Reflections on David Sudnows Death, uses of a corpse, and social worth

In the chapter Death, uses of a corpse and social worth, David Sundraw presents aspects of a county hospitals Emergency Ward life. The chapter introduces two main aspects of the Emergency Room of county hospitals: the assessment and treatment of possible DOA (Dead on arrival) patients and the use of patients bodies be they living or dead for learning and gaining medical experience. The approach to DOA patients in the county hospitals emergency room is presented in comparison to the situation found in private hospitals. In the case of the latter, each case is treated separately, with the same care, attention and use of materials. The doctors are motivated by the money they receive from their patients. For a certain procedure, a doctor fees the same amount of money from each patient; therefore he/she must treat them approximately in the same way. In the case of the doctors from the county hospital this motivation does not exist. However, since, in this case, nobody is paying a fee at all; the doctors should not make any difference between patients either. But this is not the case. In a county hospital there are certain factors that intervene between a doctors job and what really happens in the Emergency Room. These factors are not medical, they are not related to the profession itself, but rather to something that perhaps can be called the culture of the profession of doctor; and even more the culture of the county hospital doctors. Based on the elements of this culture, the medical staff asses the patients they have to treat and they decide how to deal with their cases. Moreover, it seems that from a certain point on this second type of evaluation of the patient is even more relevant and important. Therefore, besides the medical evaluation a patient should get, a second, unrelated one is done and it has a very significant impact upon how the former is subsequently undertaken. These types of assessments

are done not only, by the doctors themselves, but, by the entire medical staff: the interns, the residents, the nurses, medical personnel on the ambulance etc. These evaluations are based on certain values and norms which can be easily related to the values and norms found in a society outside the hospitals door. In evaluating a patient, the personnel of the hospital take into account certain characteristics. These are: clothing and general appearance reflecting ones economic and social status - , age and character. A person is better taken care of if he/she belongs to the middle-class rather than the lower-class, if he/she is younger and if he/she does not seem to engage in deviant behaviours. By these traits, the medical staff establishes the social worth of the patient and hence how important it is that that he/she survives. The author mentions the fact that among these characteristics which are taken into account, gender and race are not present. The evaluation begins with the medical personnel on the ambulance and it determines an entire chain of actions. After the person is medically assessed and categorized as possible DOR, the second evaluation is done and according to the conclusion the personnel has reached about the patient, their behaviour varies. When they enter the hospital they can either announce the possible DOR as a possible who can and needs to be saved or as just a DOR. The distinction between the two is made through the siren alarm and the speed at which the patient is brought in. For the possible patients there is a special siren which is turned on. This way the doctors are announced from the beginning that they should pay special attention to the case. However, sometimes, the opposite message is received, as the doctors may conclude that the patient will most probably die and therefore prefer to let the ambulance driver to assess him/her. On the other hand, if the correct message is received, then things take place differently. The doctor arrives at the patient faster, he/she makes a careful and attentive examination and then dedicates as much time and effort to save him/her as he/she (i.e. the doctor) - considers the patient should receive according to the evaluation he/she (i.e. the doctor) has made.

One of the discriminating criteria mentioned above is the patients character. The categories of people which are discriminated enumerated by the author are: the drunken, the suicides, the dope addicts, the prostitutes, the criminals, the vagrants and the wife-beaters, but the list is not exclusive. I believe that these cases can be divided into two categories. The first one is exemplified by the case of the drunken person with a stomach hemorrhage. The doctor refused to order new blood for the patient because he presumed probably in a correct manner - that the ulcer in his stomach which was the source of his bleeding was caused by the drinking. Moreover he was convinced that the incident will repeat again. We can look at this situation through Berkowitzs norm of social responsibility which states that there is an expectation that people will respond to the legitimate needs of others who are dependent upon them (Berkowitz, 1972 apud Feldman, 242, 1985) The norm also states that before helping someone, one evaluates the reason behind someones dependency and that people who are needy due to events beyond their own control are more apt to be the recipients of aid than those whose situations are seen as being voluntary and under their control. (Berkowitz, 1969 apud Feldman, 242, 1985) I believe this is the case in the situation described above. The doctor considered the patient to be responsible for the state he was in. Although a bio-medical field, governed by scientific laws, medicine still maintains a moral approach. A considerable number of scientific theories of health correlate illnesses to the individuals behaviour, which means that if one gets sick or ill, he/she is to blame. Stephen Moore speaks about the narrative of risk which states that we live in a risk-filled world in which our health is constantly under threat, and it is everyones duty to avoid becoming ill. (Haralambos, Holborn, Heald, 2004, 322) The third distinction between patients is done according to age. A younger person is much more valued than an elder one; and by elder one should not necessarily understand old, as in over 60-65 years

