Ethical dilemmas in geriatric neurology: a physician interview

Medicine/Nursing - Ethics

PHYSICIAN INTERVIEW

Doctor, thank you for agreeing to this interview. Could you briefly explain what you do, how you came to your particular specialty area, and what your educational path was?

You're welcome; sure. I've been a practicing neurologist for seven years and most of my work consists of trying to diagnose neurological ailments and alleviate their consequences through surgical intervention where possible. I'm also involved in ongoing research into age-related cognitive impairment and the neurological basis of dementia in the elderly. I was an electrical engineer in college and I first started thinking about a career in medicine after hearing a lecture about the future direction of artificial intelligence and the field of the restoration of human neurological function after paralysis through robotics. Q: So, you wanted to combine your electrical engineering background and medical applications of artificial intelligence and robotics?

A: Not necessarily. That just happened to be the subject matter of the thing that piqued my interest in medical science because I had always preferred the non-biological sciences before. I became interested in neurology and I found that the field of geriatric neurology is a lot like being a detective...a scientific detective...which appealed to me.

Q: Is that what you like most about your job?

A: Not really. That's just how I came to develop my initial interest in my field. While I do still enjoy that aspect of it, I would have to say that the most rewarding thing about my job is the experience of helping people get back significant portions of their lives wherever that is possible to do through medical intervention. Q: So, you like being able to help people.

A: Yes, very much. The fact that I get to do it in a way that appeals to my way of thinking using my particular strengths just means I also enjoy many of the ways that I get to help people.

Q: Is it a field in which you frequently encounter ethical dilemmas?

A: Yes, there are several types of ethical dilemmas that we face: some of them are general to modern medicine; others are more unique to geriatric neurology.

Q: Do you mean the decision to suspend artificial respiration?

A: No. Certainly, that is also an ethical dilemma, but in my area of neurology, the issues that come up have more to do with aggressive medical treatment intended to prolong life in patients whose neurological functioning is already below that which is necessary for them to appreciate their lives. This is something about which people disagree, but in my personal opinion, it may be more ethically justifiable to stop treating certain medical issues in patients once an individual is already suffering from significant neurological decline such as that which we see everyday in dementia-related illnesses.

Q: You don't think their lives have value once they experience dementia?

A: Well, dementia comes in many different forms and degrees. I believe that in many cases, the early stages of dementia do not necessarily make it impossible for continued life to be worthwhile. However, there is a point of mental decline beyond which I have trouble recommending aggressive treatment of certain medical ailments intended to prolong life...to prolong life that is no longer the type of life that the patient himself would necessarily wish to prolong.

Q: Do you share those sentiments with patients?

A: No; and that is precisely the dilemma I'm thinking about. I realize that it is natural for patients' families to hold out hope of recovery regardless of negative medical prognoses. Likewise, I understand that it is difficult to acknowledge...acknowledge on a psychological level...that their loved ones are, essentially, already gone once they no longer recognize their own family members and cannot perform the simplest tasks for themselves. Not so much that they are physically unable to clean themselves for example, but that they are beyond the point of even caring whether or not they are clean or soiled.

Alzheimer's, is called the "long goodbye" for that reason, because in many ways, losing a loved only very gradually after their minds are gone is much more difficult than even a sudden tragic loss of life.

Q: Do you or your staff ever make medical decisions based on your feelings about that?

A: No, never. I dispense medically accurate information to my patients and their families and I present the clearest clinical picture possible about medical choices, decisions, and the likelihood of positive outcomes and negative consequences. My staff are never in position to make such decisions either. We treat patients as they and their representatives wish based on the objective data.

Q: What do you say when patients ask for your advice on a more personal level?

A: If I think the patient and their family is capable of understanding that it is sometimes best to let nature run its course and why, in my personal opinion, that is preferable to prolonging life through every means possible, I find some way to explain in general principles without making any specific recommendations about their cases in particular. Q: Is it safe to say that that is the worst part of your job?

A: Yes. On a professional level, every procedure I perform is beneficial to me, but I have mixed feelings operating on patients in circumstances where I wouldn't have made that choice for myself or a loved one of mine.

Q: I'm not so sure I agree with that point-of-view. Don't you think all life still has some value?

A: Many people share your view, which is one reason I keep my sentiments to myself in the professional arena. But if you had as much first-hand familiarity as I do with the effects of late-stage dementia and if you could see the physical destruction and deterioration of the brain the way I do, you might come to a different perspective of what constitutes living and where "treatment" might amount more to prolonging suffering than to helping patients.

Q: Do you share your personal feelings with your staff?

A: No. I would not want any of their decisions or practices affected by that point-of-view and I don't necessarily trust other to separate their personal feelings from their professional obligations the way I strive to.

A: I understand. Thank you for being so candid.

Q: You're welcome.