Viewpoint: Ethicist on the ward round

Not so long ago in the BMJ I quipped that most professional medical ethicists could not distinguish their “gluteus maximus from their lateral epicondyle” and suggested that such ethicists should undergo a short clinical attachment (2006;333:1226 doi: 10.1136/bmj.39055.658762.59).

Soon after publication, a nephrologist kindly invited me to observe a ward round at his hospital. It proved to be a puzzling experience, not because the blood gases, creatinine levels, diagnostic tests, and myriad statistics recited by a junior doctor sounded like one of Mallarme's incomprehensible poems, but because, as the afternoon progressed, I noticed the “patient as person” fading behind this shroud of science. I felt comfortable with my consultant, my team with their dangling stethoscopes; the all knowing computer wheeled by the bedside; and the timid patient, dwarfed by our confident crowd. Ethics seemed a million miles away.

This absence of ethics was most puzzling of all. I spend my days thinking, teaching, and writing about medical ethics, but there, in a group of doctors and with the patient before me, the subject seemed alien. “Think,” I urged myself, “what are the ethical issues here?”

My reverie would soon be interrupted: “Urine output … raised creatinine levels … metabolic acidosis … abdominal x ray.” Even in cases that I knew had obvious …