Did I do no harm?

Marie-Pier Bastrash
Published online: 12 March 2017
1 Faculty of Medicine, McGill University, Montréal, Canada.
Corresponding Author: Marie-Pier Bastrash

I was harshly confronted with the concept of non-maleficence for the first time during my Pediatrics rotation; which I enjoyed immensely. My team was composed of a staff physican, three residents, myself and another lovely medical student. We all got along wonderfully and were providing what I thought was optimal care to an entire wing of sick, crusty-nosed, children.

One evening, I was asked to admit William[1], a two-and-a-half-year-old charming redhead, coming in with a severe first episode of asthma, or reactive airway disease (everyone seems to have a different term for “asthma” in children less than 6 years of age).

As I was admitting William many of my questions were directed to his mother, a woman in her late twenties with what some people might call a slightly disheveled appearance. She had dirty dyed blond hair, was wearing a rather short crop-top in wintertime, and had noticeably poor dental hygiene. She was very nervous and became teary-eyed several times throughout the interview but I believe I did a satisfactory job reassuring her that we would take good care of William and that she had done the right thing by bringing him in expediently. She was obviously very concerned for her child’s health. Despite a few quirks I had noticed in her appearance, she was attentive to his needs and acted just like any other nervous parent whose child was just hospitalized.

Over the course of the interview, I learned that William had five older siblings and that they, along with two dogs, were living in a two bedroom apartment, with serious mold and ventilation issues. I also learned that Child Protection Services, the “DPJ”, had been involved for six months trying to relocate the family to a healthier apartment.

Over the next two days I had plenty of time to interact with both William and his parents. As William’s “doctor” I was responsible for looking over his labs and vitals. I managed his oxygen during the day and performed multiple chest exams. While William’s parents behaved for the most part just like any other pair of parents, at times I noticed they seemed very agitated. Even more oddly, they both spent long stretches of time in the bathroom. It seemed far-fetched and was purely speculative on my part, but I could not shake the suspicion that they might be using stimulants in the washroom. But, having no evidence, I never voiced these concerns specifically.

However, on the third morning at rounds, I spoke up to my team about whether social work should be getting involved in this child’s care. Regardless of his parents’ at times odd behaviour, he did have a serious housing issue most likely contributing to his asthmatic picture. My staff replied that he was already being seen by the DPJ externally and that frankly, to her, although somewhat eccentric, they were demonstrating completely appropriate behavior. I did not argue –, after all, everyone on the team was more experienced than I was, perhaps I had misjudged them.

The next day, William’s mother privately asked me to speak with a social worker in order to get free parking and cafeteria coupons. I shared this with my team, insisted that my gut feeling was that something with this family was not right and that they should be seen by social work – and William’s mother was now requesting it herself! The team restated their opposite opinion, but finally agreed for William and his family to be seen by a social workers.

Like everything else in medical school, pediatrics could not last forever. After my feedback session, I left the team and began a new rotation the following Monday, not knowing the final outcome of sweet little William’s situation. But I couldn’t keep him off my mind.

The following week my curiosity got the better of me. I wanted to know how William was doing and how his family was coping so I got in contact with a colleague who had replaced me on the pediatrics ward. She explained to me that William’s clinical condition had improved, but that based on social work’s assessment, William had been put in foster care. In foster care.        The motives of this placement were not disclosed to me, but were deemed significant enough to warrant immediate foster family placement and complete removal of the parents from the child’s environment. No visiting rights.

I let that sink in for a moment. I immediately felt responsible. Responsible for having been “pushy” regarding the social work assessment. Responsible for depriving this child from his five older siblings, from both his loving parents, who had clear limitations and problems of their own, but who genuinely seemed to love their child. And I still feel responsible to this day.

How is William doing in his foster family? He is clearly too young to understand the reasons behind anything that is happening to him, but old enough to miss and yearn for his own family. “Marie-Pier,” I thought, “what do you think this placement, possibly long term, will have on his future social and affective development? What have you done to this kid?”…

This made me think about the research of Gobbard, published in JAMA in 1985, which explains the classic physician’s compulsive triad. The triad is composed of doubt, guilt and an exaggerated sense of responsibility. As I reflect on my experience of being a “healer” for William, it is obvious to me that I was embodying these three traits wholeheartedly.

I have doubts about having made the right decision in speaking up to my team. I feel guilty regarding his ultimate placement in foster care. I feel responsible for the entire situation, which, ultimately, has very little to do with my decision to speak up. After all, I just tipped the first domino, the outcome of the story was in the hands of social services, not mine. This feeling of guilt is one that I shall learn to overcome in my future practice.

I shared the story with my parents, with whom I am very close. They comforted me and told me time and time again that I made the right call, that this child will likely, be better off this way, that I should be proud of the fact that I recognized something was suspicious and that I wasn’t afraid to advocate for my patient’s best interests. They told me that they were proud of me. Yet, a few months later, I am far from feeling proud of myself.

I sometimes still think of William: at night, or at the grocery store when I see a redhead in a shopping cart playing with a box of macaroni. As a Healer, did I do no harm? I wonder if I will ever be convinced.

[1] Fictitious name to preserve confidentiality