Grandmasters of medicine
BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5207 (Published 20 August 2019) Cite this as: BMJ 2019;366:l5207
- Daniel Sokol, medical ethicist and barrister
- daniel.sokol{at}talk21.com
Follow Daniel on Twitter @DanielSokol9
Hundreds of millions of people in the world play chess, but fewer than 2000 are grandmasters, the best players. In 2019 there were only 23 active grandmasters in England and one in Wales.
By comparison I am a weak player, but every fortnight I play chess with an old friend. They are bitter contests. To avenge recent defeats I have started taking private lessons in secret with a grandmaster.
During one lesson I reached a position in the game where I did not know what to do next. None of the options seemed appealing. There was no obvious good move. “So what do I here?” I asked the grandmaster. He picked up my rook and moved it a single square to the left. “This is a slight improvement,” he said. “If there’s no good move and you feel stuck, try to improve your position a little bit.”
That evening, a doctor called me in need of urgent ethics advice. “The whole practice is stumped,” he said. An elderly patient was at home with a condition requiring immediate hospital admission. The situation was urgent and yet the patient, who had decision making capacity, refused to leave the house.
Impasse
As we explored options to resolve the problem, each was rejected until we had reached an impasse. I then recalled the grandmaster’s words: “If there’s no good move, try to improve your position a little bit.” If the patient refused to leave home, even if death ensued, then why not make her situation somewhat better at home? Perhaps she would accept antibiotics, or some pain relief. This might not save her life, but it was an improvement on the current situation. We could also start discussing end of life care with the patient.
Another example is of a patient who has a bleed in the brain. His condition improves and he refuses the catheter angiogram recommended by doctors. They fear that the bleed was caused by an aneurysm that could erupt at any moment with fatal effect. The patient’s refusal has again eliminated the best move, but could the situation be improved “a little bit”? Perhaps the patient would agree to a less onerous repeat computed tomography angiogram? Although suboptimal it is better than nothing.
A variant of the advice is that favoured by astronauts: “There is no situation so bad that you can’t make it worse.” However dreadful the situation seems, whether it’s a ruptured blood vessel or a missed diagnosis, it could get worse. Hence the importance of keeping your cool when the situation looks bleak. Much of my work as a barrister deals with doctors who, through acts of negligence, have made things worse for the patient.
The default mode, whether in chess or medicine, is to look for a good move. When no such move presents itself, we feel helpless or frustrated. In such situations the grandmasters of medicine avoid making matters worse and seek ways to make things just a little better.
Footnotes
Competing interests: None declared.
Patient consent not needed (patients anonymised, dead, or hypothetical).
Provenance and peer review: Commissioned; not externally peer reviewed.