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CURRENT CONTROVERSIES IN CRITICAL CARE |
Moral perception is intimately linked with our style of seeing and the language we use both to reflect our vision and to reflect upon our vision. John F. Murray, MD,1 has written a remarkable chronicle of 28 days in the intensive care unit (ICU) of San Francisco General Hospital, describing the tragedies and precious few triumphs of the inner city ICU. He bears witness to his roles as attending doctor and teacher in the unit and in the process reveals a pervasive style of seeing in the ICU. The book marches through the daily inventory of patients, providing an account of the excesses of highly technical care in the absence of even a modicum of everyday care such as nutrition, hygiene, and shelter. Although the book is written as a daily journal, the style is not the sort of engaged personal account that one expects to find in a journal, but it is a clinical account that reflects Dr Murray’s style of seeing in the ICU. Dr Murray’s goal seems to be to tell an objectified truth about what he sees and does and in the process exposes the futility, suffering, and expense of overzealous medical treatments. In this way, Dr Murray holds ICU practice up to the light so that its effectiveness and humanness can be looked at critically.
For me, the medium of the book’s descriptive language unwittingly becomes a major message of the book. The book is written in the familiar style of the clinical gaze described by philosopher Michel Foucault in The Birth of the Clinic.2 The objectified language of the clinical gaze excludes all other descriptive language, taking over the usual writing style of a personal journal. Foucault historically locates a radical change in the language and style of medicine with the adoption of the autopsy to study disease. The practice of autopsy was a practical consequence of the adoption of the Cartesian understanding of disengaged reasoning. Medicine seeks explanations for disease that can be visualized whether at the organ system, cellular, or genetic levels. The practice of medicine has adopted an objectified scientific language that depicts this Cartesian understanding of the body. Dr Murray’s book makes me think about the recognition practices that shape the moral possibilities inherent in the ways we meet and respond to patients and families in the ICU. The aim of this column is to reflect on the nature of our language in the ICU and how it shapes our encounters with and care of others.
Dr Murray does readers a great service by disclosing what the clinical gaze sees and understands. In this respect any physician with intensivist training could have written a similar journal. Insiders will easily recognize the disciplinary shaping of the descriptions, even with the careful editing that explains the technical language. Dr Murray’s disciplinary language is knowledgeable, incisive, and faithful in representing what the clinical gaze discloses. Pity, remorse, and even despair over the failures inherent in the work of the discipline come through the dispassionate descriptions that cannot help but conjure up the human tragedies behind the clinical accounts.
The clinical discourse takes on the style of rational calculation. Benefits and risks are weighed, and a rational array of choices is offered to the patient who then decides what he or she wants to do. The person’s life, world, and concerns are not disclosed except in distanced, condensed, cryptic accounts. The "ethics" of the situation are reduced to the right to choose and the decision-making powers of patients and their families. Explanation trumps understanding.
On Sunday, day 4, Dr Murray as the attending physician and teacher is confronted by an irate first-year medical resident:
This is my second month at "The General," and almost all my patients have been losers. In the ICU alone, of my 5 patients, 3 were drunks and 2 were junkies. Two signed themselves out against my advice, and 1 has already been back to the ER twice. They’re all trying to kill themselves. What’s the point? Why are we doing this?1
Dr Murray, who is used to these questions, gives a prepared speech about a "commitment to take care of people who need your help–all of them, not just those you deem worthy of your attention." The medical resident replies: "It’s a waste of time and money... my time and taxpayer’s money." Dr Murray replies:
You are not the first person to feel this way; it’s ubiquitous. But don’t be judgmental. It won’t help your patients, and it will drive you crazy. Concentrate on their medical problems, not their lifestyles. Compassion is vital, both for your patients’ medical illnesses and for their emotional reactions to them.... Replace your negative thoughts with sympathy and empathy. You will be an even better doctor and your patients will benefit from it.1(pp45–46)
In another section of the book, Dr Murray reasserts that although the patients’ social problems aggravate and even cause their medical conditions, he focuses on the medical problems because he can do something about them and cannot do anything about the social ills.
