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Robert Veatch is Professor of Medical Ethics at the Kennedy Institute of Ethics, Georgetown University. He received the career distinguished achievement award from Georgetown University in 2005 and has received honorary doctorates from Creighton and Union College. His new book, Patient, Heal Thyself: How the “New Medicine” Puts the Patient in Charge, he sheds light on a fundamental change sweeping through the American health care system, a change that puts the patient in charge of treatment to an unprecedented extent. In the original article below, Veatch looks at how the empowerment effected Michael Jackson’s medical decisions and the responsibility of his doctor.

Dr. Conrad Murray is the doctor who apparently administered a fatal dose of the anesthetic, propofol, to Michael Jackson in a desperate attempt to respond to his cries for help in getting some sleep. He has received rough treatment from the media. Jackson’s death has been ruled a homicide and the media are reporting that he will be charged with manslaughter. I think that judgment is too quick and want to come to the doctor’s defense.

The case is, of course, being tried in the press before we have all the details, but the likely scenario is emerging. Making some plausible assumptions, I think a case can be made for the doctor’s decisions. Let me assume, for purposes of discussion, that the doctor did not intend to kill Michael (He was reportedly being paid $150,000 a month to be Michael’s full time physician. Even if he had completely abandoned his duty to serve the patient, he would be a fool to intend the death.) Let me assume that the lethal effects were foreseeable, but not inevitable side effects of a very potent drug. Let me also assume that Michael had been informed by Dr. Murray how dangerous the drug was and how unusual it was to use it for this purpose. Possibly, he had even told Michael that the drug’s labeling did not include the use of propofol outside of a hospital and that almost all physicians would refuse to use it this way.

With these assumptions, a prosecutor will have a difficult time accusing the doctor of a crime. It is not even clear to me that “homicide” is the right term for the death. First, it is important to realize that “off-label” uses of drugs by doctors is not illegal. It is done all the time when a physician becomes convinced that it in the patient’s interest. Second, it is critical to understand that medical choices about what is in a patient’s interest are directly dependent on the patient’s goals and values. They cannot simply be read out of a textbook as if medical science can prove what is in a particular patient’s interest. (Think about whether aggressive chemotherapy is in a terminal cancer patient’s interest or whether an abortion is in the interest of a pregnant woman.) The patient’s interest is necessarily a subjective matter about which only the patient can have direct knowledge.

It seems clear that Michael was in the advanced stages of insomnia and was in excruciating agony from persistent lack of sleep. That is an awful situation about which patients often have to make desperate choices. None of us can know what was in Michael’s head that caused the insomnia or led him to plea for pharmacological intervention. We do know that other drugs had been used even that fateful night (benzodiazepines that are often used to reduce anxiety and induce sleep). These other drugs had failed to solve the problem and made the use of the propofol even more dangerous, something Dr. Murray surely knew and presumably had told Michael.

Now the question for Dr. Murray and for Michael Jackson is, given his desperate situation, is the only drug that will give him some sleep worth the very great risk of side effects, even death? Surely, for most of us the answer would be negative, but that doesn’t mean it was Michael’s answer. Given that he had apparently received the drug many previous times without side effects, I don’t see how we can claim that Michael would be wrong to decide that the risk would be worth it in his case. Deciding whether the drug is “worth it” is a value judgment, not a scientific fact that the doctor can look up in a book. Even if almost everyone else would have decided not to try the desperate off-label use, I don’t know how we can say Michael’s gamble was wrong for him.

But, you might say, even if Michael’s judgment was understandable, surely Dr. Murray was wrong to go along with his patient’s demand. Surely, other physicians would not have agreed. A physician is supposed to be a responsible professional who has the right not to go along with a patient’s very unusual and risky demand. Most physicians would have refused to provide the propofol (at least outside of a hospital) and that is understandable, but this does not prove that Michael’s value judgment about the risk was wrong or that Dr. Murray was wrong to comply. Some medical issues are appropriately judged by what is called a “standard of care.” The correctness of the physician’s behavior is judged by what his colleagues similarly situated would have done. This, however, is not a decision that should be judged by that standard. If it is possible that Michael had made a rationally defensible decision that the risk was worth it for him, then a physician is within his rights to decide to cooperate in a legal behavior if he so chooses. He surely would have had the right not to provide the dangerous drug for off-label use, but he also has the right to decide it is a tolerable risk. If he does so after the patient is adequately informed, I don’t see how we can fault him assuming that the lethal effect was not intended.

