Editorial: Shades of Gray

Trying to keep my medical knowledge current can be a struggle. Among the most frustrating and unhelpful articles I read are those that attempt to assist me with my decision making. The ones that suggest I apply statistical sorting strategies usually are beyond my computational skills or make unrealistic assumptions about my available time.

On the other end of the spectrum are authors who call themselves ethicists. I don’t know about you, but their approaches often leave me unsatisfied and unsure. I admit that physicians’ decisions can’t always be governed by what seems intuitive, but more often than not I am unconvinced by the ethical argument.

Here’s a hypothetical scenario that is an amalgam of real situations I have faced:

During the summer before entering high school, a 14-year-old develops some abdominal pain. Unfortunately, this occurs in the evening just after our office has closed. More unfortunately, his grandmother (who is in charge) takes him to the emergency department without calling one of us. The emergency physician orders a CT scan because "the surgeon on call won’t see anyone with abdominal pain without a CT scan." The study is normal with one exception: The right kidney can’t be visualized. My patient is sent home with what turns out to be the correct diagnosis of viral gastroenteritis.

More outpatient studies and a trip to the urologist determine that this is a simply a case of a congenital absence that was somehow missed by his mother’s single prenatal ultrasound.

This young man is an extremely talented football player. Over the previous 2 years, he has given up his other sports to focus on football and is pretty much assured that he will make the varsity as a freshman.

He is not a very good student, and he has a bit of a behavior problem. The only strategy that has kept him in middle school is an educational plan that requires weekly status reports from all of his teachers. If the reports are unsatisfactory, he doesn’t get to play in that week’s contest. His parents are still together, but just barely. The only thing they can agree on is their support of their son’s athletic participation.

So now I am faced with a young man who has one kidney and for whom a contact sport has become his only buffer against big-time trouble. Obviously, the decision would be much easier if the patient were a newborn or a grade-school-age child. But neither his parents nor I have the luxury of time to gradually steer this adolescent toward less-hazardous activities.

At some point, he will be faced with the reality that there is more to life than football. But this doesn’t seem to be a good time for this young man to attempt an epiphany. So I tell the family that there are many physicians who would tell them that someone with one kidney shouldn’t play football because of the risk of permanent injury. I can’t quote them any numbers, nor do I share my own anecdotal experience of 40 years during which I have seen only one traumatic kidney injury in a school sport. (It was in soccer, and did not result in permanent damage.) Any statistics I might have offered would have been viewed through the rose-colored glasses of parents who realistically see football as a lifeline for their son.

Some of you might have issued a no-play ultimatum, or at least had the parents sign some memorandum of understanding. But I’m not sure that either approach would have achieved their intended outcomes. There are other physicians who would be willing to sign a participation form if I hadn’t. And there are more than enough lawyers who could find a flaw in any written agreement. I merely included a note in the chart that we had discussed risks and options and moved on to the next decision cloaked in shades of gray.

Dr. Wilkoff practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him at pdnews@elsevier.com. This column, "Letters From Maine," appears in Pediatric News, a publication of Elsevier.