The Ethics of Counselling

Primum non nocere -First, do no harm. I remember the phrase was used in one of the first lectures I attended in medical school and it nested -sometimes uncomfortably- in my conscience as the lectures and the years progressed. It would signal me from the back seat in Pharmacology lectures and tug on my sleeve in Physiology labs when we would be asked to subject laboratory rats to unconscionable ‘experiments’ whose outcome was already known and whose purpose would have been questionable even had we been seeking a Nobel Prize rather than a passing grade.

It especially fought for my attention after I’d graduated, when my decisions would actually be accorded credence. I would be asked to see someone in pain -with endometriosis, say- who had decided she’d had enough and wanted a hysterectomy. Often she would have been aware of other options -medications or ablative surgeries- and have tried them all unsuccessfully; sometimes she might be speaking out of frustration or desperation. But in none of these situations would she have felt in control, a full and willing participant in her destiny, able to make a reasoned, or at least equitable decision for herself.

One might argue the role of the dispassionate physician here: the person who can consider the ramifications of each option, present them in a reasonable and sensitive fashion, and help the patient decide. And yet, one might also point out the possibility that the patient might be unable to make a truly informed decision for herself under duress. There’s a term used in Medical Ethics that we were also taught in medical school: non maleficence. This is a concept that suggests that it is important -no, necessary– to consider whether a particular decision might do more harm than good, no matter how well-intentioned. It is yet another version of the primum non nocere phrase that so influenced me.

If I feel the patient actually understands the ramifications of her decision, and has at least considered and then rejected other possible pathways, then I am more than willing to accede to her request and help in whatever way she feels would be in her best interest.

But I have always believed that informed, or at least insightful empowerment -if I dare use that overworked and voguish neologism- is the key to compassionate decision-making. It’s object is not so much to convince or direct, as to allow her to come to an appropriate and acceptable decision, as much as possible unencumbered by all the trappings and emotional accoutrements of pain and frustration… As I have already mentioned, the problem of counselling someone in dire straits is that her pain or anxiety, quite apart from its obvious distraction, often permeates her entire being and impedes her ability to look out for her own ultimate best interest. Sometimes, the person can hear nothing but her own suffering. Counsel has to be heard as well as given.

I’ve explored many techniques to help the person help herself: meditation, relaxing exercises, music… But apart from the latter, they do not lend themselves readily to a half-hour appointment in a busy gynaecological office. And although music is my constant companion through the day, it is often background noise, if heard at all, for the patient stressed by more immediate problems. Most are unwilling, or more likely, unable to believe that meditation or relaxing exercise, will contribute anything to the resolution of their particular issues. It is difficult for them to see through the fog of their distress, and in many circumstances they do not need to do so.

If the problem does not admit of any other solution, then action of some sort is required. If the patient has a ruptured ectopic pregnancy and shows up in the Emergency Department, the solution is obvious and immediate. If she is hemorrhaging from a miscarriage, an explanation of a reasonable approach to the problem and then a D&C is appropriate.

I am not so concerned about the conditions that do not beg for a decision, or ones that cannot be resolved in any other way -conditions for which choice is mandated by necessity. But for those afflictions for which options are available and for which none are paramount, there should be other constraints to the decisions made. These are questions of ethics again: autonomy -the patient has a right (and indeed a duty) to decide for herself, and beneficence –the doctor should act in the best interests of the patient. And sometimes this requires techniques to enable the patient to exercise this right, and the doctor to feel he is in fact acting in her best interests.

Hypnosis is one approach to this that lends itself to an office setting. It is not for everybody, nor is it necessarily attainable in each and every patient, however willing. But I feel that in my office at least, it should be a non-directional tool if it is used at all -one that seeks not to influence or counsel, but merely to engender some symptomatic relief. It is an easily teachable skill, and because the relaxation is so readily apparent to her once she has encountered it, probably an effective one that she may well decide to try again. And with some goal-direction.

I am reminded, however, of the time when I initially began to use the technique. I seemed to attract rather unfortunate referrals then. At first the referrals were for innocent things: stress relief, panic attacks… even smoking. I had to quickly disavow myself of these consultations: although gynaecology entails a lot of psychology, I don’t see myself as the answer to panic attacks.

