The practice of medicine often pits public interest against the needs and sensitivities of the individual. How would you react facing the following dilemmas? Can we remain sensitive to the individual, when the case for prioritising public health is so compelling?

Dr Lam Muk’s narrative….

Throughout the COVID-19 pandemic, I’ve been working in both the hospital’s isolation and general medical wards. Handling visitation requests from patient’s families has reminded me of an incident that occurred during my year as a houseman.

It was 3.30 am. I was lying comatose in my bed when my pager woke me up. ‘A patient has died in ward 4B. Please come and remove her pacemaker’, the nurse told me.

A cardiologist places a pacemaker inside a patient’s heart when it can’t generate the signals necessary to produce heartbeats. This device produces these signals for the patient, but naturally, it is no longer useful when its owner dies. Furthermore, it’ll explode if the body is incinerated. For these reasons, a houseman will typically remove a pacemaker after certifying its owner’s death.

Sleepily, I dragged my feet onto the ward, certified the patient, and then fetched some needles and a scalpel to carry out the procedure. I made an incision under the left clavicle; no blood spewed out. With one finger probing deep into the cut, I traced the pacemaker’s outline and the tightly packed fibrous tissue surrounding it. I then yanked the device out. A few electrical wires were still deep inside the body, but I simply cut them as there was no risk of them exploding. The unrooted pacemaker was placed onto a tray and handed over to the nurse, to be returned to the manufacturer.

After the procedure was complete, the nurse asked me to speak to the deceased’s family waiting outside the ward. I walked out to meet with them. Approximately ten family members had gathered; three or four looked middle-aged, and the rest were youngsters. I told them that I’d pronounced their grandma’s death and also removed her pacemaker. I didn’t expect the wave of uproar that was suddenly unleashed upon me.

The oldest lady raised her voice. ‘Why did you remove her pacemaker?’ she demanded.

I calmly answered, ‘The pacemaker would have exploded in the incinerator.’

The eldest man then told me sorrowfully, ‘We have purchased land for her burial.’

Dozens of calls had started to accumulate on my pager. There were now more important issues for me to deal with. I went into the ward and sought help from the nurse. She repeated my explanation to the group, ‘The pacemaker would explode.’

The family wasn’t convinced by this and continued to make a great fuss. The cut I had made on the body was deemed a blasphemy, defiling their efforts to arrange a burial where the deceased’s body could be kept intact (though not without the needle marks inflicted on her when she was receiving treatment in the ward).

The eldest lady, her arms akimbo and gesticulating wildly, roared and pointed her finger at the nurse and me. The older man reiterated in sorrowful tones how meaningful a burial was to them. Meanwhile, the others were sighing and grimacing. Disbelief shone through their facial expressions (none of this garnered much sympathy from me as I felt I was wasting time that could be better spent to treating those who were alive). The woman’s voice resonated throughout the corridor, forcing the nurse to shush her, ‘Please keep quiet. You’re disturbing the other patients.’

This appeal to the public interest did nothing to calm the situation. The family called the police who promptly arrived, unarmed. The eldest lady conveyed her family’s agonising misfortune using vivid body language. With his back half-bent, the police officer raised his hands in front of his chest and waved his arms — a gesture of appeasement but not without a hint of self-defence.

Through all the chaos yet another few dozen calls had accumulated on my pager. My patience had now run out. When the eldest lady asked me how I was going to compensate them, I answered her bleakly, ‘I will remember for next time.’

A resolution arrived at daybreak. With the family as witnesses, I bowed and apologised to the dead.

My answer added more fuel to the fire, sparking another explosion of fury and remonstration. As a houseman, I had merely stated a fact: that I was preordained to certify many more patient deaths in my career. But for this family, they took ‘next time’ to refer to the demise of another of their own (which, in all fairness, was preordained as well). The lady roared in anger and commanded that the policeman jot down this offensive statement. With the same half bent back the officer opened his eyes wide and kept waving his arms, showing no signs of taking out his notebook.

I wasn’t present consistently throughout the confrontation (which carried on for several hours), as I was the only houseman on call that night; I was obliged to go back and forth, dealing with dozens of problems from patient resuscitation to blood taking. I only made my presence known when I had to, leaving again with the excuse of being called to other wards.

