Monday, February 2, 2009

Moments of Madness…

"A disciplined conscience is a man's best friend. It may not be his most amiable, but it is his most faithful monitor." ~Henry Ward Beecher (U.S. clergyman, 1813-1887)

"The shortest and surest way to live with honor in the world, is to be in reality what we would appear to be; all human virtues increase and strengthen themselves by the practice and experience of them." ~ Socrates (Greek philosopher, 470-399 B.C.E.)

[Some 2 years ago, I wrote an editorial on moments of madness following the infamous head-butting by football superstar Zidane, which had been coined a 'Zizou' Moment. I think it is good to review the principles of that message today...]

Possibly 2 billion people viewed the World Cup finals early Monday morning (10 July, 2006, in Malaysia) riveted by perhaps the most memorable incident of the entire month-long orgy of soccer extravaganza. French football maestro ‘Zizou’ Zidane head-butted Italian agent provocateur Marco Materazzi in what must count as the most inexplicably perplexing act of the tournament.

Notwithstanding whatever the provocation, that loss of control, that one moment of madness must forever be etched in the psyche of Zidane, as one final act of regret, which has blemished the demigod-like status of perhaps the most remarkable playmaker of soccer the world has ever known over the past twenty years.

What happens when one finally snaps may never be totally explained, nor can we ever hope to finally comprehend how or why it had taken place. Volumes have now been written about this indelible incident, and I do not wish to add to psychoanalyzing the whys and the wherefores.

This ‘Zizou’ moment however has been dissected and interpreted in several ways. One most recurring theme is that of justifiable violence/retaliation, taking the law into one’s own hands when provoked, when criminal acts or even insulting verbal or physical gestures are directed against us, when we feel that our honour has been tarnished.

It harks back to faintly-remembered times when lawlessness abounds and we the helpless wretched citizens cannot depend on the authorities or law enforcement agencies to deter or to take action against these perpetrators of wrong-doing. Thus, this wrought-up sense of unquenched frustration and blinding anger had swung many toward some form of vigilantism or justifiable retribution, which seems to have become more acceptable, but which in every civil society we have always resoundingly frowned upon.

Personally, I am of the opinion that physical violence and reprisal is never justifiable and that this can only amplify tensions toward an escalating gratuitous and senseless denouement, where innocents become embroiled and are hurt or slaughtered without rhyme or reason.

Consider the rising violence and tension in Israel, Palestine and Lebanon, and the potential for wider conflict in the Middle-East. Truly, as had been so well expostulated by Mahatma Gandhi decades ago, “An eye for an eye would make the whole world blind”!

I want however, to address here the more common moments of madness, the careless thoughtless actions which we sometimes act out, unthinking yet irreparable and irretrievable: small oftentimes silly acts which thankfully do not cast huge imprints or sequelae which can change, cripple or endanger someone else...

Most, if not all, are miniscule in their impact and are forgotten almost as quickly as they are committed—perhaps our ‘venial’ sins, our little ‘white lies’.

Sometimes however, these little acts become inured and acceptable, when they are repeated often enough to become subterranean habits or subconscious patterns of behaviour, which harden the insensate and Dr Hyde-like aspect of our other selves.

As doctors however, these may have been inadvertently but unprofessionally negligent, dangerous or even lethal to our charges, our patients, but we have become just too anaesthetized to recognize their gravity, their presence even.

Yet in rare instances some or even just one of these may have implications, which can be life-changing, life-defining or even catastrophic. Pleading in hindsight, with simplistic statements that we were just being human and had been pushed to the edge of our tolerance and control unfortunately, does not make this any better or justify its severity or gravity.

Consider some of these common instances of shame, these moments of weakness, of madness even:
  • taking unfair advantage of our gullible but frightened patients by suggesting urgent but unnecessary tests or therapies;
  • preferential referring to our doctor friends or hospitals who promise some kind of kickback;
  • dishing out supplements because our patients urge or apprise us about their preference for alternative medicines;
  • deceiving or defrauding our patients by inducing them to take part in some financial deals because of our special doctor-patient relationships;
  • submitting to our baser self by engaging in sexual liaisons with our patients or their partners;
  • choosing a convenient career path to become high-level drug-pushers by indiscriminate selling of hypnotics, sedatives, cough mixtures to drug addicts;
  • selling medical certificates for a quick buck;
  • becoming serial abortionists because there’s money to be made; etc…

We would all be remiss if we do not animadvert on such acts, which are growing more common nowadays.