Then, undiscouraged, they began to send me more difficult problems: warts (yes there exists a body of literature of immune enhancement to engender a bodily response to the viral scourge of warts, et alia), endometriosis, PMS… anything for which the family doctor felt she was losing the confidence of her patient.

I have always felt more comfortable dealing with topics for which I am nominally trained, so I attacked the gynaecological issues with contemporary skill and knowledge. Only on the third or fourth visit and when all else seemed to have failed would I delve into the alternative toolbox in desperation. Sometimes it worked; often it helped. Visualization was especially popular I remember. Endometriosis? Right: visualize a field of flowers and with each breath in, you pick some, and with every breath out, you throw them away. Yes, the flowers are endometriosis implants.

When planetary eco-consciousness took hold, I had to modify the picture, however and switched it to picking up litter on the street then depositing it in a suitable refuse container… Anyway, same idea, same results if they remained enthusiastic adherents. Placebo? I don’t know, but even placebo works for a while, doesn’t it?

The problems worsened from the die-hard family doctors, however. Elated by the success of diverting their problems to me I began to get referrals that really made no sense. One that stands out particularly colourfully in my mind was the woman who was sent to me because she was anxious.

At first I assumed there was a gynaecological reason for the visit, but she quickly informed me that she was actually healthy: normal non-painful periods, no mood swings, no pelvic pain… Her pap smears were even normal and up to date, and she’d just had a mammogram.

I was beginning to despair of helping her when she admitted the reason for her visit: she was running for public office in the Philippines and was anxious about getting up in front of a crowd and speaking. She’d heard about hypnosis and wanted to try it.  Although a little out of my line of work, I thought maybe I’d try a little standard hypnosis to alleviate her anxiety since she was in the office anyway.

She looked relieved and smiled at me. “Thank you doctor,” she said relaxing in her chair. “I’ve tried everything I could think of -even tranquilizers- but I’m still terrified each time I get up there to speak.”

Although I sometimes try to explore the reasons under hypnosis and help the patient to recognize what might reasonably be expected to work for them, I decided to ask her beforehand if there was anything in particular that  worried her about speaking in front of an audience.

She didn’t give it a moment’s thought. “Oh yes, doctor. It’s in the Philippines, you know…”

I nodded pleasantly, and assumed perhaps the venue, or maybe heckling from the crowd was her concern.

“And there’s a lot of opposition to my stance on Birth Control, you know.”

I assured her we run into the same thing on occasion even here. “Sometimes it’s hard taking a stand on something isn’t it? You can never please everybody, can you?” It was so banal a comment I immediately regretted saying it, but she seemed to take some solace from my words.

“No you can’t please everybody, it’s true. And I’m glad you understand; that’s exactly where my problem lies. It’s why I want you to teach me hypnosis.”

I smiled the doctor smile, satisfied, benevolent, convinced that I was perceptive and could recognize her difficulty despite our difference in cultures and gender. I could help.

“Yes,” she continued, ” Every time I get up to speak in front of a new crowd in a strange village I’m afraid I’m going to get shot.”

I believe in counselling and I try to take the time to listen for what they sometimes cannot verbalize. I like to believe I can make a difference, but I don’t think I really helped her, you know… Maybe I should have referred her to someone else, but she left the office happy. Beneficence sometimes trumps non-maleficence, I guess -even if it’s only in the beholder’s eyes.

Dermoid

She was sitting in a black leather chair in the corner by the window holding a magazine in one hand. A small, thin woman in jeans and a black sweat shirt with  short blond hair, she watched the room like a television screen. Even in the confusion of a pregnancy-filled waiting room, she looked oddly at ease, content, smiling at the life around her: a parent at a kindergarten. She even seemed pleased to see me, although I’d never met her.

With all the problems I encounter during an average day, it is a pleasure to see someone who is happy, someone for whom the Fates have not cast a crooked die. She followed me almost casually along the long corridor to my consulting office and sat in the little hard wooden seat across from the desk as a queen might: relaxed, at ease, regal.

There was a short note from her GP outlining the reason she had been referred, but I couldn’t read the handwriting -only the name and the age: Martha, 25. “So what can I do for you today, Martha?” I said, hoping she actually knew.

