Physician and patient

by Worthington Hooker

I wish not to be understood as saying that we should never take pains to withhold knowledge from the sick, which we fear might be injurious to them. There are cases in which this should be done. All that I claim is this—that in withholding the truth no deception should be practised, and that if sacrifice of the truth be the necessary price for obtaining the object, no such sacrifice should be made. In the passage which I have quoted from Dr. Percival, he states a case in which he very properly says, that the patient’s right to the truth is suspended; but I do not agree with him, that in withholding the truth we have the right to put absolute falsehood in its place.

It is always a question of expediency simply, whether the truth ought to be withheld. And it is a question that depends, for its proper decision, upon a variety of considerations in each individual case. It is very often decided injudiciously. There is generally too great a readiness to adopt an affirmative decision. It is too easily taken for granted, that the knowledge in question will do harm to the patient if it be communicated to him. The obvious rule on this subject is this—that the truth should not be withheld unless there be a reasonable prospect of effectually preventing a discovery of it, and that too by fair and honest means.

It has often been said that the physician has no right to excite too much hope in the mind of a patient by directing his attention, as is often done, to any favorable symptoms that may appear in his case. But I ask, how is it known that in the case in relation to which this remark is made, too much hope is excited? The physician is fallible, and is by no means answerable for putting just the right degree of hope into the patient’s bosom. It is not to be expected of him that he shall always tell each patient just how his case stands. His own mind is often filled with conflicting hopes and fears, and he cannot decide clearly what the probabilities are in many cases. And if he thinks that he can do so, he may be very much mistaken. Estimates are often made most unwarrantably. An exactness is often aimed at which is impracticable. The patient in many cases has no right to such an estimate, for while it may be a mere guess, he may look upon it as a well-founded estimate, made upon a real knowledge of his case. He will therefore draw false inferences from it, and this the physician is bound to prevent, and in so doing he actually prevents deception.

The physician should always remember that though he may be aware himself of his liability to err in making any such estimate, the patient may have such confidence in his judgment, that he will consider the opinion which he may express to be of course a correct one—almost beyond the possibility of a mistake. So that however guarded he may be in expressing an unfavorable opinion of the probable issue of any case, that opinion may have too much weight in the patient’s mind.

It is by no means true that all direct questions on the part of the sick must be directly and fully answered. For example, suppose the patient asks the physician, “Do you think on the whole that I shall recover”—a question that is sometimes asked under very embarrassing circumstances. If the physician thinks that he will probably not recover, he has no right to say to him that he will, for this would be falsehood. But he has a right, and it is his duty if he thinks it for the good of the patient, to withhold his opinion from him, if he can do it without falsehood or equivocation. He may say to him something like this: “It is difficult to decide that question. Perhaps it is not proper for me at this stage of your case to attempt to do it. You are very sick, and the issue of your sickness is known only to God. I hope that remedies will do so and so (pointing out somewhat the effects ordinarily to be expected) but I cannot tell.” Something of this kind, varied according to the nature of each case, especially in the amount of hope communicated, it is perfectly consistent with truth and good faith to say; and very often when more is said, even in very dangerous cases, the physician goes beyond the limits which infinite wisdom has thought best to set to his knowledge. It is very common, as the reader has already seen in the preceding chapter, for persons to recover, particularly in cases of acute disease, when the physician had supposed that they would die. This fact should make him somewhat cautious in giving definite opinions to the sick in relation to the probable final result of their sickness.

CHAPTER XVIII.
MORAL INFLUENCE OF PHYSICIANS.

The relation which the physician sustains to the community is a peculiar one. No other man has so free access to so many families among all classes of society. He is admitted into the very bosom of the families upon which he attends, even of those that receive other visitors with a distant formality. So much is this the case, that most persons have the feeling that their physician is a sort of confidant, and on that ground they are willing that he should see and hear, in his daily intercourse with them, what would be improper to be seen and heard without the confidence of intimate friendship. And when that confidence is abused, as it sometimes is by the tattling and the unprincipled physician, how gross the abuse, and how keenly is it felt by those who have, as a matter of necessity, reposed the confidence! I say as a matter of necessity, for the very nature of the intercourse of the physician with his patients is such as to make this confidence necessary. And the necessity is recognised by both parties. The physician knows that it is expected of him, that he will pay the most scrupulous regard to the principles of honor which have relation to this necessity, and that any discovered infraction of them on his part will materially injure his professional character. He feels this instinctively; and it is this feeling which is generally an effectual safeguard against abuse of confidence, when the patient chances to be under the care of a physician who is devoid of moral principle.

