Intensive Care

Doctors in inner-city hospitals toil on the front lines of medicine. They fight the battles no one else wants to fight, treating patients who cannot or will not cooperate with medical caregivers, patients whose social and economic disadvantages make them the most likely to suffer repeated medical crises, and the least likely to be able to fend them off. They are also the last line of medical defense, and sometimes all that stands between the indigent ill, the social cast-off, the drug addict, and death. As a doctor in the Intensive Care Unit of San Francisco General Hospital, John F. Murray treats patients in desperate straits, patients for whom one of the best medical care systems in the world has failed, and many patients who have also fundamentally failed themselves. Some live, some die. Of those who live, many will be back time and again for treatment of unmanaged chronic illnesses and substance abuse-related problems. The role of the intensive care doctor is to treat the very sickest patients, but many of Murray's patients return so often, and stay so long, that he is, in affect, their primary care physician as well. They'll be treated in the ICU again and again, caught in a cycle of systemic social and medical neglect punctuated by brief periods of medical heroism that pulls them back from the brink of death.

Intensive Care: A Doctor's Journal is Murray's annotated diary of a month in his intensive care ward. Murray is an experienced, reflective physician, accustomed to medical crisis and clinical mystery, and Intensive Care is a valuable primer on what life and death are like in an ICU. Murray explains the details of medical procedures and illnesses in clear, accessible language, but what really distinguishes the book are the ethical insights he brings to each case. Murray, it is clear, thinks a great deal not just about how to treat his patients medically, but about how patients, as human beings, should be treated. He considers the tremendous costs in physical and mental suffering, and in affronts to human dignity, that accompany intensive and aggressive medical intervention, the very kind of care in which he specializes. He does not always conclude that the costs are worth paying.

Intensive Care is comprised of two intermingled parts. There are clear and concise diary entries that describe the patients and their ailments, the treatments they receive, and the interns, medical students, nurses and others who provide round-the-clock ICU care. Murray helpfully makes these sections somewhat repetitive, which assists the reader in keeping track of the patients, many of whom suffer frustratingly similar ailments. San Francisco General, like many big city hospitals, treats a large number of HIV-infected patients and substance abusers, but there are numerous individuals suffering more mundane illnesses like asthma, emphysema and heart problems as well. By providing morsels of personal information about these patients, Murray allows them to be viewed not just as clinical cases, but as persons. The rest of the book contains Murray's comments and reflections on medicine, and the social, political and ethical issues that arise from his clinical cases. His insightful and informed examination of ethical issues such as physician-assisted suicide, patient autonomy, withdrawal of life support and denial of care are thought-provoking, and in some cases, his conclusions are controversial. Through years of medical experience, for example, Murray has come to believe that in the face of medical futility, patients should not be subjected to the painful and dehumanizing process of dying in an ICU, but rather should be denied admission. Such a policy would result in many patients dying sooner than they would in an ICU, but Murray makes a case for denial of care, providing empirical evidence that includes studies showing that some, though not all patients would prefer that their lives not be unnecessarily prolonged. The astronomical costs of ICU care --both the economic and the human costs -- are also never lost on Murray, nor is the unfortunate fact that better access to primary care and social services would be both less expensive for society and more humane for patients.

Readers will come away from Intensive Care with a better understanding of the reality of disease processes and medical treatments, as well as the difficulties faced by both the patients and the caregivers in an ICU. Entertainment media have often mined this territory for drama, though in a far less thoughtful and informed way. Murray's book can serve as a detailed glossary and annotated accompaniment to programs like ER, as well as a reality check. Who would believe that a patient, after undergoing weeks of excruciating respiratory care for acute asthma, after being nursed slowly back to independence from a ventilator, could die after inhaling a carrot illicitly smuggled into the hospital? That truth is stranger, and more cruelly ironic than fiction is illustrated well by this and other cases detailed in Intensive Care. Murray's book shows that truth can also be more dramatic and more compelling than fiction, too.

© 2003 L. Syd M. Johnson

L. Syd M. Johnson, M.A., is a bioethicist and Ph.D. candidate at SUNY Albany, currently working on a dissertation exploring the implications for reproductive choices of the Non-Identity Problem and new genetic technologies.