Doctors in inner-city
hospitals toil on the front lines of medicine. They fight the battles no one
else wants to fight, treating patients who cannot or will not cooperate with
medical caregivers, patients whose social and economic disadvantages make them
the most likely to suffer repeated medical crises, and the least likely to be
able to fend them off. They are also the last line of medical defense, and
sometimes all that stands between the indigent ill, the social cast-off, the
drug addict, and death. As a doctor in the Intensive Care Unit of San Francisco
General Hospital, John F. Murray treats patients in desperate straits, patients
for whom one of the best medical care systems in the world has failed, and many
patients who have also fundamentally failed themselves. Some live, some die. Of
those who live, many will be back time and again for treatment of unmanaged
chronic illnesses and substance abuse-related problems. The role of the
intensive care doctor is to treat the very sickest patients, but many of
Murray’s patients return so often, and stay so long, that he is, in affect,
their primary care physician as well. They’ll be treated in the ICU again and
again, caught in a cycle of systemic social and medical neglect punctuated by
brief periods of medical heroism that pulls them back from the brink of death.

Intensive Care: A Doctor’s
Journal is
Murray’s annotated diary of a month in his intensive care ward. Murray is an
experienced, reflective physician, accustomed to medical crisis and clinical
mystery, and Intensive Care is a valuable primer on what life and death
are like in an ICU. Murray explains the details of medical procedures and
illnesses in clear, accessible language, but what really distinguishes the book
are the ethical insights he brings to each case. Murray, it is clear, thinks a
great deal not just about how to treat his patients medically, but about how
patients, as human beings, should be treated. He considers the tremendous costs
in physical and mental suffering, and in affronts to human dignity, that
accompany intensive and aggressive medical intervention, the very kind of care
in which he specializes. He does not always conclude that the costs are worth
paying.

Intensive Care is comprised of two
intermingled parts. There are clear and concise diary entries that describe the
patients and their ailments, the treatments they receive, and the interns,
medical students, nurses and others who provide round-the-clock ICU care.
Murray helpfully makes these sections somewhat repetitive, which assists the
reader in keeping track of the patients, many of whom suffer frustratingly
similar ailments. San Francisco General, like many big city hospitals, treats a
large number of HIV-infected patients and substance abusers, but there are
numerous individuals suffering more mundane illnesses like asthma, emphysema
and heart problems as well. By providing morsels of personal information about
these patients, Murray allows them to be viewed not just as clinical cases, but
as persons. The rest of the book contains Murray’s comments and reflections on
medicine, and the social, political and ethical issues that arise from his
clinical cases. His insightful and informed examination of ethical issues such
as physician-assisted suicide, patient autonomy, withdrawal of life support and
denial of care are thought-provoking, and in some cases, his conclusions are
controversial. Through years of medical experience, for example, Murray has
come to believe that in the face of medical futility, patients should not be subjected
to the painful and dehumanizing process of dying in an ICU, but rather should
be denied admission. Such a policy would result in many patients dying sooner
than they would in an ICU, but Murray makes a case for denial of care,
providing empirical evidence that includes studies showing that some, though
not all patients would prefer that their lives not be unnecessarily prolonged.
The astronomical costs of ICU care –both the economic and the human costs —
are also never lost on Murray, nor is the unfortunate fact that better access
to primary care and social services would be both less expensive for society
and more humane for patients.

Readers will come away from Intensive
Care with a better understanding of the reality of disease processes and
medical treatments, as well as the difficulties faced by both the patients and
the caregivers in an ICU. Entertainment media have often mined this territory
for drama, though in a far less thoughtful and informed way. Murray’s book can
serve as a detailed glossary and annotated accompaniment to programs like ER,
as well as a reality check. Who would believe that a patient, after
undergoing weeks of excruciating respiratory care for acute asthma, after being
nursed slowly back to independence from a ventilator, could die after inhaling
a carrot illicitly smuggled into the hospital? That truth is stranger, and more
cruelly ironic than fiction is illustrated well by this and other cases
detailed in Intensive Care. Murray’s book shows that truth can also be
more dramatic and more compelling than fiction, too.

© 2003 L. Syd M. Johnson

L. Syd M. Johnson, M.A., is a
bioethicist and Ph.D. candidate at SUNY Albany, currently working on a
dissertation exploring the implications for reproductive choices of the
Non-Identity Problem and new genetic technologies.

Categories: General, Ethics