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After Harm: Medical Error and the Ethics of Forgiveness Nancy Berlinger Johns Hopkins University Press, £23.50/£35, pp 176 ISBN 0 8018 8167 6 www.press.jhu.edu Rating: ★★★>
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he title of the US Institute of Medicine’s 1999 report, “To Err is Human,” truncates a well known aphorism, “To err is human; to forgive, divine.” In After Harm, Medical Error and the Ethics of Forgiveness Nancy Berlinger notes that the omission of the second clause symbolises the way modern health care has, in its preoccupation with preventing medical error, neglected the moral obligations that follow from the errors that human agents inevitably commit. In a laudable effort to address the imbalance, Berlinger applies a “religious studies perspective” to describe the words and actions that make forgiveness possible after medical harm. Before harms can be addressed they must first be disclosed. In a turn that initially seems paradoxical, Berlinger commends the norm of disclosure by appropriating the German pastor Dietrich Bonhoeffer’s theological justification for lying to his Nazi interrogators in the period before his eventual execution. Bonhoeffer was repulsed by Immanuel Kant’s notion that lying, on principle, is not justifiable even to defend the innocent from evil. Against Kant, Bonhoeffer argued that our moral obligations can never be reduced to anything less than a “total and realistic response of man to the claims of God and of our neighbour.” To discern what a “total response” requires, clinicians must gain what Bonhoeffer called “the view from below,” which subsists in the “perspectives of those who suffer.” In the contemporary medical context, Bonhoeffer’s insight is echoed by “narrative ethicists,” who emphasise the centrality of the patient’s voice in clinical ethical deliberations. In the stories of patients who have been harmed, several of which are related in the book, Berlinger finds indis-
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pensable resources for forming and refining the moral sensibilities of clinicians. Patients tell doctors, for example, that a “total response” to medical harm necessarily begins with a candid disclosure of doctors’ errors and their consequences. Yet, disclosure is not sufficient: patients also need to hear an apology. Statements of sympathy are not enough. Genuine apologies must acknowledge responsibility for the error and its consequences. For example, saying “I am sorry your father died” is not the same as saying “I am sorry for my error that contributed to your father’s death.” Berlinger is careful to note that acts of disclosure and apology in no way obligate patients and families to forgive those who have harmed them. Demands for forgiveness are demands for what Bonhoeffer called “cheap grace”—absolution without repentance. The Jewish and Christian concept of repentance requires a genuine effort to right the wrong that has been done. Because medical harm usually causes the loss of something that cannot be restored, reparations must be made. Berlinger urges clinicians and the organisations they work in to proactively and fairly compensate victims of medical harm rather than retrenching in ill advised efforts to fend off possible lawsuits. Fair compensation sets the stage for forgiveness by showing that the clinician or institution acknowledges error, takes responsibility for it, and seeks to restore the relationship with the one who has been harmed.
Doing what is right, particularly in the face of fear, is difficult. Doing right after medical harm is no exception Berlinger draws her normative concepts from religious resources, but she eschews theological arguments in favour of appeals to the usefulness of these concepts in practice. Judaism and Christianity, she argues, have so shaped the Western mindset that even secular persons “know” that harm cries out to be forgiven and that forgiveness is made possible when the one who has caused the harm confesses, apologises for, and repents of the error. Shrewd policies will therefore take these norms into account. Indeed, the most persuasive component of Berlinger’s analysis is her judgment—based on careful analysis of experiences in different regions with different healthcare
systems—that the ethics of forgiveness works. Those policies that foster greater degrees of disclosure, apology, and fair compensation actually reduce overall liability costs while improving patients’ satisfaction and doctors’ morale. Yet, by eschewing the limitations of religious particularity and invoking the pragmatic utility of the religious concepts apart from their theological moorings, Berlinger exposes important limitations of her analysis. We may, as she puts it, “engage forgiveness as a tool for addressing the needs of all parties affected by medical error,” but to use forgiveness as a tool, even for therapeutic purposes, is to do some violence to the moral significance of forgiveness. As Bonhoeffer might have said, genuine confession and repentance are incompatible with instrumental aims—or any aim that falls short of a total response to the just claims of both neighbour and God. Moreover, if Westerners indeed know intuitively that wrongs must be followed by some form of confession, apology, and repentance, then clinicians’ failures in this domain are due less to lack of knowledge than to lack of sufficient will to act on what we already know. Doing what is right, particularly in the face of fear, is difficult. Doing right after medical harm is no exception. After Harm, then, provides a valuable