Intensive Care, the Tyranny of Good Intentions

The 20th century belief in goverment power as a force for good has encouraged the practice of chasing after devils.

THE MYSTERY AND DRAMA of the Intensive Care Units continue to intrigue Americans, while either observing their own critically ill loved ones or watching the drama on the small screens in their homes. Most of them have not come to grips with the real issues or how they play out in real life. Such an attempt is made by Dr. John Murray, as he chronicles his attending rounds at San Francisco General Hospital for one month.

San Francisco General has a very lively ICU because of the city's demographics. It serves the socioeconomically disadvantaged and has a large number of people with HIV infection as well. Murray believes what he records is ordinary in most respects.

He feels his close-up offers a reasonable overview of what intensive care is meant to accomplish, how the system operates, and what obstacles can encumber the rescue of desperately ill people clinging to life or, conversely, what constitutes unreasonable torment for people bound to die. He describes situations in which patients have given clear directives not to be resuscitated. Yet their families countermand those wishes by calling 911, which results in patients being intubated against their will.

Murray describes meeting his three third-year medical residents, who were all smiles, curious as to how the next four weeks together would aid or hinder their learning. Meanwhile, he was scrutinizing them to gauge how comfortable he would be with their carrying out agreed-upon plans during rounds, and wondered if they would contact him if they were uncertain about anything.

The book contains chart entries made by Murray during rounds. He then provides a lay explanation of the reasons for the treatment that was proposed or had taken place prior to the patient's arrival in the unit. He documents such situations as a patient being intubated who explicitly requested not to be, and the angry reaction of the private practitioner who spent time getting the DNR order.

He gives due accolades to the nurses who take care of these critically ill patients on a one-to-one, sometimes two-to-one, patient basis. They have the key responsibility for making independent decisions and acting on them when there is a sudden change in a patient's condition, such as cardiac arrest, shock, seizures and other emergencies.

A journal like this is perhaps of interest to any doctor, nurse, or allied health specialist. But it is also written so that lay people with an interest in health care can gain perspective from reading it.

Doctor Murray is Professor Emeritus of Medicine at UCSF where he was Chief of Pulmonary and Critical Care Division from 1966 to 1989. He has done the world a favor, in his eighth decade of life, by giving us his perspective on such an important issue.

He is the author, coauthor, or coeditor of a number of books including the multi-volume textbook in Pulmonary Medicine, Textbook of Respiratory Medicine, third edition.

THE TYRANNY OF GOOD INTENTIONS - How Prosecutors and Bureaucrats are Trampling the Constitution in the Name of Justice, Paul Craig Roberts & Lawrence M Stratton FORUM, Roseville, CA ©2000, xiii & 242 pp, (including 40 pp bibliography and 13 pp index) $25, ISBN: 0-7615-2553-X

"What are we to do if those chasing after devils decide to chase after us?" - Sir Thomas More

When a physician at a medical meeting handed me a copy of the dust jacket of this book and asked me to review it for as many medical publications as possible, I was perplexed. Then I listened to two doctors outline the very hazard about which Roberts and Stratton warn. This important book lets us understand the manufactured crimes of which physicians are being accused - which will eventually affect all of us unless we take appropriate action.

Americans who fled tyranny and designed a "land of the free" are losing the accountability of laws that protect them from a tyranny, where government is master rather than servant of the people. The authors feel these erosions of liberty and constitutional order are not due to organized interest groups or the influence of money on the political process. Americans are losing the protection and accountability of law because we have forgotten the importance of these safeguards. We have become emotionally and intellectually disconnected from the thousand-year struggle that established the people's sovereignty over the law.

Americans inherited the English legal system in which law developed as a means of pursuing justice by finding truth. The US Constitution begins with "We the People" to ensure that law protects the people from arbitrary government power and serves the cause of justice. This revered legal system is being replaced by fear, distrust and dissatisfaction. Americans increasingly feel that breaking the law is a random phenomenon with little relationship to guilt or justice.

The authors feel that the primary obligation of each generation is to pass on, undiminished, the institutions of liberty and the legal principles that prevent law from being used as a weapon against the people. Our generation has neglected this responsibility.

Roberts and Stratton provide numerous examples and an extensive bibliography. The truth-seeking and justice-dispensing functions of the criminal justice system have been replaced by a strong executive branch with increasing lawmaking powers that are interpreted with great latitude. They equate this to the Enabling Act of the German Reichstag that gave Hitler dictatorial power and the chain of events that allowed Lenin "unlimited power, resting directly on force."

The 20th century belief in government power as a force for good has encouraged the practice of chasing after devils. Plea bargaining perverts the system by pressuring defendants to "admit to what did not happen in order to avoid charges for what did happen," which ultimately "permits prosecutors to bring charges in the absence of crimes." Coercing both guilty and innocent defendants into guilty pleas enhances prosecutors' careers and avoids the need for proof. The historic requirement that prosecutors prove the juncture of act and intent to do wrong is diminishing due to legislation, administrative rules and a compliant Supreme Court. Crimes are not solved; they are manufactured.

If administrative assaults against physicians can result in incarceration, fines, loss of retirement funds and medical licensure, no one is safe. We will all be in jeopardy if pursued by prosecutors from Medicare, Medi-Cal or the Medical Board. Reading the first and last chapters of this book while waiting for that late/missed one-hour consult may be far more valuable than the income lost. The book makes clear the unfortunate legacy we may leave to our children and grandchildren, unless we protect ourselves.

delmeyer@healthcarecom.net

www.delmeyer.net