Several years ago, I was involved in a case that illuminates the difficult position many doctors today find themselves in. The patient was pregnant, c

The Algorithm and the Hippocratic Oath

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2024-09-20 21:30:04

Several years ago, I was involved in a case that illuminates the difficult position many doctors today find themselves in. The patient was pregnant, close to delivery, and experiencing dangerous declines in her baby’s heart rate. She had been on a blood thinner, which kept me, the anesthesiologist, from placing an epidural in her back. She also had strange airway anatomy, which would make it a struggle to put her to sleep quickly if an emergency cesarean section became necessary. I advised the obstetrician to perform an elective cesarean section now, in advance, while we had good working conditions, and not to wait for an emergency, where time is of the essence, and where the delay needed to induce general anesthesia might seriously injure the baby.

The obstetrician grew quiet. She seemed to descend within herself, in that lonely region of stress and strife where people feel themselves to be in an untenable position. Several things worried her, she confessed. First, hospital management had already warned her that her high cesarean section rate made her an outlier among her colleagues, which put her job at risk. Second, the baby’s heart rate did not quite meet the criteria for when to perform a cesarean section. True, the current situation was unfamiliar and unforeseen; then again, she wondered, would hospital management, let alone the malpractice lawyers, accept that excuse? Third, she wondered how to persuade the patient to have an operation that her own rules seemed to advise against.