Computer: Define “Ethics”

When I was a first year medical student, I observed a surgery. In fact, it was the first abdominal surgery I’d ever seen. Even though I had a degree in physiology from before I had started medical school, it was all relatively theoretical. In other words, I could explain to you how the kidneys worked in general terms, but I had never actually seen one inside a human being.

There is no question that there is an aura around the practice of medicine, even today. People literally trust doctors not only with their lives, but with the lives of the people they love. I was definitely cognizant of this responsibility. But I welcomed it. I was no less the idealist than many others when I started medical school. A part of you believes that you can make THE difference, not just “a” difference. Therefore, you welcome the opportunity to prove that you deserve the public’s trust.

The whole medical world makes a great effort to persist the “magic”. Whether it is the white coat, or the stethoscope around the doctor’s neck, or the red line that indicates “entry only to medical staff”, it is absolutely clear that there is a line between patients and doctors. The truth is though, that the line is much more between regular people and doctors. Even if you are a captain of industry, you are “just a patient” when you are in the hospital.

There is a presumption that every patient will receive the same degree of care. People expect that when it comes to medical issues, doctors are blind to status, color, ethnicity and all of the other things that appear to differentiate between us. Inside the human body, you can’t tell if a person is from Nebraska or from Moscow or from Ethiopia based on the surface of their lungs.

Before modern medicine, it was actually relatively easy to provide the same level of care to everyone, and to stand above the differences that others fought wars over. The reason it was easy was because there was nothing to do. Outside of cutting off a leg due to an infection, or stitching up the wound which would often get infected in any case, there really wasn’t much that medical knowledge could help with. Just as a quick aside, we still cut off legs due to infections but much less so because of antibiotics. And there are still plenty of wound infections  because medical personnel don’t wash their hands. So it seems that even when we have a tremendous amount of knowledge, patients are still suffering far too much. But I digress.

While I was standing in that operating theater, I truly dreamt of being the one holding the scalpel. “A chance to cut, a chance to cure” is probably a phrase that is as old as our species, but it summed up a great deal of the surgical mindset. To be aggressive, to be invasive, to “get in there” and fix the problem – this was the aura of surgeons that distinguished them from “regular” doctors. Even in medicine, there is definitely a pecking order. And surgeons until today are very high up on the ladder.

I snapped out of my dream world when I heard the more senior surgeon say to the younger one “don’t do that”. It was said with the same degree of fear as a parent would scream, watching their child run into the road. The conversation between the two surgeons was inaudible to me for the next few minutes. But at one point, the spleen of the patient was removed and given to the nurse to be sent for pathology.

Removing the spleen, especially at that time, was not infrequent. It could have been done due to an abnormal finding in the spleen, including a small cancer. One other reason, which I came to learn of as time went on, was human error. Surgery is very much an issue of skill and talent. Skill you can develop. Talent you must be born with. I don’t know which of these were the reason for the error that happened at the time. All I do know is that the patient did not sign up for a removal of the spleen.

Doctors make mistakes. At the very least, anyone reading this post should know that very well. But what I remember of this case was that the patient was never told it was a mistake. I don’t remember the exact words but it was something like “unfortunately, we had to remove the spleen as well”. While this might sound like an admission, in fact it sounds much more as if some medical event happened, beyond human capability to control, that caused the spleen to be removed. Part of the aura around physicians was that they knew things, including a unique language, such that even trying to explain why the spleen was removed, to a nonphysician, would be futile. And most patients seem to accept this, even until today.

I was a first year medical student. During the couple of weeks following the surgery I observed, it was clear to me that the spleen was damaged due to human error and that the patient was not fully informed of this. What should I have done? Should I have gone to the patient and told him that in my opinion, as a first year medical student, the surgeons who treated him made a mistake. It doesn’t take Perry Mason to argue the point that I did not have the medical knowledge nor understanding to even comment on such an issue. But I knew the truth.

I wish I could say it was the last time that I saw things that should have been handled very differently, but ultimately were hidden from the patients. In Canada, during the time I studied, lawsuits were not anywhere close to the issue that they were in the United States. So fear of being sued would be hard to use as an excuse for staying quiet. Interestingly, there was a paper published very recently that argued that even in the United States, the fear of lawsuits does not guide doctors to do more tests, otherwise called defensive medicine.

As usual, I will now try to explain why technology is critical to the future of medicine. In fact, in this particular case, I can easily argue that mindless, soulless, heartless computers are the only way to maintain an ethical standard, at least in medicine.

We are very close to the point at which every element of a patient’s experience will be recorded. Whether it is the visit at the family doctor, or every moment within an operating theater, all points in time will be recorded and made available for the patients. In such a reality, it simply will be impossible to hide errors. In parallel to such systems, it is my hope that the full benefits of computerization will be realized in every aspect of medicine. In other words, the errors that would have happened without computerization, will not happen because of computers. And if these errors don’t happen, the recording of the events will not demonstrate any errors.

Computers will guide us. They will watch over us. They will force us to do the right thing, whether we want to or not. Doctors, just like “regular people”, will be subject to a tremendous level of oversight and scrutiny. Doctors who fail to function in such an environment will have to seek other professions.

It is said that an honest person has nothing to fear from Gd. This begs the question then – why does everyone looks so nervous when they are in their house of worship?

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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