Take-home Message

Working with no bias

(Fictional narrative by the doctor)

James Fleck, MD, PhD & João A de Andrade

Anticancerweb 26 (04), 2019

Dealing with an ethical dilemma is always very difficult. Generally, it involves complex and controversial decisions. Attempts to resolve an ethical dilemma may lead to redundant and, at times, inconclusive reasoning that only serves to increase one’s ambivalence. This fragility has been extensively explored in dramas such as Faust by Goethe and Doctor's Dilemma by George Bernard Shaw.

I have read both several times and I am still learning. I learned that vanity and arrogance are incompatible with good practice of Medicine. I learned that technical knowledge must be explained to the patient as a universal good that sustains shared decision-making. I learned to always to tell the truth and to respect the emotional flow of my patient and, finally, I learned to never apply moral judgements to anyone. 

As the world evolves in the expansion and acceptance of human rights, ethics has become one of humanity’s most important compasses, guiding a myriad of professional and interpersonal relationships. Ethics committees have been established around the world in all health institutions to monitor research activities and to guide the resolution of disputes. Doctors are learning to accept their inner conflicts and limitations. Emotional Intelligence and sensitivity are becoming as valuable as the so-called “technical skills”. Patients, regardless of their level of education, have learned to actively seek knowledge to inform their discussions with providers. Doctors had to learn that their omnipotent and omniscient façade was a form of rotten vanity. 

Whenever a patient was in need, I gave my best and always sought to practice supported by the highest level of evidence available in the literature and by informed consent. Whenever an ethical conflict came up, I sought guidance from my institution's ethics committee.

Peter freely expressed his ideas and I respected his position. He could only resolve his dilemma with a lot of self-reflection and I trusted that he would do it. Peter had projected in Edgar the image of his brother's aggressor and his ability to care for him was jeopardized by this prejudice. 

He chose to not directly engage in this patient’s care and this behavior was not compatible with the expectations and standards of our training program.

Peter was just five years out of medical school. His reactions were still very impulsive and this case demonstrated that he was having great difficulty in keeping the necessary professional neutrality.

I sensed that this was a teachable moment! 

I paused and slowly explained my reasoning and expectations to Peter.

During the consultation, I noticed that Peter was in a state of deep reflection and seemed very conflicted about his feelings and assumptions. Looking at Edgar's frail body, he gradually ceased to identify him with his brother's aggressor. 

After I finished, Peter acknowledged that he had made a hasty judgment. He told me that at some point he felt that his prejudice was tying his hands by the same fetters that restrained Edgar's wrists. He knew that he had to move out of his comfort zone. He understood that as long as he did not solve this personal ethical dilemma, he was violating his professional oath.

I felt that I could count on Peter! 

He was expressing his feelings with great clarity and the strategy that he used to think through his dilemma gave him confidence. Although it was a very rapid change of behavior, it emerged from a deep reflection and all his thought process was quite coherent.

Based on growing mutual respect, we joined efforts to care for Edgar.

As expected, the CT scan showed an extensive lung tumor located at the superior pulmonary sulcus of Edgar’s left hemithorax. This was the typical presentation of a tumor first described in 1932 by Henry Pancoast, hence the acronym “Pancoast Tumor”. This non-small cell lung cancer represents only 5% of all lung tumors. Although rare, it is often recognized clinically because of its location in a very specific anatomical area of ​​the chest, causing a characteristic clinical presentation. The thoracic costovertebral gutter is superiorly limited by the vertebral column and the arch of the first rib. As the tumor grows in the upper pulmonary sulcus, there is a greater chance of invading the first rib and the brachial plexus, causing intense pain that could progresses and radiates to the arm, especially in the area of ​​distribution of the ulnar nerve, which was precisely Edgar's chief complaint!

Except for the cranial trauma, there were no other abnormalities on Edgar’s physical exam, leading to the assumption that he had a less invasive tumor. Extension of a Pancoast tumor to the lower cervical or upper thoracic nerve roots could cause devastating neurological signs, with muscle atrophy, increasing pain and abnormal sensation of the arm, forearm, fourth and fifth digits. We did not see any cervical lymph node enlargement and there were no signs of paravertebral sympathetic chain invasion that can manifest by drooping of the upper eye lid, unilateral pupil constriction and, decreased sweating on the affected side (Horner’s Syndrome). Reviewing his chest CT scan, one could recognize a primary infiltrating tumor at the superior sulcus, invasion of the thoracic wall and an enlarged hilar lymph node on the same side. There were no enlarged mediastinal lymph nodes. A magnetic resonance image (MRI) showed a partial erosion of the first rib and involvement of the left brachial plexus. Fortunately, there was no evidence of invasion of the subclavian vessels, and either the cervical or thoracic vertebral bodies. No metastases were seen in the previous brain CT scan. Based on the 8^th TNM staging system, Edgar’s tumor was clinically classified as stage IIIA. 

Peter conducted a long interview with Edgar, explaining the findings of the CT scan and the MRI. Edgar was coherent, he felt confident and had been just released from the use of handcuffs, however, he still had a police officer by his bedside. Edgar was a smart guy and was following Peter's reasoning closely. Peter said that the tumor was less extensive than previously expected and that a core needle biopsy would be needed. The biopsy would provide tissue for histology and tumor markers. Both tests would be very important to guide the treatment.

Edgar asked if the tumor would be removed.

It was not the first Pancoast tumor that Peter was treating, so he had enough experience to answer that question. 

He promptly replied. 

The treatment would be a combination of chemoradiotherapy plus surgery. 

Suddenly, Edgar uttered some obscene words, became agitated, expressed facial contracture, and began with a compulsive blink of the eyes.

Peter realized that he should stop his explanation and using a diversionary strategy began commenting on the results of the latest soccer league game. 

It did not work as planned, since Edgar did not pay much attention.

Peter stopped talking and stood on Edgar's side. He did not express any reaction or feeling, just waited until Edgar calmed down, which took about 5 minutes.

Edgar, gradually and spontaneously, returned to his usual passive behavior.

Peter asked him about the pain.

Edgar said it was not so bad as long as the pain drugs came in time.

Peter decided to stop the interview. It would have no additional benefit. 

At that particular moment, Peter realized how difficult it was to treat a patient with Tourette Syndrome.

He would talk to me later to get additional advice ...

To be continued in PLOT 5… 

*      Attention: The story 3 will be published sequentially from PLOT 1 to PLOT 6 and you will always see the most recent posting. To read Story 3 from the beginning, just click in the numbered links located at the bottom of the homepage. 

© Copyright 2019 Anticancerweb

 James Fleck, MD, PhD: Full Professor of Clinical Oncology at the Federal University of Rio Grande do Sul, RS, Brazil 2019 (Editor)

Joao A. de Andrade, MD: Professor of Medicine and Chief Medical Officer, Vanderbilt Lung Institute, Vanderbilt University Medical Center, Nashville, TN – USA 2019 (Associate Editor)