Douglas R. Bacon, M.D., Editor

Shadow Warriors

any years ago, I purchased a book titled The Wizard War by R.V. Jones.¹ The book chronicles the secret technological war that was waged in World War II. This book was where I first learned about “Enigma,” the intelligence gathered by the Allies from reading secret German codes. But there was more, for Mr. Jones detailed the British radar systems as well as German coastal defenses. He wrote about electronic counter measures such as chaff, small aluminum strips dropped from bombers that obscured the radar signature of the planes and made it impossible to tell how many planes there were and what the heading was. The book piqued my interest, and over the years, I have read much more about the technology “war within a war” that was waged during World War II.

A few days after Christmas, one of my colleagues provided me with a copy of the December 25 edition of the New York Times. On the front page was an article by Lawrence K. Altman titled “The Man on the Table Was 97, But He Devised the Surgery.”² Most likely the story was intended to be a feel-good piece about how Michael E. DeBakey, M.D., survived the reconstruction of his aorta after the vessel had dissected — a cardiac surgical procedure he devised. I read with interest as the opening paragraphs detailed how Dr. DeBakey was sitting in his home study and had chest pain. He thought that he was suffering a myocardial infraction and that soon his heart would stop. That was not the case, though, and as the pain persisted and his heart kept on beating, Dr. DeBakey realized that he had an aortic dissection. The article details his refusal of surgery and his denial of the lethality of the disease. It also clearly states that Dr. DeBakey had signed a “do not resuscitate order.” Like most of us, Dr. DeBakey hoped that the dissection would “heal itself,” as happens in a very small minority of cases.

His colleagues, especially his surgical partner, gathered around him and monitored the situation. The aneurism grew in size, and Dr. DeBakey continued to refuse surgery. Eventually the crisis came; Dr. DeBakey was unconscious. Surgery was extremely risky yet could save his life. He had refused, but his partners were eager to take him to the operating room, as the time to save his life was slipping by. The ethics committee of the hospital was called in and was meeting when Dr. DeBakey’s wife stormed in and, according to the article, demanded that the surgical procedure be done. The committee agreed, and Dr. DeBakey, in the middle of the night, was about to be taken to the operating room.

So far the story reads like the heroic, romantic medical adventures that hook youngsters on a career in medicine. The reality of the blood, sweat and tears of medicine is lost. I was skeptical of a couple of the details as written in the article, for an ethics committee’s meeting was, and should remain, sacrosanct. The family should be permitted to express their desires for a loved one, yet to barge in and demand that the operation begin immediately debases the entire process of patients’ expressed desires, considered thought and deliberation that are the cornerstones of an ethics committee’s debate and ultimate recommendation. Dr. DeBakey’s actions, spending more than a month waiting for the dissection to heal, spoke volumes about his willingness to undergo the operation, and if informed consent has any meaning, would Dr. DeBakey not have the ultimate understanding of the risks and benefits of the procedure he devised?

From an anesthesiologist’s perspective, the story has another interesting twist. The anesthesiology staff at the hospital refused to anesthetize Dr. DeBakey. This act resonated with me — I wanted to cheer the courage of those anesthesiologists to withhold treatment when the patient had refused surgery. The New York Times article made a compelling case that Dr. DeBakey did not want surgery and that the ultimate decision was made by his wife and Dr. DeBakey’s surgical colleagues. Hopefully the decision not to anesthetize was made after much internal discussion and soul-searching in the belief that the anesthesiologists were acting in the patient’s best interest. To be motivated by anything else would not be consistent with the principles and practices to which all anesthesiologists, and indeed all physicians, aspire.

The reported story, however, turns ugly for anesthesiology. George P. Noon, M.D., Dr. DeBakey’s surgical partner, is reported as having said that the “anesthesiologists had not been involved in Dr. DeBakey’s care, yet they had made a decision based on grapevine information without reading his medical records. So he insisted that the anesthesiologists state their objections to the DeBakey family.” Earlier in the article, the reporter acknowledged that, as a physician himself, he had a decades-long professional relationship with Dr. DeBakey. Could it be simple prejudice that allowed this reporter to write words damning physicians for allegedly not practicing ethically by making a decision not based on medical fact? Given the prominence of the patient, the likely media attention and the scrutiny of the medical staff and the medical world at large, it would be the height of foolishness or arrogance to refuse care based on anything but the patient’s clinical condition and wishes.