This turns out to be crucial for the rest of us if we are to get high-quality, rational medical care. We have for many years recognized that most powerful, valuable drugs have anticipated side effects. If we choose to take the risk and the side effect occurs, we don’t say that the choice was a mistake. If the side effect is death, we don’t say it was a homicide. Provided the intended beneficial effects are good enough, we say that the side effect is tolerable even if it is foreseen. That, in fact, is precisely the justification for doctors’ use of narcotics to control severe pain in cancer patients even though they know that the side effect can be respiratory depression and even death. Most ethical systems have long acknowledged that such “unintended, but foreseen” deaths are tolerable. Normally, such a death is not deemed a “homicide.” Just may be, if we put ourselves in Michael’s shoes and plug in the value judgments he made, we can understand why Dr. Murray, apparently with great reluctance, was willing to go along. I can’t fault him if that was what he did.

Megan Branch, Intern

Dr. Robert J. Wicks, the author of Bounce: Living the Resilient Life, is a professor at Loyola University Maryland. Bounce is a guide for managing stress, turning it into an opportunity, and living more meaningfully in the process. In the original article below, Dr. Wicks profiles the four different types, or “voices”, of friends that everyone needs in their lives. Do you have friends who fulfill all four roles? Do you recognize yourself among them? Dr. Wicks has provided a questionnaire at the bottom of the article to help you find out where you and your friends fit in.

Peig Sayers lived in the Blasket Islands off the coast of Ireland. The winds were so great that even trees couldn’t survive and she was asked, “How can you live in a place like this?” To which she responded quite simply, “It is in the shelter of each other that the people live.”

Psychology has long emphasized the need for an excellent interpersonal network as a major element of health and happiness. As medical studies have shown us, an absence of at least one significant friend may also even have serious health consequences. So, we know we need friends. The question is what type of friends?

In my work and that which I have done with others in the field, I have found that for our circle of friends to be complete, the presence of at least four “types” or “voices” (since one friend may play more than one beneficial role at different points in our lives) are necessary—especially in today’s challenging times. These four types of friends are the prophet, the cheerleader, the harasser, and the guide. By having these “voices” in our lives, we increase our chances of maintaining a sense of perspective, openness, and balance.

The Prophet
The first of these voices which helps us maintain balance and have a sense of openness is the one I shall refer to as the prophet. Contrary to what one might imagine, prophetic friends need not look or behave any differently than other types of persons who are close to us. The true prophet’s voice is often quiet and fleeting, but nonetheless strong. She or he is living an honest courageous life guided by truth and compassion.

Having someone prophetic in our lives is never easy. No matter how positive we may believe the ultimate consequences will be for us, many of us still shy away from prophetic messages and would readily agree with Henry Thoreau: “If you see someone coming to do you a good deed, run for your life!” However, to seek comfort in lieu of the truth may mean that in an effort to avoid pain, we will also avoid responding to opportunities of real value, real life. We will merely exist and eventually die without having ever really lived. Prophets point! They point to the fact that it doesn’t matter whether pleasure or pain is involved, the only thing that matters is that we seek to see and live “the truth” because only it will set us free.
In doing this, prophets challenge us to look at how we are living our lives, to ask ourselves: “To what voices am I listening when I form my attitudes and take my actions each day?”

The Cheerleader
Ironically, one of the most controversial suggestions I might make with respect to friendship is to suggest we all need “cheerleaders.” Some might say that to encourage this type of friend is to run the risk of narcissism and denial. However, to balance the prophetic voices we also need unabashed, enthusiastic, unconditional acceptance by certain people in our lives. Prophecy can and should instill appropriate guilt to break through the crusts of our denial. But guilt cannot sustain us for long. While guilt will push us to do good things because they are right, love encourages us to do the right thing because it is natural.

We can’t go it alone. We need a balance of support. We need encouragement and acceptance as much as we need the criticism and feedback that are difficult to hear. Burnout is always around the corner when we don’t have people who are ready to encourage us, see our gifts clearly, and be there for us when our involvement with people, their sometimes unrealistic demands, and our own crazy expectations for ourselves, threaten to pull us down. So, while having buoyantly supportive friends may seem like a luxury, make no mistake about it – it is a necessity that is not to be taken lightly. The “interpersonal roads” over time are strewn with well-meaning helpers who tried to survive without such support. Encouragement is a gift that should be treasured in today’s stressful, anxious, complex world because the seeds of involvement and the seeds of burnout are the same. To be involved is to risk. And to risk without the presence of solidly supportive friends is foolhardy and dangerous.

The Harasser
When singer-activist Joan Baez was asked her opinion about contemplative, monk and writer Thomas Merton, one of the things she said was that he was different than many of the phony gurus she had encountered in her travels. She said that although Merton took important things seriously in his life, he didn’t take himself too seriously. She indicated that he knew how to laugh at situations and particularly at himself. “Harassers” help us to laugh at ourselves and to avoid the emotional burnout that results from having the unrealistic expectation that people will always follow our guidance or appreciate what we do for them. This type of friend helps us regain and maintain perspective (so we don’t unnecessarily waste valuable energy). This is truly a gift for which we can be thankful.