Are these baser instincts simply trivial moments of madness? I beg to disagree, but no, these are not momentary lapses of conscience or behavior, they are consistent patterns of ethical breaches, which should be loudly denounced. They are definitely not conduct becoming of a medical professional.

Are they occurring more frequently than we have recognized? Sadly, perhaps so. Are they simply the work of a tiny segment of our fraternity? We certainly hope so, that these are the fringe numbers which bring shame to the profession and are unfortunately tarnishing our good name with their very thick brush strokes of professional delinquency.

Nevertheless, there are other possible moments of weakness that rarely can afflict the medical doctor. These uncommon out-of-character and enigmatic errors are often one-off, but may sometimes be extremely serious and egregious, and then become ethical challenges, which have to be scrutinized.

These are moments sometimes squeezed and secreted out due to tremendous pressures of internal conflict. Pertaining to these, we must be very resolute in our self-restraint and be extremely mindful so as to maintain our innate sense of proportion, our professional ethics.

There is unfortunately for us as doctors, very little hope of retraction or turning back, once these actions are set in motion or are enacted out to the full, and we would have to face all the attendant consequences and possible sanctions.

But this is one human dimension which doctors could perhaps be better understood from the public and the governing/regulatory authority perspectives.

Because of our lofty position in society—our innate and traditional trustworthiness which the public has endowed upon us—we are often placed in an unreal pedestal of pre-eminence, which may not always be in our best interests (and certainly not in our patients’ either!), and which are often too high and haughty for us to sustain continually as fallible human beings.

It is true that as doctors we welcome even relish such respectability. Sometimes we deceive themselves that we indeed deserve such supercilious placements and snobbishly surround ourselves with such arrogance that we fail to see our humanness, our human frailty and our foibles.

But any thinking person, much more so because we are doctors, will concede that we are all imperfect and will make mistakes; that medicine is altogether more of an art (with more uncertainties than we can imagine) than an exact science that we would want it to be—whatever evidence-bases there may be to embrace and ratify.

We doctors have differing standards of practice, experience and perceptions, largely because of the multitudinous medical colleges and training that we individually have passed through. We are also of disparate personalities, which range from the benignly empathetic Dr Marcus Welby-type to the arrogantly cocksure Dr Christian Barnard-type.

We range from the placid, contemplative doctor to the brash, trigger-happy knife-wielding surgeon or catheter-brandishing interventionist, willing to try out any medical procedures or therapies whether they are experimental or just because they are simply possible.

Let the devil in the details look after themselves, benefits or harms are immaterial and does not immediately concern us in the near term… Our patients become our playground, our artistic canvas to create and display some of our audacious skills and derring-do prowess… Some of our patients may fare poorly, but some may also do superbly well, often in spite of us and our actions, or our lack of it.

Some newfangled techniques have actually been discovered from just this type of intrepid cutting-edge experimentation and hit-and-miss try-outs. But at what costs? At this current point in time when more and more documentation and accountability is expected of the medical profession, what would be acceptable and what not?

How do we draw the line on what is ethical and what may be professionally dubious or even reckless endangerment?

We must each and every one of us, contemplate and decide for ourselves, periodically and conscientiously that what we profess as medical therapy are indeed in the best interests of our patients—our raison d’être for our existence.

Our pecuniary, entrepreneurial or other self-enhancing interests must always be subservient to this singular precept, and we must make that especial effort to keep this alive and as an overarching conscience to contain our potential excesses.

How best can we help avoid or contain our moments of weakness, or madness? Simple, and yet perhaps the hardest to implement… review our code of professional conduct frequently, be mindful of our Medical Act at all times, and keep our medical professionalism at our highest level of conscientiousness always. Be what our medical training has always taught us to do—the right stuff!

Let us strive to forever be known as healers par excellence, and not be remembered for lesser baser misconduct or acts unbecoming. Let us always tame our recurrently straining moments of madness, and retain our moral anchor always.

[MMA News Editorial, June 2006; Vol. 36 (6):pg7-8]

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