Dr. Altman reports that the anesthesiologists did, in fact, speak with the family, expressing their concerns that Dr. DeBakey would die on the table. As this procedure had not been done in a 97-year-old before — and because the course of such surgery is often very rocky with people 30 years younger — this appears to be quite reasonable. At this juncture of the story, the case breaks down for me into the question: Can anesthesiologists be compelled to provide service for a patient whom they feel will die during surgery because the surgeon wants to operate? Clearly there was much moral high ground for the anesthesiologists to take, and in so taking, they made an unpopular and more difficult decision than to go to the operating room.

The pro-surgery forces were not through. Another anesthesiologist from a nearby hospital and friend of the family was recruited to give the anesthetic. Here the story turns dark. The hospital administration threatened the new anesthesiologist with assault if she touched Dr. DeBakey. The question of staff privileges was raised, and it was found that, indeed, the anesthesiologist — although working at the nearby VA medical center — did have privileges to anesthetize at the hospital. The debate raged, as Dr. Altman points out, with the concession that Dr. DeBakey did not want the surgery, but given his condition, surgery was his only hope. In the end, the procedure went ahead, and after a very stormy yearlong recovery costing well over $1 million, Dr. DeBakey has fully recovered his mental faculties and is slowly recovering his physical ones.

The New York Times reporter wrote, though, that the anesthesiologists refused to speak with him. While this clearly prevented the group from being misquoted, it did nothing to clarify the almost heroic stand they took. In believing the very best motivations from my colleagues, the decision not to anesthetize based upon the patient’s desire not to have surgery was bold. The New York Times readers needed to see that this was a complex ethical problem and that there were several valid ethical interpretations of the situation. Believing in patient autonomy, Dr. DeBakey’s actions prior to his coma were not any different from Jehovah’s Witnesses who refuse transfusion. Clearly we do not have the “right” to give lifesaving blood to someone who is unconscious do to severe hemorrhage. Why was it right for the surgeons to operate on Dr. DeBakey?

What troubled me even more was the attitude of the surgeons toward the anesthesiologists. Granted, Dr. DeBakey built the reputation of the hospital, and the staff, with his incredible work over the past half century. But does that give his surgical team, led by his partner, the right to demand that the anesthesiologists perform against their ethical beliefs? Simply put, are anesthesiologists the handmaidens of the surgeons — negating all the advances in the specialty made by physicians since that October day in 1846 — relegated to performing when told? Are we physicians, or are we simply technicians? Why weren’t the anesthesiologists part of the ethics committee debate? Didn’t the surgeons believe they had an obligation to bring their operating room partners into the discussion?

Finally, the article speaks of medicine and surgery in general, and this operation specifically, as opening a new vista in care for the elderly. Dr. Altman writes as if thousands of people over the age of 90 will come through an ascending aortic aneurism repair without impairment. While Dr. Altman acknowledges that Dr. DeBakey’s hospitalization costs exceed $1 million and that an actual accounting of the expense most likely cannot be done due to the fact that, for privacy reasons, Dr. DeBakey was hospitalized under pseudonyms, is Dr. Altman creating an unrealistic expectation for people at the end of their natural life spans? Can we justify the widespread cost, and if so, who will pay?

Just as it took years for the story of technology in World War II to come to the front, this story will reverberate within anesthesiology for years to come. Breaking the German codes was a triumph of technology and the human spirit. Dr. DeBakey’s willingness to go public through Dr. Altman and the New York Times on his very controversial, high-technology surgery is laudable. Likewise the decision not to anesthetize (despite the successful outcome of the operation) based upon the patient’s expressed wishes was praiseworthy. Yet the failure of the anesthesiology group to speak out publicly did a disservice to both the profession and themselves. As the shadow warriors of the operating room, toiling in obscurity while grappling with ethical issues that may be in conflict with equally valid surgical values, we need to step out into the limelight and explain why we believe as we do. Only when both sides of the argument are presented by thoughtful physicians can a true, respectful debate come forward. To bypass the opportunity to explain the decision not to anesthetize, and to withstand the glare of public scrutiny, makes the actions of the anesthesiologists seem less than honorable. Dr. Altman, the DeBakey family and the world at large need to know that anesthesiologists as physicians have a duty to uphold the ethical principles of practice — the keystone of professionalism — and be applauded for taking this moral high ground. To do any less negates all that we profess as a professional Society and as physicians.

— D.R.B.

References:
1. Jones RV. The Wizard War: British Scientific Intelligence, 1939-1945. New York: Coward, McCann & Geoghegan; 1978.
2. Altman LK. The man on the table was 97, but he devised the surgery. New York Times. December 25, 2006:A1, A14.

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