“A dilemma often has more than one ethically defensible response and always leaves you wondering,” writes the author, a Denver obstetrician-gynecologist and nationally known medical ethicist. Abrams, who also served as chair of the Ethics Committee of the American College of Obstetricians and Gynecologists, presents a baker’s dozen of dilemmas from medical practice, his own and others’. In a voice both tender and tough he tells each tale, disguised for confidentiality, as though it were his own. The stories have stranger-than-fiction power.
Having led myriad workshops, Abrams weaves in explanations of how law, medicine, and religion have wrangled with topics like informed consent, patient autonomy, threats to public health, and the right to die. “You will find some of them difficult to condemn and some difficult to condone,” he writes, about doctors who sometimes lie, evade, or stretch the law to the breaking point.
From the outset the good doctor takes readers on a plunge into the deep end. “Andrea” was a male for two decades before changing by surgery into her truer gender. She could not bear children, but wanted to adopt. Should the doctor keep her secret—gender change—from the scrupulous inquiry of the adoption agency? Should he keep it from her husband, whom she has not told? Should another doctor lie, pretending a woman’s early abortion was a ruptured ovarian cyst? She persuaded him that it would save her marriage, since her beloved husband, who had had a vasectomy, could not abide the single indiscretion that led to the pregnancy. Another woman swears her doctor to secrecy about a crime—rape—because she knew her husband would kill the offender if he found out: it was his father.
One chapter clarifies a rare case like that described by Jeffrey Eugenides in Middlesex (Pulitzer Prize, 2003) from the surgeon’s point of view. A girl with a hernia is found to have normal testes alongside a rudimentary vagina. Abrams explains the genetics, agonizes about how to break the news to her and her parents, and praises the Internet, where people with rare conditions can now find essential information and support. Then comes a thriller, “Confidentiality,” in which two doctors exchange information illicitly about a positive HIV test in a supposedly faithful man who would rather infect his girlfriend than admit his condition.
A case of the sterilization of a teenage female Down syndrome patient brings up the ugly story of eugenics in the past century along with the dilemma of consent for a minor who will not be any more competent in a few years when she is twenty-one. In a contrasting case, a mature woman learns that her abnormal fetus will almost certainly not survive, but chooses to carry the pregnancy despite medical risks and the doctor’s best advice. He proves to be fully supportive, though their views on religion have little in common.
With the last few cases, Abrams considers end-of-life issues. Outside of Oregon (which has a unique law permitting physician aid in dying) can a doctor prescribe drugs to hasten death? Difficult situations concern a man with amyotrophic lateral sclerosis (Lou Gehrig’s disease), a woman with early Alzheimer’s, and another with debilitating arthritis. Quality of life, patient autonomy and empowerment, and the right to refuse treatment and request palliative sedation are addressed. The author mentions hospice care favorably, but might have emphasized that most of it is home-based. Too few doctors are attuned to its benefits and may be afraid to bring it up with patients and families; as a result most patients enroll too late to make best use of the program. The book ends with an upbeat story of the author’s assist from a patient in passing a neurology exam with flying colors.
This book is wonderful medicine: intellectually rigorous, genuinely empathic, and palatable. Along with everything else, Abrams puts social history on the examining table with firm grasp and light touch. He teaches by example with a realistic balance of the unusual and the common. There may be common diseases, but there are no common patients, no wholly predictable families. Abrams holds physicians to a high standard, but makes the subject so interesting that his example could boost medical school applications as well as the quality of medical education. People who might need medical care will find out from Abrams that this high standard can and should be met, even now.