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Knowing when to bend the rules

Year: 1990
Setting: Hut in We, Lifou
Position: Private general practitioner in New Caledonia

A small familial delegation comes to my office one morning asking me to pay a house call to a relative who is unable to come and see me. He has been diagnosed with end-stage liver cancer at the Gaston Bourret Hospital in Noumea, the capital of New Caledonia. He was sent back to Lifou, the biggest and most populated of the Loyalty Islands (99 percent of the islanders are Melanesians) with painkillers and recommendations that included a complete ban on alcohol, stating, “It has caused the disease that is killing you.” So much for psychology and the patient’s emotional state!

To my way of thinking, the physician's recommendation made complete scientific sense, but didn’t consider the patient as a whole. Alcoholism is a major public health issue for the Melanesian population in New Caledonia. The situation is similar to that of the Aborigines in Australia. I knew that the patient’s physical condition was so poor that he had only a few days to live. Because of that, banning alcohol would have no impact on the patient’s prognosis whatsoever.

The patient is lying at the center of the hut and I have to wait a few seconds while my eyes adjust to the faint light coming through the door, which is the only opening in the whole structure. I listen to the patient’s medical history and give him a morphine shot. He knows that his condition is terminal and that he has only a few days left to live. When he feels more comfortable, we talk about his life. Then he asks me, “Could I have a beer?” People around him look at me with some guilt on their faces and say, “Please ignore what he said. We know it is not good for him.” But to their great disbelief and the patient’s utmost delight, I tell them that it OK as long as he does not get drunk. I want to show compassion to a this man who knew he was at the very end of his life and who wanted one last bit of pleasure.

As I walk on my way to the car, his wife asks me one more time, “Are you sure he can drink his beer?” When I remind her of her husband’s prognosis, reality sinks in and she becomes suddenly grateful. “I love this man in spite of everything. He is the father of my children and I want him to be happy at the end of life.”

Lesson for the doctor: Sometimes in medical practice, compassion is needed more than science. It is an art to know when.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

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