A sharing by Tan Yew Seng
Pulling the Plug
This drawing is a composition of 2 scenes: on the right was presumably a group of doctors (one of whom was sporting a stethoscope) huddled in discussion. They were notably portrayed as having faceless and disproportionately huge heads with amorphous bodies. Emanating from 2 of the heads was a speech bubble that described pictorially the content of their discussion — “pulling the plug”. On the left hand side of the picture was a drawing of what appeared to be a very ill patient: the eyes were closed; the mouth hidden behind an oxygen facemask; the hairless head; and perhaps not so strangely, the bodily contours that were demarcated with “broken” lines that may “ signify the deterioration of body integrity. A tear drop flowed down from his left eye, and above him were the words in red “I can hear you”, floating without a speech bubble.
By juxtapositioning the 2 scenes, the artist intended for us to watch them together and possibly to highlight the contrasting valences. They were separated by a slant divider which imparted a sense of dynamic tension between the scenes. Yet, the division was incomplete — the divider being disrupted by the patient’s pillow, which subtly suggested that the patient and doctors were actually in physical or temporal proximity — same time and space but yet divided.
I believe this drawing was a depiction of “moral distress”, which may be defined as a state of anguish when one encounters a moral transgression, where one may even acknowledge responsibility, but because of the real or perceived constraints, becomes a party to the wrong-doing.
The medical student had chanced upon a medical discussion of “pulling the plug” in the presence of a supposedly comatose patient. What caught the medical student’s attention was the patient’s tear as the doctors spoke. It was unlikely that the patient could speak, but it was probably the medical student’s empathetic awareness of the patient’s experience or perhaps the projection of his wish that the patient may remind the doctors that what they were saying was insensitive and hurtful. Yet through it all, she or he probably did not protest to the doctors, and perhaps by mere association with the medical profession, she or he becomes an inadvertent accomplice by compliance.
Another issue that one may identify with the picture was the danger of regarding medicine as an intellectual process that objectifies patients, puts diseases in front of persons and their families, and ranks treatment over care. The outcome of such an unfortunate approach is dehumanization — the indignity of which the perceptive student had reacted to. Yet it is important to also remember that doctors were once perceptive and sensitive medical students. What has changed them so deeply that they had become oblivious to this patient’s experience? While there are many factors, I would draw attention to how the medical students and doctors might have been supported (or not) in emotionally difficult situations like dealing with the patient’s dying and death. It is not unknown that when faced with seemingly insurmountable and repeated challenges at work, one way to protect their integrity is by emotional distancing and depersonalization. Often, such behavior may be justified by invoking professional objectivity, professional boundaries, ethics and even subverted notions of “palliative care”! The systemic challenges behind this state of affairs are deep, but it is only when we consider that we are no less human than our patients, and just like them, we deserve care and compassion, that we can meaningfully address these complex issues.
Dr Tan Yew Seng is a family and palliative medicine doctor now working at a private oncology centre.
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
