A Doctor's Duty

By Charles Krauthammer Sunday, July 13, 2003
    • Around the world, hearts were broken when news came that the conjoined Bijani twins had died on the operating table. Having lived in tortured unity for 29 years, they traveled from their native Iran to Singapore for the surgery meant to set them free. The doctors who performed it were devastated. When you lose a patient, particularly when the patient dies at your own hand, the heartbreak mixes with unbearable guilt. The doctors are asking themselves the same question everyone else is asking: Should they have done it?

    The doctors certainly knew the risk. They knew that with the women's shared circulatory systems, the risk was great. They might have underestimated the technical challenges, but they did not deceive their patients. The sisters, highly educated and highly motivated, knew full well the risk of never waking up from the surgery.


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    Indeed, they never did. Should the surgeons have attempted such a risky procedure on patients who were not dying, and, in fact, were not even sick?

    For all the regrets and second guesses, it is hard to see how the answer could have been anything but yes. The foundation of the medical vocation is that the doctor is servant to the patient's will. Not always, of course. There are times when the doctor must say no. This was not such a time.

    Consider those cases in which outside values trump the patient's expressed desire. The first is life. Even if the patient asks you to, you may not kill him. In some advanced precincts — Holland and Oregon, for example — this is thought to be a quaint idea, and the state permits physicians to perform "assisted suicide." That is a terrible mistake, for the state and for the physician. And not only because it embarks us on a slippery slope where putting people to death in the name of some higher humanity becomes progressively easier.

    Even if there were no slippery slope, there is a deeply important principle at stake: doctors are healers, not killers. You cannot annihilate the subject you are supposedly serving — it is not just a philosophical absurdity, it constitutes the most fundamental violation of the Hippocratic oath. You are not permitted to do any harm to the patient, let alone the ultimate harm.

    There are other forms of self-immolation, less instantaneous and less spectacular, to which doctors may not contribute. Drug taking, for example. One could say, The patient wants it, and he knows the risks — why not give him what he wants? No. The doctor is there to help save a suffering soul from the ravages of a failing body. He is not there to ravage a healthy body in the service of a sick and self-destructive soul.

    Doctors are not just biotechnicians. They must make judgments about, yes, the soul. Before serving a patient's will, doctors have to decide whether it is perverse and self-destructive. One has to ask what kind of plastic surgeon would repeatedly do his work on Michael Jackson. Or on the Manhattan socialite, known now as the cat woman, who had her face tweaked so many times that it changed inexorably into that of a feline.

    Do sex-change operations fall into this category? Some doctors believe that prospective transsexuals really are born into the wrong body; the surgery is therefore corrective. Others argue with equal force that gender dysphoria, as it is known, is a psychiatric affliction and that mutilating the body to fit the afflicted psyche is to inflict a double injury on the patient. The area is gray enough, and the controversy serious enough, to leave the matter, as we have, to the conscience of the individual physician.

    But we ought never leave the decision to the individual physician when we come to the two redlines: no assistance in self-destruction (whether gradual or immediate) and no assistance in mutilation.

    That is all, however. Beyond that, the patient is sovereign and the physician's duty is to be the servant. Which is why the doctors in Singapore were right to try to separate the twins. They were not seeking self-destruction; they were seeking liberation. And they were trying to undo a form of mutilation imposed on them by nature. The extraordinary thing about their request was that it was so utterly ordinary. They were asking for nothing special, nothing superhuman, nothing radically enhancing of human nature. They were only seeking to satisfy the most simple and pedestrian of desires: to live as single human beings.

    The twins suffered from an error of nature, a mistake in individuation. They were asking for nothing more than the possibility of solitude. To risk everything for this was perfectly rational — indeed, an act of nobility and great courage. Their doctors were assisting heroism, not suicide. They should feel no guilt, only sorrow that victory once again went to nature, in all its cruelty.