Doctored (6 page)

In Harlem the roads shimmered shiny black. Red taillights winked at me through the watery haze. Police sirens were sounding out loudly. On 116th Street, dented low riders slinked by, windows open, music blaring. My headlights caught a lonely figure under the elevated train tracks.

I called Sonia to tell her that I was almost home. “How did Lamaze go?” I asked. Regrettably, I had missed it again this week. There was silence. “Honey?” I heard sobs.

“We need to talk,” she finally said, composing herself. “Dr. Edwards just called. She thinks the baby is in danger. She says I need a C-section before she goes on vacation next week.”

 

TWO

Odd Conceptions

Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.

—Physicians' charter

Sonia and I'd had a hard time conceiving, but not because of a lack of diligence. We tried everything: ovulation sensors, Kokopelli figurines, yoga, meditation, Clomid, Pergonal, intrauterine injections, in vitro fertilization (IVF), even mystical appeals to a Hindu guru (who confidently predicted we would have two boys). Nothing worked. The failures left us feeling tense and frustrated.

In early 2003, at the midway point of my fellowship and shortly after our third unsuccessful attempt at IVF, we went on vacation to the Caribbean island of Anguilla. We both needed a break. We had been trying to get pregnant for over two years—Sonia was now thirty-two, and I was thirty-four—and we were quietly panicking that our efforts had become futile. One afternoon shortly after we arrived, I went for a walk alone on the sun-swept beach, where I met a shirtless loafer named Clement Clemons. He was tall and handsome, with brown dreadlocks emanating from his red bandanna and a quiet, dignified island air. We got to talking, and by and by he invited me to his “tavern,” a tourist attraction just up the road, where he said we could get “happy together.” With Sonia relaxing by the pool at the hotel, I accepted his proposition. After hopping about two hundred yards on the scorching white sand, we arrived at the back entrance to a bamboo shack, where a group of Americans were lounging on cheap rattan furniture, taking hits from a water pipe. Tiny lamps dangling from wooden beams bathed the room in a chocolaty orange. I sat down, and almost immediately the rim of a water bong was sealed around my lips and thick white smoke was gurgling through a purple curlicue shaft. The giggling tourists egged me on. It was a scene right out of the dorms at Berkeley.

Soon towering speakers were piping out joyful Dead tunes, and I was tripping heavily in a hallucinatory mix of speed and calm. Out on the deck, I gazed at a stunning palm-fringed tableau. It felt as if I were in a movie, a contrived visual narrative of an unsuspecting traveler stoned to oblivion in a foreign land. My mind was moving randomly through an array of interconnecting circles. Why is there space? How did it arise? Why are there jeans and tile floors and chairs of different material? So much we don't understand!

Clement joined me on the terrace. His bandanna gave the illusion of streaming the colors of the rainbow. “This is the strongest shit I've ever smoked,” I told him, feeling dizzy. He just laughed.

The late-afternoon sun cast long shadows across the wooden deck. The sky was painted in swirls of pastel mixed with bubbly streaks of white. It reminded me of springtime in Berkeley, and thus of Lisa, my college girlfriend. What had happened to her? Where was she now? The last time we'd spoken was before I got married, when she recalled the scooter rides in the Berkeley Hills in those carefree early days. So strange that I didn't still think about her every day: those brown curls and milky white skin; the raffish grin. At one time all paths of thought had converged on her. I used to obsess about her, her disease—lupus—and the miscarriages doctors predicted she'd have. I remembered that birthday eve when my father asked me, “Don't you want children?” and my anguish for her gave way to my own desires. In the end, I abandoned her because I didn't have the courage to cope with her illness. I gave her up to avoid the terrible fate of being without her.

I suddenly became aware that Clement was talking to me. “Why you so serious?” he said.

I shook my head and continued to gaze at the beach.

“Somethin' is botherin' you,” he said. I glanced at him. Fervidness was radiating from his dirty yellow sclera. I mentioned the problems that Sonia and I were having.

“You are injurin' yourself,” he intoned. “And you are hurtin' her, too.”