counterbalance to innumerable calls for systemic reforms to reduce medical error. To err is human, and human error requires the response that Berlinger thoughtfully summarises in her ethic of forgiveness. By clarifying the nature of our moral obligations after medical harm, Berlinger’s book also highlights a complex challenge for the medical profession: how to form medical professionals who will, in the face of real threats to their own reputations, pride, and financial security, willingly disclose medical harm, apologise for their errors, and take concrete steps to fairly compensate patients for what has been lost. Such actions require more than knowledge of cultural norms. They require virtue because, in some real and necessary way, faithfulness to Berlinger’s ethic of forgiveness places the doctor at the mercy of those who have suffered harm. Nothing less will count as a total response to God and neighbour, and nothing less will make possible the forgiveness for which clinicians hope. Farr A Curlin assistant professor, section of general internal medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago
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reviews
Christopher Frayling Reaktion Books, £19.95/$35, pp 240 ISBN 1 86189 255 1 Rating: ★★★>
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ictional narratives in literature, film, and television help shape public perception of scientists and doctors, their values, and how they behave; they also promote a shared self identity among professionals. Cultural commentators and medical historians’ interest in how clinicians and medical scientists are represented in feature films has developed in parallel with the use of films in teaching, which is now a popular means of stimulating debate on biomedical ethics and professional conduct, in undergraduate medicine and medical history courses.
The Hypochondriac By Molière Directed by Lindsay Posner Almeida Theatre, London, until 7 January 2005 www.almeida.co.uk Rating: ★★★>
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indsay Posner’s production of this Molière translation provides an evening of farce and silliness with semitragic undertones. The antihero Argan (played by Henry Goodman) is the self pitying hypochondriac of the title whose obsession with his bowels and bodily emissions allows to him fall prey to the cream of French medical quacks. Goodman plays him with insecure energy as he sits in his overlarge armchair/commode, his feet not quite reaching the ground and red clogs perched on his toes, making him appear more like the overgrown child that his gold digging wife treats him as than head of a household. Argan is a pitiful character who, when asked, “What do you do?” will, instead of saying upholsterer or brewer, exclaim that he, in fact, “aches all over.” He embraces his 1344
Christopher Frayling’s book characterises several thematic variations in the portrayal of scientists and doctors in Western cinema, from silent movies to modern blockbusters. He has cast his net widely, studying posters and publicity stills as well as films and scripts, and compiled an entertaining survey. The only disappointment is the staid selection of illustrations. Frayling argues that the cinema has always had an uneasy relationship with scientists, who are usually polarised as saints or sinners, although more often the latter. Whenever the names Boris Karloff or Lon Chaney appear in opening credits, we know that we are in for a terrifying hour or two with a maverick scientist—usually a test tube short of a full rack—or his wayward creation, hell bent on creating mayhem. Deranged scientists are usually male. Female scientists are more often depicted as subservient assistants, only noticed by their male colleagues when they loosen their hair, remove their spectacles, and smile demurely while delivering critical data. One of the most engagingly titled sources quoted is Alberto Elena’s 1997 article, “Skirts in the Lab: Madame Curie,” although Curie is the archetypal scientist as heroine. Cinematic science has often played on prevailing phobias, says Frayling, such as public fear of atomic research in the 1950s. In 2005 producers are probably packaging films featuring killer viruses to capitalise on
supposed infirmities with glee and, paradoxically, the more serious his quack doctor declares his condition to be, the more pleased he becomes. Argan’s eyes twinkle when he speaks of the time (two years ago) when he had six months to live. Argan relishes inhabiting the sick role; being “ill” provides him with his daily ritual, from the various tonics he takes, to the balms he rubs on his chest, to the enemas that he appears to enjoy a little too much. He is too squeamish to inspect his own bowel motions, instead expecting his nurse to do so and to ladle them into glass jars that are displayed on shelves about his study. What is appealing about this production is the intelligent wit of the script that is matched comfortably by (literally) toilet humour that would not be out of place on the television comedy Little Britain. Comic force also comes from Thomas (John Marquez), who is betrothed to Argan’s daughter, Angelique. Thomas is to qualify as a doctor; Argan has promised Angelique to him as it is always useful for a raging hypochondriac to have a doctor in the family. Thomas’s father describes his son proudly as someone “who has natural lack of imagination, and a slowness to understand new ideas [that would] stand him in good stead in the [medical] profession,” surely characteristics that the General Medical Council desires in the selection of medical students.