Guides
The three types of friends we’ve looked at thus far are each part of a necessary community. The prophet enhances our sense of single-heartedness. The cheerleader generously showers us with the support we feel we need. The harasser encourages us to maintain a sense of proper perspective. Complementing these three is a cluster that, for lack of a better name, shall be referred to as “guides.” Such persons listen to us carefully and don’t accept the “manifest content” (what we say and do) as being equal to the “total content” (our actual intentions plus our statements and actions). Instead, they search and look for nuances in what we share with them to help us to uncover some of the “voices” that are unconsciously guiding our lives, especially the ones that make us hesitant, anxious, fearful, and willful.

To determine whether or how these voices are present in our lives, several questions or statements seeking further information about the composition of our circle of friends might be helpful:

• Do I have people with whom I can simply be myself?

• What type of friends do I value most? Why?

• What do I feel are the main qualities of friendship?

• List and briefly describe the friends who are now in my life.

• Describe ones who are no longer alive or present to me now but who have made an impact on my life. Why do I think they made such a difference in my life?

• Among my circle of friends, who are my personal heroes or role models?

• Who are the prophets in my life? In other words, who confronts me with the question: To what voices am I responding in life?

• Who help me see my relationships, mission in life, and self-image more clearly? How do they accomplish this?

• Who encourage me in a genuine way through praise and a nurturing spirit?

• Who tease me into gaining a new perspective when I am too preoccupied or tied up in myself?

• When and with whom do I play different (prophetic, supportive …) roles as a friend?

How do people receive such interactions. Having a healthy and balanced circle of friends can aid in stress prevention and personal-professional growth. This is an obvious reality. The important point here is that with some attention to this area, we can immeasurably improve the role that encouraging, challenging, and guiding friendships can have in our lives. In turn, it can also provide an impetus to fill similar roles with others, which can also be a deeply rewarding experience for us—though they are roles that we must take with care as well if we are to remain resilient and passionate and be able to continue to reach out without being pulled down.

Elvin Lim is Assistant Professor of Government at Wesleyan University and author of The Anti-intellectual Presidency, which draws on interviews with more than 40 presidential speechwriters to investigate this relentless qualitative decline, over the course of 200 years, in our presidents’ ability to communicate with the public. He also blogs at www.elvinlim.com. In the article below he reflects on the time before Obama takes office. Read his previous OUPblogs here.

In recent weeks, President-elect Obama has shown himself to be a cautious pragmatist. In keeping Defense Secretary Robert Gates in his cabinet, he is signaling to his liberal base that there will be no precipitous pullout from Iraq. In selecting Senator Hillary Cinton to be Secretary of State, he has endorsed her aggressive campaign stance toward negotiating with rogue-nations. We no longer hear about the windfall profit tax on oil companies that Obama had proposed during the campaign trail, and the next president is probably going to wait a while to repeal the Bush tax cuts for the wealthy.

Barney Frank said it best in response to Obama’s claim that there is only one president at a time, “I’m afraid that overstates the number of presidents we have at the present time.” There is so much frustration against the Bush presidency, and so much pent up anticipation for what is to come that if they had their way, Democrats would have moved inauguration day to the day after November 4. Liberals looking for change are doubtless disappointed and even agitated, but this is an administration-to-be saving its ammunition for the battles ahead.

The perceived prudence of the president-elect must be viewed in the light of the fact that he has no authority to do anything now. (He is not even a Senator anymore.) All the power he possesses now comes from the law of anticipated reactions. Until he takes the oath of office, he has no formal authority, though he possesses more power now than he ever will. Some call it a store of good will; journalists call it a honeymoon. But this is power that will not persist; it will start to dissipate just as Obama hits the ground running. As he finally sits down to to take the presidential test, and the distance between hope and reality, rhetoric and action narrows, his honeymoon, like the law of all good things, will end.

That is why I do not expect the prudence ex ante to continue ex post. Now is the calm before the storm. Come January 20, there shall be a flurry of activity and a big stimulus package which would include, among other things, a big infrastructure program to rebuild roads and bridges around the country. There is so much pent-up anticipation for Obama to use his electoral mandate that he is likely to benefit from the restraint he is exercising (and the angst he is causing) now. This man who has proved adept at beating the Clintons at their game during the primary season will not likely repeat their mistake of front loading his first 100 days with more than he can handle. His legislative agenda will not be cluttered, but it will surely be bold.