On Being A Coward

Power tends to corrupt and absolute power corrupts absolutely — John Emerich Edward Dalberg-Acton, 1st Baron Acton

It was my second night as a houseman. A patient with end-stage colonic cancer had developed a massive per-rectal bleed, a nurse told me. I sensed the emergency, put down the work at hand and rushed to him. Like a Sims who found themselves in front of a fire, I danced frantically for a few seconds when I spotted the dark reddish excrete in the blue pan before I could calm down and come up with a plan: Take blood. Transfuse later. Intravenous normal saline for blood pressure maintenance for the moment, and if that does not work, vasopressor.

I started to bustle around the patient. When I was taking blood, he kept moaning, ‘I cannot stand this. Let me die. Just let me die.’ ‘Don’t move! How could I help you if you keep moving!’ I shouted, with the whole universe’s moral rectitude behind me.

His blood pressure was still low after I had given 2 bags of normal saline. Family members had not yet arrived. I gave him some vasopressor after consulting the resident doctor who was standing by the bed with me, listening to the patient groaning. It was a meandering, endless moan that allowed only a few sporadic mutations in musical scales. I almost thought that he had forgotten how to breathe. Vocalising seemed to be his only way of living at that moment.

‘So you gave him vasopressor.’ The medical officer mumbled, almost to herself.

‘Yes.’ I stood by her and answered cautiously, fearing that I might have done something wrong. I dared not mention that this was what she had agreed to on the phone.

‘I did not anticipate the condition to be this bad,’ she said wearily.

‘Don’t move! How could I help you if you keep moving!’ I shouted, with the whole universe’s moral rectitude behind me.

Another patient behind us spoke with amused resignation: ‘Hey, could you guys give him some medicine to keep him quiet? He has been groaning for hours, no one could sleep with that.’ The medical officer and I looked at each other. Neither of us replied. No medicine can stop the dying from groaning, as both of us knew,

At that time I thought he was really going to die. He did not.

That night I continued with my business in other wards. I only returned to the same ward in the morning to attend to another patient. Every time after a night shift, I felt like I had died another death. Submerging myself in the twilight made me feel as if I had just reincarnated: the day before felt like my previous life. So I saw sunlight shining through the window; I saw a new world and I saw him, sitting in a chair, jaundiced and cachexic and quiet. He was facing the windows and eyes out of focus. On the drip rack was a pack of fresh blood and a pack of normal saline.

He survived, I thought. He, like me, witnessed the sun of another day. But, for this I felt sorrow, though I did not tell him this feeling.

Gradually I found myself a decision-maker. I no longer consulted medical officers whenever problems arose. That’s why it did not take me a single second to say no to a daughter who, in anticipation of her mother’s passing, asked to hand-feed her mother. The medical officer had determined that her mother must not be orally fed before a speech therapist has made the required assessment.

‘Sorry.’ said I, ‘I cannot bear the potential consequences.’

Perhaps the daughter hates me. She may say that I am an abuser of power, who would not even grant such a mundane wish to her dying mother. But I would defend myself by saying that whilst I was indeed appearing to be cruel, I did so not out of authority, but the lack of it.

Because I was a coward I worried if the medical officer would blame me for not doing my job or if family members would question my conduct.

I was a houseman. Supposedly, I had the power to let a patient eat or forbid him from doing so. I had the power to prescribe or stop the medications he was taking… but, in fact, I didn’t. I had no real authority. Because I was a coward I worried if the medical officer would blame me for not doing my job, or if family members would question my conduct… So I always played safe. I practiced defensive medicine, prioritising keeping the patient’s heart beating. Even when I could not keep them alive, I still resorted to all means to keep them from dying… at least not under my hands.

Then I recalled those security guards who were once rude to me. Those who scolded me for breaking the most minute rules, for entering places I was not supposed to — even when the host does not seem to mind at all. I once looked down upon them: poor little abusers of the little powers they have! Did they not notice that their employer hasn’t even said anything about the ostensible ‘misbehaviour’ at all?

Now I understand. They used their powers to strictly enforce the rules not out of a desire to control, but out of fear: fearing that once they do not make good use of it, those who give them power will take it back. The truly powerful do not dirty their hands by showing their powers to mere people.

Now I am a medical officer. I am vested with more authority and I try to use that power appropriately. For example, I use it to persuade family members of terminal patients from asking for vasopressor to be used; meet with the close family members and after explaining the potential side effects of feeding, let the family members feed the patient. But sometimes I am forced to use power; to insert a gastric tube for a dementia patient, or use a positive pressure ventilator, or perform cardiopulmonary resuscitation.

This is a paradox. When we use power, power also uses us. In the age when medical technology was not so advanced, many people died of diseases that modern medicine can completely cure. Fortunately, we have developed a variety of life-sustaining technologies to help patients through their weakest time and allow them to survive their treatment. For the first time in history, human beings have gained the power to extend life.

However, when the same life-sustaining technology is used on patients who are bed-bound for a long time and cannot communicate, it becomes a tool to delay death. The technology is right here. As a doctor, do you use it or not? Why not? Is it negligence not to use it? I know I have the right to use these technologies. And many times, I have no power not to use it. Because this is my duty.

Strangely speaking, only by getting promoted to a higher rank can I obtain the power for inaction. I think I always owe an apology to the terminal cancer patient and the mother-in-law. I can argue that I did nothing wrong; everything was in accordance with the procedures, but I should have been a braver person. Nonetheless, regardless of whether I have the right to apologize, the two patients probably have no chance to hear it.

Dr Lam Muk. HKU MBBS 2016