She let her eyes rest on the picture hanging behind me for a moment before they fastened on my enquiring expression. A beatific smile crept slowly across her face and her eyes unlocked briefly as she considered her response. “I have a visitor,” she said finally, barely able to confine her growing enthusiasm.

My eyes narrowed for a split second before I could stop them. “A visitor..?”

“Dermoid,” she replied as factually as if she were informing me she had a sandwich in her purse and no further explanation was necessary -as if the very word would answer all I could possibly want to know.

“How..?” I wasn’t quite sure where to start.

“I had some pelvic discomfort so my GP ordered an ultrasound, and voila: 6 centimeter dermoid, left ovary.”

Succinct, factual, if a bit unconcerned, she seemed comfortable with the condition. Most people confronted with an ovarian tumour would have been worried about cancer. “Well, I’m going to have to get a bit of background but you seem quite knowledgeable about the diagnosis… I take it you’ve looked up dermoids.” She looked so calm.

She sighed and would have rolled her eyes had I not been watching her. “Of course! Wouldn’t you?”

I smiled and nodded my head. It was clear she wanted to tell me about them, so I decided to forgo the history for a moment. “So what do you understand the term to mean?”

“Want the Wikipedia explanation, or one from a university website?”

I shrugged; she probably knew more about them now than I did.

“I’ll put it in my own words then, okay?” Now she was the bright child in class who had an answer to the teacher’s question. “Dermoids are interesting,” she started, her enthusiasm visibly building as she spoke. “A dermoid is a tumour that develops almost entirely from the ectoderm -one of the primary germinative cell layers in the early embryo. Tumours that develop from the germ cells are sometimes termed teratomas.” She studied my face for a moment to see if I was understanding her. Evidently satisfied that I was, she continued. “Ectoderm develops into skin, nerves, and so on…” Pleased that I seemed to be following her, she added “Mesoderm develops into muscle, Endoderm into gut…

“So anyway, a dermoid cyst is derived from ectoderm and contains… oh, like hair, sebum, cartilage, teeth… Teeth! Can you imagine that! And sometimes even thyroid tissue…” She sat back in the chair, eyes at peace now that she had explained her rapture.

I sat back as well; she wasn’t finished.

“Dermoids are usually removed -especially the bigger ones- because they can twist, cutting off their own blood supply… And a small percentage can develop cancer. Skin cancer -can you imagine?” she said excitedly and then suddenly focussed on my face, a hopeful expression on hers. “Do you know why they develop?” She read my expression. “No, I guess not; nobody seems to have a clear explanation…” Her face brightened. “But everybody seems to have heard of them. My boyfriend’s in business school and even he knows the name.”

She paused; I blinked, happy to be able to say something. Anything. “They’re called ‘Medical Student Tumours’ because they make such an impression on medical students that they remember them years later, even if they’ve gone into Cardiology…”

She smiled contentedly, pleased to be associated with something so popular.

“But…” I wondered how to put the question. “Why did you say you have a visitor, Martha?”

This time she did roll her eyes. “Ectoderm, right?” She waited for my nod. “And Ectoderm makes brain?”

“Well, nervous tissue…” I wasn’t sure what she was getting at.

She crossed her arms and stared at me like a parent waiting for her child to make an obvious connection.

But I didn’t; I still haven’t. I know I disappointed her.

Acknowledgement

Medicine, like Fashion, has its vogues, its conceits if you will. Admittedly less capricious, they are nonetheless as unpredictable. Think, say, of the menopause. Until relatively recently it was largely ignored. There were so many other health issues in a woman’s life, that if she was fortunate enough to survive to the menopause it was seen as propitious, not a condition that in and of itself required treatment. It was merely what happened when you got old, like failing memory or forgetfulness. Remember the riddle of the Sphinx that Oedipus solved: What has four legs in the morning, two at noon and three in the evening? The answer, of course, is Man -or in this case Woman. Menopause is merely the third stage -the evening stage- and as natural as the other two.