I nodded, staring at the turquoise water.

“Don't worry,” he said. “You will have a boy.”

I turned to him. His face was vibrating. “A boy?” I said.

He nodded confidently. “A son.”

“How do you know?”

“Because I am a Rastafarian.”

“What does that mean?”

“It means I believe in me, and I believe in you, too.”

That night I told Sonia about Clement's prediction. She seemed pleased. Though neither of us really cared whether we had a boy or a girl, Sonia, having grown up in a family of girls—two sisters, mostly female cousins—had been hoping for at least one boy. Later at the hotel, lying awake in bed, I told myself that if I ever had a child, I would be a different kind of father from my own dad, who had been too busy with his professional struggles to develop friendships with his children. He did a passable job—acceptable in that era—and we all ended up just fine. But he didn't elevate to the highest ranks of parenting. He used coarse tools, like guilt, to foster the behavior he desired. I wanted to be a father with influence—in a good way—over his kids, unlike Dad, who had been too preoccupied with his own problems to garner that authority.

Just as Clement prophesied, Sonia did get pregnant a few months after we returned from Anguilla, and all signs pointed to our having a boy. The first sign presented itself at the beginning of the second trimester, when a homeless man, stooped and stinking and clutching a Bible, turned to us as we were walking along Seventy-seventh Street and shouted, “It's a boy!” A week later, as we were riding on an elevator in our building, a four-year-old boy pointed at Sonia's gravid belly and whispered something to his mother. After we stepped out at the ground floor, Sonia tapped me on the shoulder. “Did he just say…” She hesitated.

I nodded.

“What?” she demanded.

“He said, ‘It's a boy,'” I replied.

Pleasantly spooked, she sank into a soft couch in the lobby and laughed. That is what she had heard, too.

Life, for the most part, was good. The tension of getting pregnant had evaporated. I was near the end of my fellowship and starting to interview for jobs (and was looking forward to finally achieving some financial security). Sonia herself was finishing her internal medicine residency at Lenox Hill Hospital on the Upper East Side and was mulling an offer to become chief resident for a year. After the stress of the previous two years, we couldn't have asked for a smoother patch.

But then, midway through the second trimester, Sonia developed a complication of pregnancy that required us to choose between two surgical treatments: one was standard; the other, which we selected, was more novel and appealing. Two weeks later we found ourselves at the Ambulatory Surgery center at Roosevelt Hospital. Sonia was lying on a narrow gurney in a room with four or five other patients. An intake nurse went over her medications, allergies, and medical history. When I told her that Sonia was eighteen weeks pregnant, she switched pens to mark down this fact in bright red ink. Soon Sonia was hooked up to a fetal monitor, which traced a normal heartbeat on pink graph paper.

A few minutes before the operation was scheduled to begin, a physician's assistant came up and demanded that Sonia sign a consent form for the standard surgery we did not want. When she refused, he said the operation was going to be canceled. Perplexed, I demanded to speak with our surgeon, Dr. Levinson.

“We were told this was our decision,” I cried when he showed up a half hour later.

“I'm just learning about this now,” Levinson replied calmly. He was a stocky Jewish surgeon in his late forties with an impressive professional record, including stints at the National Institutes of Health, that belied his awkward, slightly vacant air. He explained that the anesthesiologist, with whom he exclusively worked on such cases, had decided the procedure we had chosen wasn't safe because he couldn't ensure that our baby would get sufficient oxygen during surgery, an assessment that Sonia and I, as doctors, as well as our obstetrician, Dr. Edwards, with whom we had consulted, did not agree with. “I know you're upset—”

“Upset? I'm furious! We thought everything was a go, and now you're telling me this?”

“Everything I told you was correct from the way I understood it when we spoke—”

“Then tell me you're going to do the operation. We'll sign anything you want. These asshole anesthesiologists always raise objections. They don't know the patient or the situation.”

