Arquivos Brasileiros de Cardiologia - Volume 85, Nº 4, October 2005

Point of ViewPoint of ViewPoint of ViewPoint of ViewPoint of ViewPoint of View

Mailing Address: Max Grinberg – InCor • Av. Dr. Enéas de Carvalho Aguiar, 44 – 05403-000 – São Paulo, SP - Brazil

E-mail: max.grinberg@incor.usp.br Received on 01/26/05 • Accepted on 04/29/05

I Forbid, Therefore I Assist

Max GrinbergInstituto do Coração do Hospital das Clínicas – FMUSP - São Paulo, SP - Brazil

“We forbid in the present to keep hopes in the future”

Benefit without malefaction, an ideal in Medicine; non-maleficence more than beneficence, a bioethical realityin physician’s daily routine1-3.

It has been a long time since Hippocrates (460 B.C. -377 B.C.) left us the message, “... do not harm the patient…” It has become a symbol of medical ethics and, havingbeen sent from generation to generation, it has acquireda status of bioethics principle4. It is a piece of advice onresponsibilities and a strategy of safety.

Every process of medical science requires being carefulagainst retrocession in humanization. Negligence towardssociable and more humane caring for is also a way ofiatrogenesis.

For the non-maleficence principle, the physician mustabstain from causing an intentional damage5-7; theintention to safeguard from iatrogenesis, a sworn-in dutyat graduation, is carried out by the bed under some ways:do not start the evidently harmful (including class 3procedures), to avoid whatever is doubtful and that ismore like class 2b than class 2a (absence of beneficence),and do not insist before a bad outcome, despite beingclass 1 procedure (non-maleficence having priority overbeneficence).

By acting exactly the same as a superego, non-maleficence is an ethics filter to select and keep thosewith a probability of being punished based on Article 29of Medical Ethics Code as an act of imprudence. Avoidingapplying what most colleagues would not do is notnecessarily non-maleficence, but highly majority, it is theconcept that has taught us since College. It is basic inmedical guideline conception.

Non-maleficence discourages the raptures of creativityaside ethical principles, evidences through researches andcommon sense. Thus, it is an alert so the wings of Hermescaduceus are not used when there is the temptation forcertain flights “aside scientific.” Curiously, the lesser theyare used, the more ethic miles are accumulated.

Non-maleficence practice scenario uses to have twoenvironments: the circumstantial and the required.

In the first one there is the encounter of the patientand his/her clinical situation with an ethic profile, honesty,secrecy and efficiency from the physician. Unfortunate

conjunctures happen and make Medicine Ethic Councilsto apply warnings and censure.

In the second environment, the adaptations ofbehaviors after selection of understandings and abilitiesare carried out; adjustments take place based on eitherconvictions on distinction between necessary (amputateand gangrened limb) and unnecessary (opt for a clearlyallergenic medication in the history of that patient) evil,or in socioeconomic conveniences of that physician-patientrelationship. Primum non nocere kidneys under acutefailure, without using radiological contrast; the stomachjust ill-taken by a medicamentous gastritis, suspendinganti-inflammatory drug; operative field interrupting theuse of medication that has been preventing from athromboembolism. Bioprosthesis shall be preferable tometallic one that cannot be protected due to personaland infrastructure conditions for a good lengthenedanticoagulation control.

In the name of clinical prudence, it is avoided “pushing”the patient in a slippery slope8,9, by recommendingrestrictions; they sound as anti-negligence. In fact, partof them seems as not outline precious limits of realusefulness; sometimes, it is the memory of anunsuccessful case that provides sufficient “practical base”for the physician, so he/she does not want risk a repetition.

So, restrictions give rise to reflections on justifiedpaternalism. In general they are abstentions of habits bythe patient, just as minimizing any opportunities of a riskbecoming an event. They use to be objectively verbalized,without much consideration and with occasional socialdamages to the patient. Privilege with clinical evolution,with patient’s life and opinion from relatives is a classicbehavior, but surely subjected to conflicts with thedefinition of damage in the New Dictionary of MedicalEthics: nothing is harmful unless it is felt as bad for whosuffers, meaning that damage is a subjective concept.

Prohibitions are justified for the attention from thephysician with the chance, the unknown and uncertainties,which are three ghosts haunting professional practice. Wewould say that not doing is a way of knowing how toexperience a difficult stage intending the pleasure, obviouslynot the one of the moment, but that of a risk-free future.The patient who, after all, agrees that the sacrifice wasworthy, thus gratifies the physician, but we should not

Arquivos Brasileiros de Cardiologia - Volume 85, Nº 4, October 2005

I FORBID, THEREFORE I ASSIST

forget that there was no control group, nor the patient wascontrol of himself/herself. Depriving himself/herself fromsomething customary can, nevertheless, be understood bythe patient as more harmful than delaying the cure. Thereare patients seized with influenza who are compliant andthose who are disobedient with recommended rest, wishingto remind us on motivation plurality that permeates theexercise of autonomy.