And then came Hormones. By replacing what was lost, it was hoped there wouldn’t be a stage three -or at least not for a while. True, Medicine was just responding to changing societal health and the revised expectations engendered by a longer life, but change it did. The hormone replacement therapy paradigm persisted until it became evident that the supposed benefits came with seemingly unanticipated risks. The hormones were not the hoped for panacea, helpful as they often were. So we’re currently in the interregnum, the uncomfortable time between one paradigm and the next.

Another topic in the shifting medical sands is attribution. Names. We keep renaming things, as if by doing so, we somehow expunge the past and wipe the slate clean. Take, for example, disease that is spread by sexual contact. Historically, of course it seemed appropriate to name it by its source. So the appearance of Syphilis in Naples after a fifteenth century French invasion naturally suggested the condition be termed the ‘French Disease’. Some offense was likely taken, so after a while, this and other ‘social diseases’ as they were also once called, were renamed venereal diseases -VD for short. And then, as people began to stigmatize that term, it was changed to Sexually Transmitted Disease -STD. Well, you guessed it: same result. So poof, it is now STI: sexually transmitted infection.  Of course, some terms clearly needed to be changed: Mongolism to Down Syndrome, for example. Or ‘retarded’ to something more politely descriptive such as ‘mentally challenged’.

Perhaps I am being too reductionist here, but you can see the changes: the wide to the narrow tie, the cuffed pants to… Well I’m sure you take my meaning. We are, as the curse has it, condemned to live in interesting times.

But as trivial as name changes might seem, and as revisionist as new attitudes to ageing could appear, there are some fundamental shifts occurring in Medicine that bespeak a new awareness of its role in patient care. There was a time when the doctor’s word was unquestioned -indeed unquestionable, given the hitherto arcane and unavailable sources of his knowledge. If you disagreed with the diagnosis you were free to leave and seek another opinion, but not to challenge. If mistakes were made, there was little hope of recourse or redress, little hope of discovering whether there had in fact been mistakes. Diseases take unexpected turns, surgical success is contingent: things are not always remediable.

This is still the case, obviously, but doctors are becoming more open about explanations and patients about asking for them. It is still a work in progress to be sure, but there is reason for hope. There was a time when pride of place ruled even more than today, when to explain an outcome -to have to explain it- was akin to a subliminal admission of guilt. This is perhaps too severe a judgement, and yet there is a thread to the argument that seems to hold even today. But the hope lies in apology: the acknowledgement of fault, however tenuous and however unintended. It’s an affirmation, of sorts, for both parties; it’s a recognition that we share a common trait: none of us is perfect. We know that of ourselves; why should we not expect it and accept in others when they admit it? Especially if they admit it.

“I’m sorry.” It may not solve the issue, but there’s a sort of resolution embedded within it. It may seem a faint hope that this will become the norm -naive perhaps- and yet I see it coming. It’s how one caring individual deals with another.  An apology is a first step and a big one. Alexander Pope assessed it the best, I think: ‘To err is human, to forgive divine’. I’d like to think that both the profferance of an apology and its acceptance is a characteristic of humanity as well. It is also a first move in the slow dance to understanding what it means to offer care, or to accept it from another.

Fibroids

I sometimes prefer to call them leiomyomas -it’s more descriptive of a condition that involves muscle cells- or even fibromas. I said this by way of beginning an explanation to a patient who was sent to me for them; she looked at me as if I had just sworn at her -belittled her condition. I hadn’t meant to…

“Hiding behind medical words, doc?” she said, unsuccessfully attempting a smile.

I suppose I was. Her mother had endured a hysterectomy for fibroids, her sister had developed them and was booked for surgery, and  a recent ultrasound had discovered  several 3-4 cm. nodules in her own uterus. Now I was trying to fool her with new words: a different type of fibroid that maybe you didn’t have to remove.  She’d looked them up, and talked with her family, and now was convinced that hers needed fixing too.

Not too long ago, that’s what you did with fibroids: you either removed the fibroids, or the organ that carried them. Period. They were clearly abnormal and shouldn’t be there in the first place. They pushed on things inside the abdomen, could grow really large -and, oh yes, they made you bleed. No, hemorrhage! End of story. And besides, for Marlene, it was a family tradition, a rite of passage into the next phase of womanhood: after the kids, the hysterectomy.

