Death by proxy?

Death by proxy?

DIVERTICULUM in the cervix. I give her prophylactic antibiotics and she promises to return to hospital as soon as she starts Empathy with patients is ...

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DIVERTICULUM in the cervix. I give her prophylactic antibiotics and she promises to return to hospital as soon as she starts Empathy with patients is all very well1 bleeding (or has pain or a fever) so that but one particular source takes the we can prevent severe complications. concept to extremes. In Medical Ethics 1 Two days later she is admitted with Today, published by the British Medan incomplete somewhat septic aborical Association, one peculiar sentence 1 tion. The uterus is evacuated and we caught my eye: "Dying should not be1 do a laparoscopic tubal ligation at the an event suffered in isolation but same time. The evacuation and the should ideally involve those close to the tubal were free of charge ligation patient". who earn more than although persons Z$400 are not entitled to free treatClare Thompson The Lancet a little ment, but she was able to bit and the hospital economic authorities believed her.


by proxy?



cry when

they are HIV negative On

Tuesday afternoon at the gynaecological clinic (fee per visit for paying patients Z$34) one of the last patients I see is a woman of 38 years who demanded a termination of pregnancy. Why? is the logical question in a country where abortion is only allowed for a few indications. "Because my boyfriend’s wife died two weeks ago from AIDS". Being HIV positive can be, depending on the personal opinions of the authorities on how to interpret the law and how far the medical superintendent is prepared to stick out his or her neck, a possible indication for a termination. "I have to test you before we can try to organise an abortion", I say. After some hesitation she agrees. A week later while I am seeing one of the first patients of the clinic the secretary brings me the HIV result: negative. I have already seen the patient in the waiting room, I think she might be very anxious so I rush to the waiting room and whisper the good news in her ear. She starts crying loudly, not of joy but of disappointment. She has lost her indication for a legal abortion. Later on we discuss things. She divorced in 1991 because her husband married a second wife. Her husband was ordered by the court to pay maintenance for their daughter, now 10 years old. The husband disappeared to South Africa: no maintenance. She is lucky she has a job, which pays Z$450 a month. She pays Z$200 a month for her house to the city council. She was "forced" to have a boyfriend because she needed a son for all sorts of reasons including her old age pension. She now has that son, he is one and a half years old. Her boyfriend, now a widower, is allowed to visit their son and her but has to use condoms. Something went wrong, hence this pregnancy which she is convinced will ruin her. She insists that she will have whichever way an abortion. It appears she knows somebody who is prepared to abort her for Z$160 with a root of a





Bulawayo, Zimbabwe


The Medical


(with apologies to



We seek him here, we seek him there, Those ladies’ seek him everywhere. Is he in heaven?2-Is he in hell?3 That demmed, elusive Pimpernel.4 Peter Nicole

Köping, Sweden


The ladies of the switchboard.


Enjoying a well-earned, post-round coffee on the balcony. At an administrative meeting. Pimpernel: a doctor whose bleep isn’t working.

3 4

Hostage to


I went to see my consultant and he told me I could go back to work. All good things come to an end. He still hadn’t seen my MRI scan. The scan had been slotted in late at night on day three of a ten-day admission. Subsequently, despite heroic efforts by several doctors on the team, the pictures had evaded capture. Now, six weeks later, in outpatients, the medical student has been dispatched to snaffle the pictures. He duly returned, having tracked them down to the desk drawer of one of the consultant radiologists. We looked at them together. There’s

gainsaying it; high-tech medicine is highly impressive. At the time of the scan I was in pain, with nerve root irrino

tation from left Ll to L5 inclusive. I had just finished reading An Evil : Cradling, Brian Keenan’s book about his ordeal as a hostage in the Lebanon. Keenan was moved repeatedly from one



another, usually wrapped

in plastic sticky tape and concealed in a small metal compartment underneath a lorry. His captors assured him that the lorry was wired with explosives, to allow the driver the honour of selfdestruction in the event of attempted

capture by rival militias or Western agents. The MRI scan procedure involved lying for half an hour in a breezy coffin-shaped tube, with four episodes in which I was asked to lie completely still for five minutes, whilst the machine made a vicious low-frequency humming noise. Driven by a futile impulse to relieve the pain by moving position, three seconds would have been my preferred limit for keeping still. It was difficult to resnt the urge to press the panic button and abort the scan. I thought Keenan would have coped better, to be sure. Worse, I could picture the likely spoken headline on the local gossip grapevine: "6 foot GP panics in routine

X-ray procedure". I suggested cheerfully to my consultant that 100 mg of pethidine prior to MRI scanning would have been a helpful manoeuvre. Expressions can be difficult to read, but I think he gave the look we doctors reserve for the feeble-minded and aspiring druggies. I dropped the subject. me




soft and hard


am spending part of a sabbatical in an advisory capacity, precepting family medicine trainees and modelling com-

munications skills. The consultations are unhurried and have engendered an observation relating to the young and how they thrive on certainty. For them, much of medicine is "obvious", with the book telling you what to do, particularly where the hard facts of laboratory science are concerned. It is a distillation of consensus and so, almost by definition, cannot be "wrong". The other day, a trainee and I searched through four textbooks to learn the influence of ingesting iron or vitamin C on the guaiac occult blood test. The former, according to "Primary Care Medicine" by Goroll, May, and Mulley (2nd ed, 1987: 253) can interfere with the test, whereas the 8th edition of "Current Surgical Diagnosis and Treatment", edited by L W Way (1988: 441), holds that it has no effect. Vitamin C, if one consults Branch’s Office Practice of Medicine" (2nd ed, 1987: 1248), can produce false negative results, but, if "Harrison’s Principles of Internal Medicine" (12th ed, 1992: 261) is referred to, a false positive may be encountered. It is unlikely that all are right, so, as a veteran dealer in uncertainty, I was how soft hard science


Joseph Herman

Jerusalem, Israel


to note