So, the daily routine of a physician witnessesresignations: the one connected to the own denialto imprudence, in favor of non-maleficence, and theone connected to patient’s behaviors, in terms ofanti-negligence.

“Don’t run, don’t eat, don’t travel, don’t work, don’tplay, don’t stress” are used to being recommended, whensafe elements for a proactive procedure are not availableyet. It is the guidance for the moment, labeled as “ofcommon sense”, related to a dedication – perhaps aneuphemism for excess of authority or even egocentrismin some occasions – with the “in the view of the doubt.”It is a “just for a while” procedure.

Such modality of caution towards supposed eventunleashing agents through the combination of clinicalcircumstance with patient’s life’s peculiarities, has apresumed primum non nocere the heart as an example:when it is included in the list of organs suspected fromcausing thoracic pain, it is not advisable to ask for it ina physical activity other than propaedeutical, untiletiopathogenic clarifying. The intention for zero risk-event would fit in the “... do not harm the (organ ofthe) patient...”

The French philosopher René Descartes (1596-1650)got to the conclusion that a clear conscience of his thinkingproved his own existence. Aware of the patient’s risk, thephysician proves the reason for his/her existence. Byparaphrasing the famous Cogito, ergo sum, “I think,therefore I am”: I forbid, therefore I assist... the patientto not assist the event.

Prudence due to prohibition

“The cardiologist has a prohibition that bioethics itselfrecognizes”

Prudence ethics that worries about predictableconsequences protects the intention of a zero risk-event.Such dedication is usually practiced for the future,inclusive, with a professional defense component.

Behavior associated to chance assessment arefrequently the Achilles’ heel through which societysubmerges the physician in ethics courts.

Uncertainties on the future determine the prohibition,as one never knows if the one before us is that “only” 1%that will confirm statistics.

The scenery of restrictive behavior is usually a clinicalsituation in which propaedeutical trinity, sound, figures,images, does not give sufficient diagnostic clarity.

Characters interact. The physician plays a usual roleand the patient his/her debut. Remind that the physicianis always involved in additional forces at the value of ajustified prohibition, not only due to the clinical experienceof the “science of uncertainties and art of probabilities”,but also through conditioning to the Medical Ethics Code,in which 112 (77%) from the 145 articles have it isvetoed to the physician as a caput.

Era-procedure

The aphorism of Peter (Summary I) is an era-procedureof era-prohibition-type10,11. It provides a historic dimensionon conflicts, between the patient’s wish and thephysician’s authority. The restrictive procedure representedthe responsibility of the physician in preserving the life ofthe cardiac woman by speaking louder than the instinctfor lineage. Paternalism exerted in terms of the absenceof conciliatory solution of interests.

Since then the extraordinaire improvement of riskof pregnancy-benefit to cardiopathy relationshiphas transformed aphorism into an object of interest ofMedicine. Currently, a mother ’s heart has alwaysfit in Cardiology.

The lesson learnt is: what physicians produce scientificprogress and make beneficence available by means ofcompetent care contributes to make objectives inphysician-patient relationship compatible. It is the greatestachievement of the physician, fruit from his desire inimprove Medicine, as it cannot be forgotten that thephysician makes Medicine and not Medicine that makesthe physician.

Progresses strengthen the principle of autonomy,especially in elective care; conditions are created to foreseebenefits, be committed with the means and honor thedecision made in the presence of mishaps in the way; itis a way to encourage certain hidden competences inwho was brought up under heteronomy.

Paternalism seems to be more present in emergencysituations12, even because the system is usually structuredin heteronomy prevalence.

Every one does the adaptations that may understandas convenient in this bioethical scale betweenpaternalism and autonomy.

Summary I - Peter's Aphorism

Michel Peter lived for 69 years (1824-1893); professor of MedicineCollege of Paris, he won the Capuron Award from Academy ofMedicine of Paris, in 1875, for his observations on cardiopathyand pregnancy. He became and eponym and a symbol of therelationship between paternalism and limitations of Medicine.

“... in practice, with cardiopathy, from the hygiene point ofview, it will be preferable that the woman does not get married;if she does, she should not be a mother; if she got it once ortwice, in case of a well-succeeded birth, she should abstainfrom breastfeeding...”