Dr Murray’s honesty and his desire to present his practice for public scrutiny are laudable. There is much to be corrected in this inner city ICU. His account is excruciatingly realistic in tone of voice and style of discourse. But as a veteran of the same culture and place, reading this everyday clinical discourse, I am struck by the moral failure of the clinical gaze when we in medicine and nursing use it as our primary or exclusive language. His account demonstrates what this language discloses and what it leaves out and how it influences how we meet others. Finally, the book’s consistent clinical gaze reveals what decisions can show up as concerns and what discussions can occur from detached observation and concern. Typically, ethicists focus on ethical judgment and all but overlook how our language and styles of practice shape moral perception and thus open and close down humane possibilities.3
The ICU as a place of lifesaving technical interventions exemplifies the modern quest to separate the social from the medical, emotion from reason, and mind from body. Our impersonal clinical reporting can cause us to meet and to explain others in narrowly prescribed ways. Although Dr Murray recommends compassion and empathy (and I do not doubt that he strives to deliver both to his patients), his received clinical language predictably and effectively omits any descriptive account of compassion and empathy. The objectified gaze causes clinicians to look on as if they were in a theater, or observing through a glass window. Encounters and first person experiential accounts are left out. As Foucault points out, the patient seen from the perspective of a "clinical gaze" reveals disease rather than the suffering or unique person. David Michael Levin4 has written about the problems of the philosopher’s gaze similarly:
Since Descartes adopts the observations of a spectator as model for a philosophical understanding of self-awareness, it should not be surprising that he would take the spectator’s observation as paradigmatic of our relationship with others. This model, in which an odd visuality in self-experience is extended to constitute a perverse relationship with others rests on the metaphysical dualism of mind and body.... Having posited them as two separate substances, it seems to make sense to talk about the mind’s observation of the body that is essentially "outside" it. Making the body external in this way, however, turns the body into a purely objective body, leaving it dehumanized, mechanical, thing-like, "mine" because I can control it, but visible and observable like anything else.4
Descartes’ clinical discourse has given us much. We dare not ignore the possibilities it opens up for combating disease, but rather we must critically evaluate how it affects our relationships with patients. The danger lies in allowing the language of the clinical gaze to be totalizing, so that it crowds out other types of language for seeing and meeting the patients and their families. I cannot imagine either facing or assisting in surgery without the safety of the distance gained by the clinical gaze. Technical competence in medicine requires fluency in clinical language. However, consistently separating the social and the medical creates a gulf that makes it all but impossible to meet the other in solidarity and compassion. We need better dialogues between clinical and human concerns and increased fluency in language that expresses human experience and concerns.
Objectified clinical language need be neither the primary nor the only language used when meeting those for whom we provide care. The language of the clinical gaze itself precludes seeing the other as a person who is neither the same as I am nor wholly different. I share a common humanity with those I meet. In his epilogue, Dr Murray concludes:
It is important for people who are clinging to life to fight for it, and struggle. Yet we need to improve our understanding of how and why these battles are fought and what victories and losses result from them. Most of the truly remarkable improvements that have been made in ICU treatment since its beginnings nearly fifty years ago have been medical and technical. The ethical underpinnings of critical care have evolved much more slowly, and unresolved issues remain.1
I propose that the usurping of other languages of meeting and caring for others is at the heart of this delayed ethical development in the ICU. We do have other languages in which to meet and understand our patients and their families. Dr W. Thomas Boyce4 contrasts his clinical gaze with an encounter through the eyes of a mother’s love. The encounter changes his perception of the patient, and consequently changes the possibilities available in the clinical situation:
A little more than a year ago during my month serving as the attending physician on the pediatrics ward of the University of California, San Francisco, I ran across a dying boy who, together with his mother, reminded me, as I often am reminded, of the troubled, myopic vision so characteristic of the medicine I have learned and practice. He was a relatively young boy (I will call him Blake), no more than seven years of age and afflicted with a terminal, disfiguring version of mucolipidosis. For those unfamiliar with this disorder, it is a genetically based storage disease involving the pathological accumulation of complex carbohydrates in many tissues of the body, including the bones and joints, the heart, eyes, liver, spleen, and brain. It is a disease that is slowly progressive, usually ending in death from heart or lung failure within the first decade of life.Over the years of Blake’s short life, the unabated metabolic hoarding of carbohydrates had severely deformed and retarded him. His eyes were clouded and protruded from his face as did his tongue, like the overstuffed contents of a pastry shell too small to contain it. The gums surrounding his peg-like teeth were similarly engorged and frequently bled when disturbed. His massively swollen heart was failing, and he perennially threatened to drown in the secretions that flooded his airway. His chest and belly, glutted with a liver and spleen many times their normal sizes, had together become a single, reddened, congested globe from which four largely useless limbs projected. He was, in short, a small, grotesque tomato-of-a-boy whose appearance turned away even the most forgiving eyes.
Blake also was not overly grateful for the abundant, cutting edge medical care being provided for him. I think he somehow sensed that he was nearing the end of his time, and he had decided that the sticks and pokes and serial examinations did almost nothing to allay the other torments that his disease had long prolonged. So, the approach of doctors, nurses, technicians, and all the other assorted hospital personnel was greeted abruptly with a raspy incoherent grunt and a flailing motion of his arm that meant, indisputably, "Get out of my face!" ...My own ability to humanly care for Blake also was compromised by the physical sight of him and by his stolid indifference or antagonism to my best efforts on his behalf.
One July evening, held in the hospital late by a series of unanticipated events, I approached Blake’s room at an unaccustomed hour. His young, single mom, who was at her own place of work for the daylight hours of most days, was sitting on the edge of the bed, deeply immersed in a conversation with Blake. I paused, and then settled at the door, transfixed by the scene before me in the darkened hospital room. Blake’s mom was talking to him. In hushed and comforting tones she spoke of the day, wondering how things had gone, asking him about his new nurse, reviewing for him the events of her own day at work. As she spoke, leaning over her son, her hand stroked his forehead and hair in a mundane gesture that filled the room with her love for the boy.