The debate’s key point was why we had removed the pacemaker of a patient who was going to be buried. The nurse explained again that it was in our guidelines — pacemakers are removed as they explode in incinerators. The family disputed this, pointing out that this was unnecessary as they had planned for a burial. ‘You should not have assumed that we would proceed to incineration without asking beforehand!’ they argued.

We called the senior nurse. He searched among dozens of cabinets and finally found a dust-covered guideline. It read, ‘Patients sent for burial may be exempt from pacemaker removal.’

They had indeed suffered from a loss which they should not have been subjected to. So, why did everyone, including me, find them so irrational and demanding?

The family became even more agitated. Now that they knew there was a guideline, why had it not been followed? And why had both the houseman (me) and the nurse claimed that they had never seen it before?

A resolution arrived at daybreak. With the family as witnesses, I bowed and apologised to the dead. The saga finally came to an end. I could now go back and get some sleep (or so I had hoped — I was immediately called to take blood for a patient on a ventilator).

The following day, colleagues gave me their condolences and derided the family as barbarians. To me, the family had been unreasonable. Yet a question lingered in my heart. They had indeed suffered from a loss which they should not have been subjected to. So, why did everyone, including me, find them so irrational and demanding?

Let me try to answer the question now. In the medical system, those who are living are deemed more important than the dead. This rationale drives the Hong Kong Hospital Authority to ensure that medical personnel attend multiple courses covering the finest details of life-saving procedures, whilst allowing guidelines regarding the treatment of deceased patients with pacemakers to gather dust on the shelf. The focus is on the living.

At the same time, 90% of the dead undergo incineration in Hong Kong. Among the remaining 10% who are buried, few will have a pacemaker. When you balance the numbers of dead against the vast population of those still living, it’s obvious where the priority should lie and arguably, the family who shouted about their pain, disturbed other patients and occupied my time, acted selfishly.

Put simply, the alive are more important than the dead. Therefore, even though the family did suffer, it didn’t entitle them to enrol on the medical system’s list of ‘problems-to-be-solved’.

***

Not only are the living more important than the dead, but it seems that some of those who are alive are deemed more important than others.

My colleague recently received a complaint from the family of a 90-year-old, bedbound, tube-fed patient. During his hospitalisation, the nurses charted his vitals every four hours, but the family questioned why these had not been checked more frequently.

There is a textbook answer to such complaints, and it’s an economic one. Medical resources are limited and should be spent cost-effectively. For every scarce resource, a priority exists. The priority should be given to patients who would receive the largest marginal benefits from medical interventions. A patient with good premorbid status would benefit significantly from frequent monitoring, whilst the 90-year-old would have died as a natural progression of life, no matter how frequent his monitoring was. Providing him with more medical resources than other patients is unjust.

Medical resources are tangible and measurable. The dilemma of patient-visiting during the COVID-19 pandemic is another economic issue, but an intangible one.

Before the pandemic, patient visits were mostly without costs (families blocking hallways and setting up obstacles around crash trolleys were perhaps the greatest threat). When COVID-19 broke, it gave birth to an additional potential cost: the risk of a community outbreak caused by a patient’s family acting as a vehicle for viral spread between the ward and the community. Such black swans are rare but catastrophic. Their occurrence can undermine public confidence in the medical system and trigger a crisis beyond a simple community transmission chain.

Early in the pandemic, I worked in a surveillance ward, where pneumonia patients were admitted and sent out to general medical wards until a COVID-19 diagnosis was excluded. The test takes a few hours. One day an elderly lady with advanced cancer was admitted for severe pneumonia, and I told her son that she might not make it. The son requested a visit which I rejected.

‘Can we buy personal protective equipment ourselves, then?’ asked the son.

‘If personal protective equipment is that effective, there wouldn’t be in-hospital transmissions.’ I answered.

For the sake of public interest, someone must be sacrificed. In the case of visits, public interest is served by preventing community outbreaks originating from hospitals. But this threat isn’t tangible enough for most people to understand. If something hasn’t happened before, people are unlikely to fear its consequences. If there’s no fear, there’s no motivation for people to make sacrifices.

I shuddered, realising my hypocrisy. Where had the public interest gone now?