She seemed disappointed when I told her they were quite small, and that their location made it unlikely that they were contributing significantly to her heavy periods.

“Then why are my periods all over the map and heavy like this? When I was younger, they hardly showed.”

I tried to put fibroids into some perspective for her. “Well, first of all, fibroids are really very common. Up to 30% of caucasian women at thirty years of age have fibroids. That’s how I remember it,” I said, smiling, and dotted my pen on a diagram of a uterus I keep on my desk to illustrate the size they might be at that age. “And in some populations, genetics probably plays a big role and the figure might be as high as 50%.” She became all eyes.

“Fibroids are usually very sensitive to estrogen and so they tend to grow more rapidly in a woman’s mid to late forties when they get a lot of unopposed estrogen -estrogen that’s not being opposed by progesterone…” I could see I was losing her. “You’re what..?” I snuck a look at the chart. “Forty-eight?”

Her brow wrinkled. “Forty seven, doc.”

“Well, when you were twenty-seven, you probably ovulated each month and then your ovary would produce progesterone and…”

Her hands slipped onto the desk in front of her and she leaned over it and stared at me. “Doc, I’m not here to talk about what my ovary does or used to do. I’m here to talk about what my fibroids are doing now!”

She had a point.

“And more particularly, what you are going to do about my fibroids!”

“Well, I don’t think that…”

“My sister’s fibroids are small, too and she’s getting them out.” She sat back for a moment, convinced she’d scored a point. “She’s two years older than me and she’s got six.” Her face took on the determined look of someone  dealing with a small child. “How many have I got?”

I looked at the ultrasound report her family doctor had sent along with the consultation request. “It just says ‘multiple fibroids, the largest of which is three centimetres in diameter. They all appear to be intramural in position with no submucosal component.’  They usually only describe the biggest ones, because sometimes the others are too numerous to count.”

Her expression showed some interest. “Sub what?”

I showed her on the diagram that a submucosal fibroid juts into the lining cells of the uterine cavity. “They tend to be more of a cause for heavy periods than the ones that are growing in the middle of the muscle of the wall: that’s probably because they create an increased surface area where more endometrial cells can grow.” It seemed a good argument to me. “So your fibroids are small and not sticking into the uterine cavity.” I drew what I hoped was a convincing fibroid in the muscle wall, careful to keep it a decent distance from the lining cells in case she wanted to argue about surface areas.

“But I got a lot of ’em doc,” she said, almost proudly. “My sister only has six and she’s getting a hysterectomy.”

“Well,” I said, stalling for time -I could see the writing on the wall already. “There are other things we can do for fibroids…”

Her arms suddenly appeared across her chest as she pretended to listen politely. It was what you had to do at a doctor’s office sometimes. “Like what?” she said with her mouth, while her eyes dared me to find something acceptable to her and her family.

“Like embolization: cutting off the blood supply to the fibroids so they shrink down by about…”

But she was shaking her head vehemently. “Doesn’t sound natural!”

“Well, if we could get you to menopause without surgery that would be really natural -given that you have no symptoms except a recent onset of heavy periods, and there are…”

“No symptoms? What would you know about symptoms, doc?” she said, giving what she could see of me above the desk a critical once-over and rising to her feet. “I can see I’m wasting my time here,” she muttered, gathering up her belongings from where she had scattered them on the floor beside her chair. “I knew I shoulda gone to a woman!”

“Marlene,” I said to her back as I rose to see her to the door. “I was merely suggesting that there are options with fibroids; they don’t all have to end up being removed.”

She turned to face me, and I could see the muscles of her jaw twitching. I had obviously crossed some sort of threshold. “Doctor,” she said coldly, “Despite your age, you still haven’t learned when options are needed, and when they’re…” She paused to consider the word. “…Unnecessary and insulting. If I’d wanted a choice, I would have asked you!” And with that, she turned and walked out.

I’ve thought about this a lot and I’m still not certain whether she was right. For a choice to be truly that, shouldn’t it be made from a list of things that might also work -an informed choice, in other words? Wouldn’t it be irresponsible of me as a doctor merely to accede to the initial wishes without explaining what else is available?

It would be easier, I’ll admit, but I doubt if I could sleep at night…