NEUROSURGERY, THE PUBLIC AND THE LAW*

J. GRAFTON LOVE, M.D. Section of Neurological Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

(Received for publication May 19, 1961)

EFORE beginning my presidential ad- information can be obtained except the uni- dress, I should like to express to the versity of hard knocks, I think it may be B members of the Harvey Cushing useful to present a few examples of pitfalls Society my sincere thanks for the impressive which may undermine the way of the neuro- honor you have conferred upon me and, by surgeon, but which nonetheless can be reflection, upon the institution I represent. ] avoided by the exercise of good judgment am additionally indebted to you for this and a certain degree of practical insight. opportunity to speak to you about some Neurologic surgery to me is still the queen questions which seem to me of prime impor- of the surgical arts, intracardiac surgery not tance to our society, to the specialty of neuro- being excluded. W. Lister Reid, 12 senior hon- surgery and certainly to the public and our orary neurosurgcon-in-charge in the Royal relations with the public in the light of both Prince Alfred Hospital, Sydney, Australia, the law and our destinies as neurosurgeons. has, I think, expressed this succinctly in the What I have to say may not be new, but it is following paragraph: important enough to warrant repetition for "When we think about Neurology and Neuro- older members of our specialty and to re- surgery we must realize that the Brain is the mind younger members of what may lie Temple, the Spirit, the Delicate Mechanism that before Lhem. controls every tissue in our bodies. There is so much that we do not know about this Central I do not know what the situation is here in Control Mechanism that it is not possible to put Mexico in relation to the problems I shall set too much Effort and Research into an attempt to forth, and for that reason many of my re- solve its many mysteries, and to treat its numer- marks may seem of no great moment to our ous maladies." Mexican colleagues. If some of the questions THE PATIENT SHOULD BE TOLl) I shall mention present no difficulties in your Neurology and neurologic surgery have country, you arc to be congratulated on your not yet come to be the exact scientific disci- good fortune. plines that I was led to believe them to be or It is entirely possible that in the course of as I thought they were when I was a medical this presentation I may say some things that student. As a student it seemed to me that are unpleasant to hear. In so doing, however, we knew reasonably well how the brain and I certainly mean no personal affront to any- spinal cord and their peripheral connections one, and I hasten to affirm at the outset that functioned, and it thus followed that anyone no one realizes more than I that the final who took the trouble to learn neuro-anatomy responsibility for the care of the patient could arrive at the exact diagnosis of almost reposes with the physician to whom the any given condition by adding up the symp- patient has entrusted his life and physical toms and signs in a sort of rationalistic integrity. r6sum6. The older members of this society no Members of this society of course know doubt have encountered many of the prob- that such an action simply is not true and lems about which I shall speak. Yet, since I cannot be true. What is more, we all know know of no source from which some of this that for the most part we are confronted with * Presidential Address at the meeting of the Harvey grave risks when we undertake an operation Cushing Society, Mexico City, Mexico, April 18, 1961. on the nervous system. The nature of our 567 568 J. GRAFTON LOVE surgical efforts being what it is, we realize what he said about heroic measures in CA that any procedure that we propose may Bulletin, and I should like to repeat a para- bring great benefit to the patient, but we arc graph fr()m his remarks: also mindful that our intervention umy be "When a doctor and his consultants have sin- accompanied by risks. Consider what we all cerely judged that a patient is incurable, the de- know: that the simplest operation on a pe- cision concerning further treatment should be in ripheral nerve can result in greater disability terms of the patient's own interests and reason- able wishes, expressed or implied. Proper treat- than the patient had before the procedure ment certainly includes the use of all natural was performed. Surely, then, we cannot do means of preserving life (food, drink, etc.), good less than to exercise every care and to weigh nursing care, appropriate measures to relieve every risk in arriving at a diagnosis and in physical and mental pain, and the opportunity of planning and executing the operative proce- preparing for death. Since the professional stand- ards of conscientious physicians vary somewhat dure. Next, the inescapable corollary is that regarding the use of further means, such as artifi- the patient and his anxious relatives should cial life-sustainers, the doctor should feel free in be told in unmistakable terms exactly what is conscience to use or not use these things, accord- involved and what the chances for success ing to the circumstances of each case. In general, and failure are. It is far better, in every re- it may be said that he has no more obligation to use them unless they offer the hope of some real spect, to preface the operation with such an benefit to his patient without imposing a dis- understanding than it is to try to explain, proportionate inconvenience on others, or unless, after the operation, a result that is not what by reason of special conditions, failure to use such either the patient or the neurosurgeon de- means would reflect unfavorably on his profes- sired or anticipated. We must insist on what sion." has been well named an "informed con- It is very distressing to me, and much more sent."~0 distressing to the anxious and grieving rela- It is, I believe, a wise precaution to explain tives, to stand beside a patient who has in- to patients and their relatives, particularly curable cancer or irreparable damage to the when they ask about the risks of surgical brain, and observe a tube in the bladder, a procedures, that operations on the brain tube in the stomach and a tube in the tra- sometimes can be followed by paralysis, chea, while oxygen is being piped in and anti- aphasia, impairment of vision and other biotic agents are constantly being injected. untoward developments. We should be pre- Indeed, sometimes even a thoracotomy pared to defend these risks as constituting wound is visible, through which cardiac mas- less of a hazard to the patient than the disease sage for an arrested heart has been carried that we are seeking to overcome. out. By all means, we ought also to consider I believe the patient and his responsible carefully and to appraise judiciously the relatives, after they have been informed of potential benefits and relief of suffering as the facts, are the ones to decide beforehand opposed to the prolonged hospitalization and that such heroic measures should not be needed care and expense to the patient and instituted. The physician, who knows that his family before we undertake palliative these measures are of no avail in respect to procedures. Today, in view of the fact that the future turn of events, should not have to more efficient pain-relieving drugs and tran- await the request of the responsible relatives quilizing agents are readily available, I doubt to desist from them. that the same indications are present that Many years ago, when I was very young obtained some years ago for cordotomy, and not very experienced, I was tireless, lobotomy and sectioning of sensory roots. night and day, in administering therapy to a patient who obviously could live only a few HEROIC MEASURES days because he had an incurable disease. I fully agree with the remarks of my col- The Roman Catholic priest, who was also league, Dr. Edward H. Rynearson, la and watching the patient with me and who had