Matters of life and death and quality of life

Some doctors deal with matters of life and death on a regular basis. If the cardiac surgeon ignores the leaking aneurysm, the patient will die in minutes. If the anaesthetist fails to intubate at once, the patient will asphyxiate. In an emergency department in the United States I was present when a patient shot through the back was admitted by helicopter, his chest opened up within seconds of landing, and his heart pumped manually by a trauma physician. It was impressive, high octane medicine. In the course of a recent conversation with one of those life and death doctors, I lamented the plight of a young woman who had lost a leg in a road crash. Her life had been forever changed. She could no longer do things that we take for granted, such as swimming or taking the train or wearing certain clothes. The doctor remarked, to my surprise, that, though regrettable, “it wasn’t a matter of life and death.”

This dismissive attitude reminded me of the businessman character in Saint Exupéry’s Little Prince. In this novella the narrator is stranded in the desert when he encounters a wise, otherwordly little prince who recounts stories from his and other planets. The businessman inhabits one tiny planet. He spends his days counting stars for no apparent reason and repeatedly tells the little prince not to disturb him as he is concerned about “matters of consequence.”1 The little prince’s beloved single rose, unique and under threat on his planet, was in contrast inconsequential, the businessman says. There is no denying that it is important for a doctor to fix a damaged heart, and in some cases so too is counting stars, but the truth is that all doctors deal with matters of consequence. Hospital doctors hold no monopoly over such issues.

In one of John Mortimer’s Rumpole stories, Rumpole, under strict instructions from his tyrannical wife, visits his general practitioner, Dr MacClintock, a “small, lightweight, puritanical Scot who looked as though he existed on a glass of cold water and a handful of Quaker Oats a day.”2 At the end of the consultation Dr MacClintock tells his overweight patient, “Let’s face the fact, there is a great deal too much of you, Mr Rumpole,” and prescribes a Spartan diet of Thin-O-Vite. Life and death doctors might well concede that Dr MacClintock was dealing with a matter of life and death, albeit at a dull, chronic level. Without a change of diet, the fried slices, rashers of bacon, sausages, buttered crumpets, jam roly-poly, Château Thames Embankment, and small cigars so enjoyed by Rumpole would doubtlessly lead to an early demise.

But what of doctors who, instead of pumping the exposed hearts of mortally wounded patients, deal on a daily basis with blocked ears, sprained ankles, and other mundane afflictions?

When I was a law student I spent one evening a week at a community law centre, armed only with a meagre knowledge of the law and a dose of common sense, trying to solve the legal problems of the local folk: a tenant was tormented by voracious bed bugs, a young lady lost her part time job for swearing at a customer, an impecunious student squandered his savings on a broken computer, and other sorry tales of this sort. These were the law’s equivalent of blocked ears and sprained ankles. Damages seldom exceeded a few hundred pounds. Yet, for the individuals involved, many of whom felt nervous just seeking legal help, these ostensibly trivial matters meant a great deal.

The same is true of patients. Whatever the doctor may think about their gravity, few people visit the doctor for ailments they consider trivial. Like the little prince’s rose, their problem is, to their eyes, important. A sound grasp of this fact lies at the heart of a good bedside manner. Excising a tumour may be more dramatic than removing wax from a person’s ear or treating a corneal ulcer, but they are all potentially matters of consequence, looming large in the patient’s consciousness. Each intervention shares the fundamental aim of improving the patient’s quality of life. How I remember the awful days spent at home, afflicted by a corneal ulcer, half blind and in agony at every blink; and how blissful the relief when the drops prescribed by the ophthalmologist finally took effect.

In John Mortimer’s story Dr MacClintock paradoxically drops dead in front of the bon vivant Rumpole, who, a glass of champagne in hand, muses, “It’s the quality of life that matters, isn’t it? The quality of life. And the hell with Thin-O-Vite.” What can be more important, more consequential, than the quality of one’s life? Not all medical practice is a matter of life and death, but all medicine deals ultimately with quality of life.

In medical heaven I doubt that Hippocrates, Maimonides, Osler, or whoever it is who assesses the new entrants will look on the cardiac surgeon more favourably than the rural GP, or the ophthalmologist, on the basis of a crude life and death criterion.