Ethics and neurosurgery

Abstract

If you were to scan the critiques of modern medicine offered by various thinkers, you would glean their despair over the declining societal consciousness. This concert of painful perspective is a pointer to the overall decline in social and medical ethics, neurosurgery not excluded. This piece is an attempt at keeping the gentle flame of neurosurgical ethics burning steady and bright, against the cyclonic winds of crass commercialism. Ethics, as a word, has had a chequered career. English lexicons trace it to the Sanskrit word Swadha, which briefly connotes a sense of self-respect that as a mere custom denies you the right to do anything wrong, even when not policed or monitored. It is an inner conviction about what is proper and philanthropic, a conviction sustained in action under pressure. Ethics cannot be taught, much less available in coaching classes. At best, Ethics can be imbibed along the lines of Thomas de Kempis’ ‘The imitation of Christ’. This necessitates that we have amidst us neurosurgical role models of integrity, of character; that the students may take as a role model. All told, Ethics is one’s innate being, one’s weltanschauung. The peon of the President, Prime minister or the Principal may be more ethical than the boss. To that extent, to be ethical, is to be ready to walk, as the Kathopnishad says, on the razor’s edge. Could Buddha, Swami Vivekananda eulogizes him as the Light of Asia be the Presiding Diety of Neurosurgery? Neurosurgery is privileged to handle the most evolved among cells, namely the neurons, the repository of buddhi, chaitanya or cosmic consciousness, and capable of perceiving and expressing the same. Neurosurgery thus could choose to go the way of Lord Buddha, and follow an Eightfold path pithily presented below. Firstly: Primum, non nocere. ‘Above all, do no harm’. The fact that Hippocrates had had to enunciate this as the leading ethical code 4 millenia earlier implies that all therapies are inherently pregnant with iatrogeny. Arthur Bloomfield after an iatrogenic tragedy pleaded that every hospital should have a plaque in the physicians’ and students’ entrances stating: ‘There are some patients whom we cannot help; there are none whom we cannot harm’. Neurosurgery has the magical touch of restoring the might to the paralysed. Equally, the opposite can as well happen. What is powerful for good, can be potent for evil. Secondly: Quieta non movere, meaning Don’t fix it if it ain’t broke. Perfect ease is compatible with the grossest, manifest pathology, the 1000 tumors in a person with von Recklinghausen’s being but an example. Hoerr’s Law frankly declares: ‘It is impossible to make an asymptomatic person feel better’. The corollary is that, should you yet interfere, you can surely make the person feel worse. In an age of preemptive strikes, modern medicine has not lagged behind, and has spawned its 5-star check-up clinics the world over. This multistarred place can be magical in the sense that a person may walk in, and a patient may walk out; a tragic-comedy enacted because of the medical obsession with some abnormality/ ties detected in a person fully at ease. It was the Lasker-awardee Rustom Jal Vakil who bemoanded that the ECG machine may have done more harm than the atom bomb, a lament loudly echoed by Harrison of the Harrison’s Principles of Internal Medicine fame. The state-of-the-art imaging techniques – MRI of the spine for example – are equally pregnant with the havoc they can wreak by misleading a technocrat into justifying an unwarranted adventure, albeit, at the expense of the patient. Distorted body geography sans disturbed history is the surest recipe for grave iatrogeny. We need to appreciate that an investigation no matter how sophisticated is rooted in vestige, meaning a trace, a footprint. Surgery under such circumstances is rank subjectivism of the operator wherein the only objectivism is the price that the patient must pay. Trust a person’s own body, when you cannot trust an abnormality that you may encounter on investigation. Thirdly: Eric Ericsson felt that the Golden rule of practical medical ethics can be borrowed from Talmud; Do what you ­ capital YOU would be done by, and not do what you would choose not to be done by. Walter Alvarez, the pioneer gastrointestinal surgeon at the Mayo Clinic observed in his autobiography The Incurable Physician that, whereas everyday patients young and old were ‘curatively’ treated by gastrectomy and vagotomy, not one of the physician