Arquivos Brasileiros de Cardiologia - Volume 85, Nº 4, October 2005

I FORBID, THEREFORE I ASSIST

Moment-procedure

“The cardiologist does his/her best to look at themoment of the heart to see the future of the patient”

Moment-procedure is the one that would be “just fora while.” It has been applied in the beginning of anobservation period, expectation of usefulness inanticipation to the ideal clinical-laboratorial clarifying, orin the sequence of a treatment, among adaptations.Moment-procedure includes the common sense opinion,the one that reacts through the perception of the icebergtip and expects the refining of diagnosis plurality andadmissible treatment in the submerged part.

Such conformity with the possible may providesecurity to the patient, as a link between his/hercustomariness of health and the awareness that thedisease, in fact, took place.

Moment-procedure is a priority commitment of thephysician with means, but that makes itself sensitive topatient’s expectation for the result, regardless of thenecessary period to compose a specific treatment.Furthermore, it is “eternal as long as it lasts,” in thecondition of temporary with the same ethicalresponsibility as definitive.

Moment-prohibition-type is moment-procedure that,among obscurities, favors zero risk-event. At that point,the intention is to avoid discomforts until death13.

Each moment-prohibition is always a touch inphysician-patient relationship kaleidoscope. It happensdue to the necessary professional sensibility of who willbe the object of restriction. The resulting image “of themoment” determines the modality of the bond: the profilesare either perceived as “doctor, I’ll do whatever you tellme to,” or as “doctor, I cannot take that.”

Moment-prohibition, even for the fact of being far frombeing the “etiopathogenic” solution, is always a test forautonomy practice. As it builds in a diffuse logics, a certaincredit magnitude to pros and cons takes place, whichcan be differently surmised by the patient; there are thosewho dare choosing cons and say, “I’ll only stop havingmy beers if the exams show something” and those whoacquiesce and simply take pros with ellipses of what if...or for the sake of conscience….

Moment-prohibition that was rejected by the patientfor being strict for his/her routine may sound, subsequently,as “he/she did not follow my guidance,” in the view thattends to paternalism, or as “he/she decided to take therisks,” in autonomy’s view.

For that reason, moment-prohibition must represent aphysician-patient consensus, by allying a “paternal”dedication through zero risk-event with a right for freewill. So, the logics of prohibition remains in the field ofethics and, as much as possible, far from the view of ataboo, whose disrespect requires “purification” through ascapegoat…, for example, the physician.

The intention of determine a way that leads to themore or less under consensus objective results in pact.They are bonds that are set after presuppositions ofprohibition having been weighed. Adaptations arefacilitated through good practices of communication.Balance is the harmony of the advised with the wished.

Event at non-compliance

“But the patient wanted it like that, he had the lastword, justifies the doctor, but the relative says right after,“yes, and the last word to you, before dying...”

The physician-patient/family relationship uses to shakewhen the decision from the patient of non-complying withthe prohibition recommended by the physician,materializes in the event that he/she understood assomething that “only happens to the others.”

Clashes of word against word produce verbal splintersand the fragments from letters and syllables jointthemselves in new words and throw back the abuse.Friction between the opportunity the patient has to exerthis/her free will and the inability in being authentic at themoment of the event, results in a kind of wound thatexposes the plurality of human nature11.

In those occasions, the guilty person hunting seasonstarts and one of the weapons listed has the difference oflevel of information between physician and patient asammunition. The sight points at the target of aninefficiency image and the trigger lock is the MedicalEthics Code. When it backfires, the claimer feels as avictim of corporativism. It is part of the game.

Would the assertion that the physician knows moreabout diseases and the patient knows more about thesick person be an equalizer argumentation?

In a view of partnership with symmetry, the modelpatient of the physician who values the principles ofbioethics is the one who enjoys the mission of the advisor-physician and, at the same time, feels well-informed bythe consultant-physician without the feeling of beingsubjugated by impositions by the executor-physician.

The lack of familiarity with the risk run by the“disobedient” would represent a censure to physician’srespect for the right for autonomy exerted by the patient14.The heteronomical thought works as follows: the non-physicians are lay people; patients are non-physicians;therefore patients are lay people. The autonomiccompensation of such syllogism is that people have valuesand responsibilities on the decision.

In a discussion, the concept of lay person and theverbalization of the values adapt in accordance withinterests (Summary II).

Power unevenness allegations are also observed4. Eachphysician sees himself/herself with a level of authority toapply a moment-prohibition before professionalresponsibility; it may represent since keeping the thankfulpatient in a ready medical care to the figuration of being

Arquivos Brasileiros de Cardiologia - Volume 85, Nº 4, October 2005

Summary II

1. Blustein J, Fleischman AR. Urban bioethics: adapting bioethics to theurban context. Acad Med. 2004; 79: 1198-202.

2. Sommerville A. Juggling law, ethics, and intuition: practical answersto awkward questions. J Med Ethics 2003: 29: 281-6.

