Medicine in small doses
‘I was a junior consultant in a large teaching hospital in Melbourne. I had been on call the previous night and all the members of the orthopaedic unit were reviewing the patients who had been admitted and treated under my care. One of the surgical registrars had telephoned me during the previous night with advice on the management of a patient and I had agreed to his suggested treatment. It was clear on reviewing our decision the following morning that another course of action would have been preferable. The registrar was questioned about his actions and he turned towards me and said that I had agreed to it. I denied this and said that he must have been mistaken. I lied and put my reputation before his. My memory of his reaction is burnt into my soul and can still see the hurt in his eyes. I had betrayed him and I am sure he never trusted me again’.
This powerful and emotion wrenching vignette is but one of the many, about 14 in total, that Macintosh uses either from his own experiences and those of others that provides the context as he takes us on a journey exploring the ethical, moral and philosophical background to the concepts of trust, betrayal and informed consent, some of the vital ingredients of the doctor–patient relationship.
From the beginning, I must declare a conflict of interest as I was Macintosh's orthopaedic resident in 1976, not the registrar in the vignette, and he sent me his book for my opinion, and I have done my best in this review to be objective and honest.
Macintosh was a consultant orthopaedic surgeon, but not the stereotypical orthopaedic surgeon in that he followed a path not often travelled to undertake a Masters of Bioethics paying tribute to Peter Singer and Helga Kuhse for this change in his career. He then completed a PhD, the genesis of this book and acknowledges Justin Oakley his supervisor. Oakley's short forward emphasizes how Macintosh ‘lays bare the emotional contours and nuances of the practitioner–patient relationship’, and how ‘trust is the essential glue that holds medicine together’.
His interest in this subject was sparked some 25 years ago by a patient's response to his explanation of the complications of a certain operation when she interrupted to say: ‘I don't need to know all that, I trust you!’
It is therefore a scholarly analysis of the concepts of trust and betrayal, with a very strong surgical flavour, not in the clinical sense but in the experiential sense as although retired from clinical practice, he remains as fellow of Royal Australasian College of Surgeons (RACS) and refers to that association with pride and often to the trainee–surgeon relationship.
It will appeal to surgeons because of this link, the many vignettes and reference to the College's challenges with bullying, sexual harassment and discrimination and how the College responded, also how the white Anglo‐Saxon male stereotype of the surgeon is changing with the influence of European and Asian migration and how women are making their mark in orchestrating change. Some surgeons might find it a bit hard going as he delves into the ethical, moral and philosophical literature to substantiate his assertions and opinions.
Paradoxically, many may find this stimulating as he refers often to the classical philosophers – his favourite being Aristotle, Shakespeare particularly Hamlet, the Bible and Greek mythology, all providing cogent examples of trust and betrayal.