First, Do No Harm
Lisa Belkin
Simon & Schuster, New York City
1993, 270 pp., $23
Houston's Hermann Hospital, a tertiary care hospital that attracts the critically ill and injured, has limited funding for patients whose care is uncompensated. Consequently, care providers in the hospital face many hard treatment decisions. In First, Do No Harm, Lisa Belkin skillfully chronicles six months of the struggles faced by Hermann Hospital's ethics committee.
The makeup of Hermann Hospital's ethics committee is similar to that of most other hospitals' committees: many clinicians; a few administrators, nurses, spiritual advisers, and social workers; an attorney; and one or two nonmedical people from outside the system. As with most ethics committees, its function is to set ethics policies and educate the professional staff. The clinical advisory task is to help attending physicians make treatment decisions that are often soul wrenching.
In a personal, emotional, and historical review, Belkin describes patients and their families who present treatment choice dilemmas to care givers. Ethics committee members rarely learn these intimate stories. Belkin also presents glimpses of committee members' past experiences that undoubtedly color their views of the dilemma.
Personal experiences with death, debilitating illness, and overwhelming family burdens determine the ethical opinions of each person involved—patient, family, care giver, and ethics committee member. As a long-time member and chairperson of a general hospital ethics committee, I am familiar with clinical dilemmas; but I have never been privileged to know what each patient, family member, and ethics committee member has experienced.
Most of us are familiar with the principles of medical ethics—autonomy, beneficence, nonmaleficence, and justice—but we also learn that one's background of family, ethnicity, culture, religion, schooling, neighborhood, training, and experience may determine what one thinks is or is not ethically correct.
Belkin discusses the following cases: a seven-month neonate, a newborn with a meningomyelocele, a teenager with short bowel syndrome, a 97-year-old demented woman admitted with a profound stroke, and a 65-year-old trauma victim, who is paralyzed and wants to die.
One case she presents involves a patient who became a quadriplegic after a gunshot wound in the neck. He required a tracheostomy and a special wheelchair. When hospital funds were exhausted, the patient was discharged. No nursing home would accept him. Fortunately, the hospital staff, members of the ethics committee, and his family (elderly immigrant parents and an eight-year-old son) were able to provide home care successfully.
In addition to such cases, First, Do No Harm also includes a brief history of the evolution of the ethics committee in U.S. hospitals, which must deal with complex technology, high expenses, more lifesaving and life-prolonging possibilities, legal fears, and moral uncertainty—all of which make life-and-death decisions more frequent and more difficult.
This text recounts the drama surrounding choices in ethical dilemmas. I found First, Do No Harm to be fascinating in the descriptions of the personal dynamics and history of each person described in the vignettes. The short chapters flow smoothly, making the book easy to read.
William Rock, MD
Chairperson, Ethics Committee
St. Mary's Hospital Medical Center
Madison, WI