old, but also someone aged around 40 years old. The efforts made to resuscitate a young person are considerably higher. Sudnow associates this type of discrimination of the patients with the social value or worth that person has for the medical staff. Another aspect which is noteworthy in this type of differentiation between patients is their physical appearance. Although it is a matter of saving a life, when it comes to mouth-to-mouth resuscitation the medical staff may refuse or avoid performing it on an old person, for example. The intern that Sudnow mentions in his description was not able to surpass his disgust in order to try to save the old lady patient. It seems that in the County hospital the fact whether a possible DOR patient lives or dies depends on much more than the abilities of the doctor or on the resources the hospital holds. At the end of the day, having certain characteristics and features may be more important in saving a persons life than the actual objective biological chance of surviving. The latter can be denied of an individual provided he/she presents certain traits which are not positively evaluated by the medical staff. To a certain point, there is something one can do in order to raise his/her chances of getting a better treatment at such a hospital like avoiding certain behaviours or always dressing in a decent manner, but in the end no one can change their age or the way they look especially if one belongs to the middle-low class or to the lower-class. The second aspect brought into discussion is the use of the corpses for gaining medical experience. The cases and surgeries at County hospital could be classified into usual, or just work and rare. The first cases are not granted much attention and regardless of how serious the condition of the patient is, they are approached more or less in the same manner, with indifference and lack of interest. These are the routine procedures and surgeries, to which most of the staff is probably familiarized with. The rare cases, on the other hand, receive a special attention, not only from the doctor, intern or resident who is in charge of it, but by the rest of the medical staff as well. Thus, in order

to assist or participate in a rare case, the staff is willing to perform worse or to perhaps complicate an otherwise simple procedure like an appendectomy, for instance without considering the patients best interest. Another compromise which is done for the sake of teaching and learning and at the expense of the patients is to perform unnecessary medical procedures on patients who are on the operating table without their consent. These procedures are performed on patients who also represent rare, interesting cases for the staff. The patient is not informed of the procedure performed on him/her. The procedure, as bringing no medical benefit for the patient, ultimately represents an invasion and a harm done to the latters body. A question that comes to my mind is why are these doctors interested in rare cases in the first place? They clearly show no interest in improving their skills in order to operate better and save more lives; otherwise I assume they would be more preoccupied with each usual case they get as well. As Sudnow presents the situation, curiosity is what drives these doctors to do the above mentioned things; and it seems to be a curiosity without a clear purpose. On the other hand, their interest might be to gain these skills in order to promote and be better regarded by their peers. Again, the bodies they use for this purposes are selected. They belong to the same categories enumerated above: the old, the poor and the morally reproachable. In her book, Medical Sociology, Minako K. Maykovich (1980) discusses a related topic: the ethics of medical experimenting. She speaks about the cases of experiments presenting certain risks for the people who participate in them. In many of them, the people conducting the experiment do not disclose the whole information to the participants as they know that this would prevent many of the latter from giving their consent. The conductors of the experiments themselves are many times unaware of the extent to which the side effects of the experiment may harm these people. Therefore they misinform them to a certain point. However, in order

