ways than like a mechanism for justice or for quality assurance." And this: If my testimony [for the medical defendant] is less compelling than that of the ethicist testifying for the other side, maybe their baby will get new shoes. Or this: "If the babies die, they usually don't sue." With the arresting summation: "Faith in the procedural fairness of this system helps ameliorate our shame at the rampant inequality that is all around us." You might now conclude that you had stumbled upon a thinking and feeling liberal (the rarest kind!), and, quite possibly, you have. But what you have really discovered is The Lazarus Case: Life-and-Death Issues in Neonatal Intensive Care by John D. Lantos, MD. Lantos is a generalist who is thoroughly conversant with modern neonatology and is evidently aware that this newest and largest of pediatric subspecialties is still just general pediatrics (albeit with a lot of superficial technical chrome for a remarkably constrained age group), for he currently serves as Section Chief of General Pediatrics at the University of Chicago, Chicago, Ill. And he has read widely, thought deeply, and written felicitously about the history and future of many and most of the ethical issues that (should) concern us—his bibliography alone is worth the price of the book. Neonatology has surely progressed from the days (circa 1950) when the supervision of academic nurseries was usually assigned to the most junior faculty member for attention during the lunch hour or between outpatient assignments. But now, The money that flows through NICUs [neonatal intensive care units] is, after all, the rushing river that feeds the little spring that nourishes the growth of the medical malpractice cases. Lantos traces how all this has come to pass by inventing a malpractice case that is a composite of many of his own experiences. His vehicle is a pretrial "discovery" deposition in which he is an "expert" witness in the defense of a physician who has made the decision not to pursue the aggressive delivery-room resuscitation of a 25-week (gestational age) infant. The infant, a double-footling–breech presentation and premature (a triple whammy!), goes on to resuscitate himself after a significant nonbreathing delay and thereafter suffers the usual array of postnatal disasters so frequent in these tiny "survivals." The previously cooperative parents (who owed the hospital $1 million) sue (for $35 million, after a delay of 3 years) because of the absence of resuscitative effort as physician punishment for their unfortunate outcome. They hire a lawyer who is a retired physician and clearly a worthy adversary for Lantos: "Can studying philosophy tell you whether what a doctor does in a particular case is right or wrong?" Most of the book comprises their colloquy during the deposition, with frequent lengthy and insightful asides in which Lantos sets forth the philosophical history and ethical examination of the issues presented. They're all here—informed consent (and refusal), codes of ethics, illness severity scores, chronic disease, quality of life, living wills with advanced directives and organ transplants, and so on. About informed consent: [Informed consent] is probably the most revolutionary, the most rudimentary, the most misunderstood and misused term in all of health law and bioethics. About futile treatment: . . . overtreatment by doctors of patients who do not want to be treated versus insistence by patients that their doctors provide them with futile treatment. About brain death: These were cases in which the dream of mechanical medicine became the nightmare of humanistic medicine, in which the machines were so effective that they began to do evil, in which an excess of reason led to ultimate irrationalities. And standards of care: He and I were doing more to define the standard of care for neonatal resuscitation than all the neonatologists in practice in the world, or all the consensus panels, or all the scientific studies. If he could get a $35 000 000 settlement for his tiny client, then the standard of care would certainly move toward mandatory resuscitation for all the 25-week babies whether or not the scientific evidence supported it, experts endorsed it, or doctors in active practice thought it was medically or ethically appropriate. Pace, silicone breast implant makers! Woven into and among these issues is an insightful commentary on "expert" opinions, tort litigation, and the wisdom of the jury system. Lantos even offers empathy for a lawyer's love of the law: "We settle most cases eventually and never get to make those ringing closing arguments to the jury." Lantos is clearly the product of a liberal education who frequently uses fiction (Dostoevsky is a favorite) to illustrate concepts of law, philosophy, and ethics. He is writing here for both a lay and professional readership. He struggles with the lawsuit as a public morality play, wherein legal standards are applied to medical and ethical judgments and where "In many cases juries are more moved by bad outcomes, even if they did not result from negligence, than by bad practice itself" in a setting where " . . . neonatal technology had outpaced the law and . . . the law needed to be changed." He laments the opinions of courts that have been thus outdistanced by reality: "It was that the decision about whether to continue or stop treatment was not made by the properly empowered moral authority." The Lazarus Case is a trifle pontifical and significantly autobiographical. Lantos' checkered past includes a tour with the National Health Service Corps among the countercultural ex-hippies of Appalachia, West Virginia. At one point he soliloquizes that his career in academic pediatrics has stalled, and he wonders whether he'll ever make it as a division chief. Should Chicago ever confirm that worry, I would encourage him to quit academics and write full-time. Editor's Note I wholly support Dr Nelson's opinion. The content and writing quality make this an extraordinary book. It should be obligatory reading for all who enter the field of pediatrics.—Abraham Bergman, MD
TI - The Lazarus Case: Life-and-Death Issues in Neonatal Intensive Care
JF - Archives of Pediatrics & Adolescent Medicine
DO - 10.1001/archpedi.156.9.948
DA - 2002-09-01
UR - https://www.deepdyve.com/lp/american-medical-association/the-lazarus-case-life-and-death-issues-in-neonatal-intensive-care-4fCODgUHSO
SP - 948
EP - 949
VL - 156
IS - 9
DP - DeepDyve
ER -