Coercion

August 25, 2010

The surgical attending said to me, “The more pain he has from his ulcer, the more he will realize how serious this is, and the more likely he will be to consent to the surgery.”

I had just thrown my stethoscope around my neck like a yoke at the beginning of my shift when the phone rang. It was a senior surgical resident: “I’m coming down to the ER with my attending. The patient in Room 8 is not to receive any pain medication under any condition.” 

“Come again?” The moans coming from Room 8 made it difficult to hear the voice on the phone.

“The patient in Room 8 has a perforated peptic ulcer and needs to have surgery, but he is refusing consent for the operation. He needs to understand that he will be in tremendous pain and will probably die if he doesn’t agree to surgery, so don’t give him any kind of pain medication of any kind!” The surgical resident sounded quite upset.

I sighed. “OK - tell you what I’m gonna do. I haven’t even seen the patient yet, but I’m gonna draw up 10 milligrams of morphine and walk into Room 8 and inject this directly into his IV. Then I’m gonna get a big cup of coffee. If you see any creamer on your way down here, please pick it up for me, big guy.” I hung up before he had the chance to spit out a reply.

True to his word, a whole herd of surgeons came bounding into the ER a few minutes later. I picked the shortest and meanest and loudest guy as probably being the attending. “Who is the…person…that gave morphine to my patient?” asked the short, angry surgeon, through clenched teeth.

I rose slowly, swirling my thick black coffee. “That’s me.” I acknowledged the senior resident with a nod, “What, no half and half?”

“What’s the matter with you? This patient has a perforated peptic ulcer. He has free air under the diaphragm. Every minute that we wait, he is spilling gastric contents into his abdomen and increasing his mortality.” The surgeon paced back and forth, bumping into the collection of residents and students, glancing into the room where the patient lay quietly.

“Why doesn’t he want the surgery?” I asked.

“He wants a second opinion or some other kind of crap,” the senior resident snorted. “I showed him his X-rays but he wasn’t listening. I asked him why he came in here if he didn’t want our help. This guy is going to die because he is too stupid to understand that he has a life-threatening condition and now you gave him morphine so he has no pain.”

The surgical attending looked disgusted. “The more pain he has from his ulcer, the more he will realize how serious this is, and the more likely he will be to consent to the surgery.”

I put my coffee down and started to take off my white coat. “You know, I have an idea. How about I hold him down and you punch him in the face until he agrees to the surgery?” The medical student’s jaw dropped open. “Or maybe you hold him down and I’ll punch him in the face until he agrees to the operation? C’mon, let’s go.” I started to move toward the patient’s room, but the pack of surgeons stood standing like green and white cows in a field.

“What are you talking about?” the attending surgeon asked. He was off-balance and just smart enough to know it. The resident was trying to keep up.

“You can’t withhold pain medication to force a patient to agree to surgery! That’s coercive! How can a patient in severe pain ethically agree to anything? That’s the whole point behind torture! Should we waterboard him too?” I was starting to shout and I had to bring it down a notch. “If you spent five minutes with the patient, you would realize that the guy is absolutely terrified. He wants to talk with his wife and his wife asked us to call his pastor, who is on his way.”

The resident made a move toward the room. “Don’t go in there!” I could feel the anger building again. “How can you guys be so…illogical? Just go back upstairs and wait for us to call. It shouldn’t take long.”

It didn’t. The pastor arrived. He had been a combat medic in Vietnam and probably understood as much as the resident about the consequences of an untreated perforated peptic ulcer. The patient took some more morphine, calmed down, and agreed to the procedure.

My colleague had witnessed the whole scene and offered to accompany me to anger management classes whenever I felt the need. Funny - that’s not the only time someone has made that suggestion.