Blake’s eyes, moist and utterly devoid of his stern resistance, looked up into his mother’s face, absorbing every moment, every piece of her presence there with him. Relaxed and more peaceful than I had ever seen him, Blake seemed to melt into his mother’s eyes. She stroked his round, swollen face and said to him, "Oh, my beautiful, little boy."
Suddenly I understood what I had not understood: When this mother gazed at her bloated, dying son, she physically saw a person I had never seen. Transformed by her eyes’ willingness to see the child beyond the disease, Blake had become a different being, an individual no longer diseased and distorted, but a frightened child visibly changed by his mother’s love.
In the months since that night and since his death later in that same year, I often have thought of Blake and his mother. I have thought of how limited my vision of my patients has been, of the peculiar and short-sighted lenses through which so much of our vaunted medicine is conducted. I have thought of how mysteriously my own way of seeing Blake was irreparably changed by the experience of watching his mom truly see him and respond to him for who he, finally, was.5(pp145–146)
Our meeting and recognition practices in the ICU shape the concerns and content of rights-based ethical decision making because they determine how families and patients will be revealed and understood. We dare not allow our medical explanations to eclipse our human encounters and understanding. What we see must be another person and not just a scientific examination. The encounter and language can be as simple as meeting the person and their loved ones in their particularity. For example, in the following narrative the nurse intermingles medical facts with the person’s life.6 She describes a 60-year-old African American man who is quadriplegic from a motorcycle crash many years ago and who is disfigured by a radical neck surgery for cancer. He is admitted to the ICU for respiratory failure, and the healthcare team struggles over the decision to treat him with mechanical ventilation, knowing that weaning him might be difficult, if not impossible:
Nurse 1: I think we could have made a decision on not treating him fully, based on what he looked like and what we thought he was. And I really stood up for him. I don’t think some people ever got beyond just looking at him and just saying: "this man is disfigured and not able to take care of himself and whatever." As far as prioritizing the beds, if we were really strapped for beds, they would think about putting him on general care and taking him off the ventilator. But no one thought it was an easy decision.Interviewer: It sounded like you had a strong feeling that he wanted to live. How did that come about and do you know when it came about?
Nurse 1: I think he always had it. He was an incredible fighter. I mean I would see him angry or I would see him withdrawn. But even withdrawn, he was actively withdrawn. He wouldn’t look at you. He would follow you, track you in the room and everything but then wouldn’t look at you.... At one point in time the physicians were asking him: "You want to die, don’t you?" They weren’t trying to do him any harm. No one ever didn’t take care of him. He just gravitated towards these excellent physicians. I don’t know how.
Interviewer: What do you think was different about the way you saw him versus the way the doctors saw him when they thought that he wanted to die?
Nurse 1: I don’t think they stood with him and looked at him or gave him a Pepsi, or saw him watch the ball game. He really derived a lot of pleasure from living.... I think it was more of a case of their perception of quality of life and our perceptions of George’s quality of life and as we got to know him more and what he was like at the skilled nursing facility, [we concluded] that the quality of life for him was really very good.... They didn’t see him as a social director on his unit. He was a spokesperson for the patients. He helped people who had alcohol and drug problems. He had a girlfriend there who was also wheelchair bound and they sued public transportation together. They were the Valentine King and Queen. I think the doctors just looked at him and saw: "this is as good as it gets, and this is really depressing, and he is really depressed and so why continue? This is torture." He was a really big baseball fan and wanted to watch the ball games...to me that is not someone who has given up.... [Later in the same interview after describing his active measures to control his day, she comments] Somebody who is that manipulative or that active in planning my day is really not somebody who doesn’t want to have to deal with living or doesn’t have the strength to go on.6(pp20–21)
The nurse’s encounter with George is moral and relational. She meets George as a human being with particular concerns and a life. Her response mirrors the strength and imagination that George himself experiences. She sees beyond George’s disease and disfigurement, thanks to her openness to George, the social worker, and the active concerned friends from the skilled nursing facility. In the narratives about Blake and George how we see and meet the other person as particular persons with life concerns opens up a moral and sentient space. Both the language and style of vision alter the nature of ethical comportment and what can be considered in ethical decision making and action. Levin4 notes that eyes are for tears as well as vision and concludes:
...that crying, the confession and seal of our belonging, our connectedness is the root of vision. And that, when our vision is uprooted, detached from our sensibility, our capacity for feeling, it becomes blind. It loses its ethical bearings, falls into an abyss, and sooner or later will have to face the consequences of madness.4
In the next 50 years of working in ICUs, we can focus on enlarging our capacities to meet patients and their families with compassion conveyed through a language of caring that establishes our basic connectedness. Developing our moral sensibilities and possibilities in relation to our lifesaving technologies will require more than the objectified clinical vocabularies and clinical language that we presently use. Perhaps such development cannot be accomplished without some public space for weeping and for considering illness and death as human passages and not just clinical courses of disease.
To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
This article has been cited by other articles:
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  L. Day Healing Environments and the Limits of Empirical Evidence Am. J. Crit. Care., January 1, 2007; 16(1): 86 - 89. [Full Text] [PDF]
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