to be able to pull the entire thing off they must select people belonging to certain categories. These people are in most cases more vulnerable and they are less likely to have the will, means and power to act if things do go wrong for them. In addition, the author states that people who are more likely to undergo such experiments have a low social worth associated to them: Those who are most exposed to experiments appear to belong to specific subservient categories such as fetus, children, patients, military, prisoners, and the poor, all of whom are powerless or are viewed as expendable (Lasagna, 1970 apud Maykovich, 1980, 453) Nonetheless, in the case of the studied county hospital, the people that underwent the routine procedure of inserting an endotracheal tube were only the ones regarded as those being powerless and having a low social worth at the same time. Childrens corpses, for instance, were not used for this purpose. To a certain point we might say that these doctors seem to use the bodies and corpses of patients they assess as having low social worth or value in order to practice and gain more experience so they are able to save and better treat the people who have a higher social worth for them. One special category of people who are used in both alive and dead experiments is represented by the suicides. They are not regarded as deserving to be saved. It might be that the rationale of the doctors is that since that person has inflicted that much damage to his/her own body, the damage they inflict during their explorations is nothing, in comparison. Therefore, if the norm of social responsibility is to be applied to these cases, then we can say that since the patient is viewed as fully responsible for the dependences situation he is in, then the doctors act accordingly. On the other hand, no one asks himself/herself the question what determined those patients to commit such acts. There is a contrast between the doctors attitude towards such acts which at a first glance would seem to reflect that they highly value life in general and their lack of interest and care for people who enter the hospital door each day with a possible DOA tag.

The people who work at the county hospital seem to have a culture of their own, a special set of values, norms and rules which guide their everyday activities. To a certain extent, they objectify their patients and perhaps we might compare treating a patient to fixing a broken object. The routine procedures are done with lack of interest since there is nothing challenging about performing them. On the other hand, the unusual situations are approached with curiosity and interest, because of their rareness and special character. They do not, however, involve a special care when engaging in their resolving. It is more of a selfish interest, rather than an altruistic one. Care and interest are not strange to the medical staff, but are rather conditioned. A patient is to be treated as a person if he/she is perceived in such a manner, which implies that he/she must have certain features and qualities. If these lack, then the person is objectified and approached accordingly. I believe one of the reasons these things do occur is because they can occur. There is no one there to control them properly. Although, everybody knows the general, common sense rules of being a doctor, no one applies them. There are no punishments for those who break the rules, and after all, the law. The medical staff accepts these informal rules and applies them altogether. I find it surprising that in an entire hospital where the staff changes, where interns and residents come and go, there are not people who report these kinds of situations. . At their job, people assess other people they dont know every day and act accordingly. Most probably the woman at the grocery store will smile and be polite to an elegantly, middle-class young woman or man and will frown when having to serve a drunken person, but her behaviour wont change those peoples lives significantly. In the case discussed here, it is a matter of life and death. On the other hand, watching people die everyday is part of the routine of the job. In order to perform this job properly, it is said that one must detach oneself from the patient, from his/her suffering and focus on the

medicine. This means that it is better for a doctor not to regard the individual he/she is treating as a person anymore, but more as a patient, as a case that needs to be solved The author also stated his point of view about the private hospital he researched. Although all the above described actions and ways of approaching patients is not present in a private hospital, the reason does not seem to regard morality, but rather the fact that in these hospitals the control is more strict. At the end of the day, I believe that doctors should be able to detach themselves from their patients suffering and regard them, to a certain point, as broken machines which need to be fixed. This may allow them to focus more on their job. They also need to improve their skills in order to perform better, so they should practice when and how they can. This is part of their culture. But, the same time, these doctors are not isolated. They are part of the society as well and one would say they should respect its norms and values as well; not only the written ones, like the law, but also the general unwritten ones. If we look at the situation from another angle, though, we may also state that the culture of the county hospitals is derived from the general society culture. We may regard Sudnows behaviour descriptions as appalling, but these types of attitudes can be observed outside the hospital as well. The rest of us do not have other peoples lives in our hands as often, but how is one to know if, after years of doing the same thing, he/she would act any different? Can we be sure that we would not lose our interest, that we would not just simply become blas? Through his study Sudnow may not have discovered the exact reasons why the medical staff at county hospitals act the way they do in treating their patients, but he has offered a valuable insight into this world.

References: Feldman, Robert S. (1985). Social Psychology. Caledonia: McGraw-Hill; Haralambos, Michael, Holborn, Martin and Heald, Robin. (2004). Sociology: themes and perspectives. (6th edition). London: Harper Collins Publisher; Maykovich, Minako K. (1980). Medical Sociology. Sherman Oaks: Alfred Publishing;