The next day, a youngster with advanced cancer was admitted due to severe pneumonia. I explained to his parents that the prognosis wasn’t good. I told them, ‘We will arrange the COVID test as soon as possible so that he can be sent to the general medical ward’ (where the visiting restrictions are more lenient). ‘If it comes to the worst-case scenario, I will try my best to see what can be done to let you two accompany him.’ I promised.

Huh? What had I just said? I shuddered, realising my hypocrisy. Where had the public interest gone now? Yes, losing one’s child is painful. But should I not assume that losing one’s child is worse than losing one’s elderly mother, or that parents are more in need of seeing their dying child than children are of seeing their parents?

Such assumptions are wrong. Nobody’s pain should be weighted and yet in this case, I let sympathy overcome me, rendering me unable to resist the urge to exercise discretion.

The son of the elderly patient and the youngster’s parents may have been in the same degree of pain, but I sympathised more with the parents. A few cases tend to elicit my sympathy: families of patients suffering from acute illnesses and the families of young patients. One hundred years old? Bedbound for years? I understand the relatives’ sorrow, but we have to protect the public interest….. Resources are limited, so I resort to a seemingly objective standard to prioritise and allocate visits, though this so-called objectivity is, of course, my subjectivity.

The policy is well-meaning and rational, but I feel like an actress playing in an absurdist drama every time I say these lines.

If doctors are not exempt from being subjective, then families certainly won’t be. When a loved one is on his death bed, the family deduces that they are the saddest people in the world and the most deserving of sympathy and discretion. To lecture them on public interest (something as non-tangible as community outbreaks resulting from hospital visits) is preaching to deaf ears.

Yes, I have exercised discretion. There are different forms of visits: from two people looking through the windows into the ward, to the whole family walking to the bedside and gathering around, to relatives holding patient’s hands to say goodbye. Informing the family what level of contact is permitted is the inevitable dramatic climax: ‘You can enter the ward two by two but don’t enter all at once’, ‘You may look at him, but please don’t touch him.’ The policy is well-meaning and rational, but I feel like an actress playing in an absurdist drama every time I say these lines.

And then the family inevitably bursts into tears, ‘He loves the whole family being together, and now we can’t all be by his side to say goodbye!’, ‘We can’t hold his hand -even when he’s dying!’ The ambition of protecting 7 million Hong Kong citizens is too enormous to place on one family’s shoulders.

Even though everybody’s pain should be treated equally, and families are bound to be subjective in their distress, the reality of sacred resources in visitations should not be ignored. Seven million Hong Kong citizens will bear the consequences of unrestricted patient visits. Still, I have to resort to a system of imperfect subjectivity to exercise my discretion. Unfortunately, the family’s subjective pain and the objective limits of the hospital can’t be reconciled. As long as COVID exists, the rules on hospital visits will remain cruel and absurd.

However, whenever I’m sad, I try to remember that many others on this Earth are also experiencing sorrow — not just me. It’s the inevitable road to adulthood: the realisation that although your world seems to be collapsing around you, the sun in the real world will continue to rise and set as usual.

I’m now working in the airborne isolation ward. Most of my patients are diagnosed with COVID-19, while others are suspected cases with high pre-test probability. Unlike in the general medical wards where patients share a 60-patient group chamber, here they enjoy VIP single suites. I just scolded a patient’s daughter who refused to let her mother be discharged to the general medical ward despite her negative COVID-19 result. The reason? She knew more germs existed in the group chamber than in a single room. I reprimanded her, ‘The hospital isn’t a hotel!’ Of course, it’s not wrong that she cherishes her mother and wants the best for her. However, it’s not right that she forgets all the other patients who may also be mothers to other people.

Everybody’s pain deserves to be valued. Yet with a limited number of resources, not everyone’s anguish can be treated equally. Maybe much of the disillusionment we feel stems from the expectation that others should value our pain as much as we do. However, whenever I’m sad, I try to remember that many others on this Earth are also experiencing sorrow — not just me. It’s the inevitable road to adulthood: the realisation that although your world seems to be collapsing around you, the sun in the real world will continue to rise and set as usual.

Dr Lam Muk graduated from HKUMed in 2016. She is currently working as a medical resident in a public hospital in Hong Kong.