In the above remarks, I do not refer merely to the secrets which, either from choice, or necessity, are so often entrusted to the physician by his patients. But I refer to the confidential character which marks his whole intercourse with them, extending to all the little nameless acts which makeup that intercourse. He enters the dwelling of the sick as if he were one of the family, and the very office that he is to perform disarms all formality, and pre-supposes intercourse of the most familiar character. The patient is to speak to him not of a foreign subject, nor of some one else, but of himself, of his own body, of its pains and ailments, and that too with sufficient minuteness to communicate an adequate knowledge of his case. In doing so, he calls into exercise not only the scientific acumen of the physician, but, mingled with this, the sympathy of the confidential friend. If he has been the physician of the family for any length of time, and has been with them in many scenes of suffering, ready to relieve, so far as in him lay the power to do it, this feeling of affectionate reliance is deep and ardent; so much so, that it is a severe trial to the sensitive mind to be obliged to consult a stranger, even though there be nothing in the case to disturb the most refined and scrupulous delicacy. Especially is this so when the patient is a female. In her case the confidence reposed is of the most sacred character. And shame be to the physician who dares to trifle with it—who dares to offend in any way the delicacy of a patient, whom necessity has placed in such near relationship to him. It is principally this relationship, which the physician holds to the mothers and daughters of the families upon which he attends, that introduces him, if he be a man of honor and principle, as the esteemed and loved friend into the very bosom of those families.

One circumstance, that makes the intercourse of the physician with his patients familiar and intimate, which I have as yet barely hinted at, merits a more particular notice. I refer to the sympathy which he has felt with them in their seasons of suffering, anxiety, and affliction. It has sometimes been said, that the physician, from his familiarity with scenes of distress, becomes unfeeling, and incapable of sympathizing with others. This may be true of him, if he from the first look at the sufferings of his fellow-men only as a source of emolument to himself. If at the onset he enthrones this perfectly selfish and therefore hardening principle in his bosom, he will of course become devoid of sympathy and benevolence. But if he does not this strange violence to his natural sympathies, but lets them flow out, as he goes forth on his daily errands of relief and mercy to high and low, to rich and poor, and especially if he be faithful to the poor who can give him nothing but their blessing and their prayers, his sympathy and kindness will be so often drawn out, and under such a variety of circumstances, that they will become more tender and active, instead of being blunted and repressed. True, he will not have that mawkish sensibility which vents itself in tears, and sighs, and expressions of pity, but stops short of action, or, if it ever reaches forth its hand, does it but fitfully, and with none of that steadiness so essential in giving relief and support to soul or body in its feebleness and suffering. If he ever had any of such romantic and unpractical sensibility, he has cast it off in his actual service in the fields of benevolence, into which his profession has necessarily led him. He has learned over and over, the lesson of active sympathy. He has learned it often under circumstances of discouragement, and sometimes without even the show of gratitude being offered to him. He has learned it, I am glad to say, (and I say it with some tender recollections,) with signs of gratitude in his patients, which are not to be mistaken—with the blessing of those who were ready to perish, but who were saved by his timely and persevering exertions. He may appear to the casual observer to have merged the feelings of the man in those of the physician—to have surrendered his humanity to the cold and stern demands of science. He may seem to be devoid of sympathy, as he goes to work midst scenes of suffering, without a tear, or even a sigh, performing his duties with an unblanched face, a cool and collected air, and a steady hand, while all around are full of fear, and trembling, and pity. Yet there is sympathy in his bosom, but it is active. It vents itself in the right way—in doing. There is feeling there. It is not destroyed, but its manifestations are under control. It is from this power of control which he has acquired, that the physician or surgeon may appear to others to be utterly without feeling, even when a tide of emotion may be pressing his heart almost to bursting, because he knows that a valuable life is hanging upon those very exertions, which he is making with all the seeming coolness of indifference.

I have said that the feeling of the physician vents itself in action. Before that action begins, his emotions are often oppressive, more so than those of the by-standers; for he knows all the difficulties and dangers of the case, and sees the very points which should excite anxiety. Watch him while preparing for a serious operation. Though he may appear to the careless observer perfectly cool and undisturbed, you may see in his unguarded moments a betrayal of the strong under-current of feeling, which he endeavors to conceal. The occasional sigh, followed perhaps by an incidental remark to a by-stander, as a diversion to his feelings, just as the boy whistles to destroy his fear, the compressed lips, the slightly trembling hand, as he busies himself in making his preparations, thus finding relief to the pressure of the excitement within by external acts, some of them perhaps needless—these and other signs show it. And these signs may appear up to the last moment of delay. But the instant he begins the operation, they are gone. The hand may tremble till the knife touches the flesh, and the blood begins to gush; and then it is firm, for his feelings have now found relief in action.