3. Grinberg M. Conheço & Aplico & Comporto-me. Identidade bioéticado cardiologista. Arq Bras Cardiol 2004; 83: 91-5.

4. Gillon R. Medical ethics: four principles plus attention to scope. BrMed J 1994; 309: 184-8.

5. Beauchamp TL. Methods and principles in biomedical ethics. J MedEthics 2003: 29: 269-74.

6. Rajput V, Bekes CE. Ethical issues in hospital medicine. Med ClinNorth Am. 2002; 86: 869-86.

7. Harris J. Consent and life decisions J Med Ethics 2003; 29: 10-15.

REFERENCES

8. Shivkumar K, N Weiss J. The slippery slope of human ventriculararrhythmias. J Cardiovasc Electrophysiol. 2004; 15: 1364-5.

9. Tvoci P, Pizzuto F, Romeo F. The slippery slope. Eur Heart J. 2004;25: 1480-2.

10. Grinberg M. Epônimos em Cardiologia. Ed Roca, São Paulo, 1999.

11. Grinberg M, Cohen C. Falando com o coração, auscultando a bioética.Rev Soc Cardiol Est São Paulo 2002; 6: 805: 20.

12. Larkin GL, Fowler RL. Essential ethics for EMS: cardinal virtues andcore principles. Emerg Med Clin North Am. 2002; 20: 887-911.

13. Father Kevin O'Rourke. Medical error: some ethical concerns. Thebest protection against error remains the physician's traditional senseof professional responsibility. Health Prog. 2004; 85: 28-31.

14. Gomez CJ, Gomez RJ, Luna MA. Is bioethical training useful inpreparing doctors to take decisions in the emergency room? Med Law.2004; 23: 551-66.

illegally captive in a ward. In that latter case lies theconcept of discharge at request, a literal exit to a moment-prohibition that involves the matter of free will in thepresence of apparently irreconcilable incompatibilities.

Power unevenness is inversely proportional to animaginary number of those quotation marks of beginningof a dialogue: the abundance of those suggests thedecision had a leveled impact of bilateral opinion forces.

The role of the patient’s record

In the frustration due to the lost of the bet againstrealities of life, incomprehension from patient/familycomes to surface and generate conflicts. Consequently,ethical and legal demands appear.

It is the behavior in physician-patient relationship thatreinforces the pertinence of Anna Karenina principle forthe physician-patient relationship. According to theRussian writer Leon Tolstoy (1828-1910), all good resultsare alike, but every bad result is peculiar in its way.

Ways are not few in Medicine, connected to thedisease, the physician, and to the patient. Combinationsare infinite, not only because each patient has his/herown disease, but also because there are differences ofbehaviors among physicians and even for the samephysician in different occasions.

It is important to remember that there is no vaccineagainst indictment based on the Article 29 of MedicalEthics Code against a professional who was honest indoubt, secret concerning the agreement and efficient atmanaging the limitations of Medicine. Secondary victoriesinfest unjustifiable protests, a hectic activity of claimers,in which the physician is the one who shivers.

Without the protection of social immunity, the physicianneeds his/her own system of ethical immunity; his/herdefenses are crystallized in the quality of information he/she recorded in the patient’s record.

For that reason the remembrances on decisions takenin the presence of a moment-prohibition, and theadaptations that form many versions, either vanish orliquefy before dissatisfaction towards the event. So, thereliance of the patient’s records is always welcome.Reliable and solidary, as due to the interdependence ofinterests, it is important that it is a wish of fidelity withsimplicity and of prudence with justice.

Patient’s record is the life certificate that records amoment-procedure that intended to postpone the deathcertificate, or better, that intended to “prohibit it for a while.”

JAD, 48 years old, finance executive, used to workout every dayand played tennis on weekends. After a check-up he wasrecommended to change his life habits and dissuaded to practicephysical activity until a diagnostic clarifying was ready. Fifty dayslater, JAD had a cardiac arrest during a match point. Besides not following the prohibition, JAD kept on smoking apack a day. In the last return to the cardiologist, he said he wasfeeling well taking aspirin and statin and that he would "take abreak" to complete the exams. The patient had told his family only a part of medical orders. JAD's clinical record brought credibility to the physician's wordagainst the complaint made by his widow to CRM (ConselhoRegional de Medicina - Medicine Regional Council). JAD's intentionto select what he would accept or not from the physician's wordwas documented and, thus, the suspicion of medical negligencewas removed. It was clear that the patient assumed the risks, by resorting tohis free will.

I FORBID, THEREFORE I ASSIST