“I understand—”

“I don't need understanding!” I shouted. “All I want to talk about is how we can make this happen.” I was infuriated, not only by the precarious position in which we now found ourselves but also because I was sure that the unfounded fear of a lawsuit was at least partially driving the anesthesiologist's decision. Nearly half of all anesthesiologists, and almost 100 percent of physicians in high-risk specialties such as neurosurgery, cardiology, and obstetrics, will face a medical malpractice claim at some point in their careers. Malpractice litigation is often the most stressful experience in a doctor's professional life. Most doctors do not discuss it with colleagues or even with family members; it is a hidden shame. And though I might have sympathized with the anesthesiologist if I'd been on the other side of the doctor-patient dyad, none of this mattered to me as my pregnant wife lay on a gurney. Dr. Levinson was silent. “I'll go to the head of the hospital if I have to,” I threatened, but I could tell from his expression that there was nothing more he was going to be able to do.

Trembling with anger, I left the room and went back to Sonia in the preoperative waiting area. I sat down beside her and stroked her hand. Looking at my face, she started to cry.

As the hours wore on, I continued to press our case. I demanded explanations. I asked for second opinions. When I requested that the anesthesiologist, a handsome Italian fellow with a bushy mustache, more business executive than doctor—and we, it seemed to me, more like job applicants than patients—recuse himself, he snapped that he did not want to talk in “lawyerly” language. He was acting almost like a conscientious objector, but I wasn't sure what he was objecting to. Which moral principle was he defending? First do no harm? Professional integrity? A paternalistic duty to protect his patient from a mistake? Or were his considerations being driven by more knavish concerns? My father-in-law, also a doctor, tried to negotiate. No one would budge.

So, finally, we said no. I wasn't going to let Sonia be pressured into an operation she did not want. At six o'clock, after waiting in the hospital for almost eleven hours, we went home to think about what to do.

Our case illustrates a basic conflict in modern American medicine. A patient's right to self-determination is the prevailing ethic, but in reality doctors routinely place limits on it. For example, when a patient's demand clashes with a doctor's moral convictions, ethicists have argued that doctors can deny treatment. Gynecologists can refuse to perform abortions because of moral or religious beliefs. Physicians in intensive care units often withhold treatments they deem futile, especially for terminal illnesses (as I tried to do with Delmore Richardson, the brain-damaged patient in the CCU).

But conscientious objection is a relatively rare impetus for denying treatment. A more common situation is one in which a patient's request conflicts with what a doctor believes to be good medical practice (and thus exposes the doctor to a possible charge of malpractice). In such cases the objection is over professional, not moral, integrity, though obviously moral questions are raised. In a doctor-patient dispute, who has the right to make the final call? Should doctors just do a patient's bidding? We talk about a patient's right to refuse treatment. But what about the right to demand it?

After I had started working at LIJ, a few months past this incident, I took care of a middle-aged man who had been admitted to the hospital with fever and shortness of breath. The man, Eric, was in his early forties, thin but toned, with colorful tattoos and a pallid countenance. A chest X-ray in the emergency room showed fluid in his lungs, but initially we did not know why it was there. An echocardiogram provided the answer. On one of his heart valves was an infected mass of tissue, a vegetation, flapping around wildly like a flag in the breeze. It had severely damaged the valve, resulting in congestive heart failure.

Heart infections, caused by bacteria entering the bloodstream, can usually be treated with intravenous antibiotics; surgery is reserved for only the most complicated cases. In Eric's case, a CT scan of the head showed several small bleeding sites, probably caused by parts of the vegetation breaking off and lodging in his brain. Surgeons decided that the valve needed to be replaced to prevent further injury.

A consulting neurologist recommended an MRI (magnetic resonance imaging) before surgery to make sure the infection had not caused any brain aneurysms that could rupture and bleed in the operating room, causing a stroke. When the scan showed no aneurysms, the neurologist asked for a cerebral angiogram to exclude even tiny aneurysms that the MRI might have missed. Though fairly routine, angiograms in rare cases can cause strokes because a catheter is threaded into the arteries that supply blood to the brain. Eric decided that although he wanted the surgery, he did not want this test.