The Algorithm and the Hippocratic Oath
20th September 2024
Several years ago, I was involved in a case that illuminates the difficult position many doctors today find themselves in. The patient was pregnant, close to delivery, and experiencing dangerous declines in her baby’s heart rate. She had been on a blood thinner, which kept me, the anesthesiologist, from placing an epidural in her back. She also had strange airway anatomy, which would make it a struggle to put her to sleep quickly if an emergency cesarean section became necessary. I advised the obstetrician to perform an elective cesarean section now, in advance, while we had good working conditions, and not to wait for an emergency, where time is of the essence, and where the delay needed to induce general anesthesia might seriously injure the baby.
The obstetrician grew quiet. She seemed to descend within herself, in that lonely region of stress and strife where people feel themselves to be in an untenable position. Several things worried her, she confessed. First, hospital management had already warned her that her high cesarean section rate made her an outlier among her colleagues, which put her job at risk. Second, the baby’s heart rate did not quite meet the criteria for when to perform a cesarean section. True, the current situation was unfamiliar and unforeseen; then again, she wondered, would hospital management, let alone the malpractice lawyers, accept that excuse? Third, she wondered how to persuade the patient to have an operation that her own rules seemed to advise against.
The changing work environment in which many doctors practice medicine leads to such moments of uncertainty—and all but guarantees that they will occur more frequently. As more doctors work for large companies, they have bosses they must answer to. Rules for how to practice medicine have multiplied exponentially, and their bureaucratic enforcement makes doctors afraid to violate them. With science forming the bulk of their medical and post-graduate education, doctors also feel bewildered when faced with questions that touch on the moral, the political, and the philosophical.