current concerns regarding pandemic influenza. Avian flu spread by migrating birds or the recently reconstructed 1918 flu virus or the release of long dormant viruses from melting polar ice caps offer ripe scenarios for fictional, rogue science. On the other hand, screen biographies of “good guy” medical scientists have been perennial favourites. “In Hollywood we realize that those scientists keep right on discovering better and better things all the time,” commented scriptwriter Anita Loos. The Story of Louis Pasteur (1936) dramatised his struggle against the Academy of Medicine, which tried to block him at every step: “He’s not even a doctor, only a mere chemist.” Bacteriologist Paul Ehrlich’s story was told in Dr Ehrlich’s Magic Bullet (1940), despite the Hays Code, which stated that “sex hygiene and venereal diseases are not proper subjects for theatrical motion pictures.” It took five years and 18 scriptwriters, including Aldous Huxley and F Scott Fitzgerald, to bring Madame Curie (1943) to the screen. At least she made it. Jean-Paul Sartre’s over-long script for Freud, the Secret Passion, written in 1959, was abandoned. As he later commented: “One can make a film lasting four hours if it is about Ben Hur, but the Texan public will not put up with four hours of complexes!” Colin Martin independent consultant in healthcare communication, London
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HUGO GLENDINNING
Mad, Bad and Dangerous: The Scientist and the Cinema
Toilet humour: The Hypochondriac
When Argan gives up on Angelique marrying Thomas, the inspired solution is for Argan to join the medical profession. His induction ceremony suggests that all you need to become a doctor is not medical knowledge but a tailored white coat and the ability to recite the Latin declension of anus and enema. This excellent production may present an entertainingly cruel caricature of hypochondriasis, but it is one in which, I am sure, many doctors would recognise elements of their own patients. Aula Abbara preregistration house officer, Central Middlesex Hospital, London
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reviews
PERSONAL VIEWS
NETLINES
Am I safe to fly? Am I safe to anaesthetise?
d Clinical Cases and Images is a useful resource that brings together various pearls of medical wisdom and aims to bridge the gap between clinical theory and practice (http://clinicalcases. blogspot.com). This well organised site contains a good collection of case histories, with links to imaging, and clinical examination and procedure websites, making this a feature rich site with a strong focus on clinical learning.
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n a recent trip I arrived at to Mexico It also should be remembered that the City airport for an overnight flight captain had two other officer pilots with back to London at 9 40 pm to find him, whereas I usually do my job alone. the flight postponed to 6 am the next day. Another group who work alone and who The reason was that the flight crew’s hotel have the potential to damage others is lorry had caught fire and the crew had had to go to drivers. The amount of rest they must have is hospital, disrupting their rest pattern, and so strictly regulated and monitored by a tachothey needed to sleep. Like the other 351 pasgraph. Should we have some similar system sengers I was disappointed. Just before this for when we are on call? A further difference trip I had worked several days and nights on between pilots and anaesthetists is that the call for a busy intensive care unit, and I was types of emergencies pilots have to deal with looking forward to recovering after my trip are, fortunately, rare. Emergencies are much and then having a normal Sunday at home more common among the elderly patients I before my week back at work as an intensive anaesthetise when they undergo major care doctor and anaesthetist began. I realised surgery. that if the crew members were tired and made The airline industry is much more regua mistake I might never get home again, so I lated than medicine. The UK Civil Aviation accepted the hotel voucher, had dinner, and Authority limits the numbers of hours a went to my room. pilot can fly to 900 a year and 100 every 28 During the flight the captain took time days. Under the influence of unions many to speak with me and we were able to discuss safety conscious airlines have reduced this the way he reached his decistill further. Anaesthetists sion to delay us all by eight can’t just cancel intensive hours. The discussion The Medical Act care when a colleague helped me to clarify my does not give the unexpectedly goes off sick, thoughts on the differences but perhaps we should be between our two profes- GMC power to more assiduous in cancelsions when we don’t have regulate doctors’ ling elective lists. Would it enough sleep and the be better for us all to work reasons we behave so hours shifts? The airline trade unions limit what happens differently. during and after pilots’ standby periods. Nobody wants a plane to crash and Calls are made only after an eight hour rest injure or kill passengers, especially the pilot. period, and a pilot’s routine work the next But there are also good financial reasons not day is cancelled if the pilot is called in. to crash a plane. Besides the airline’s initial The final part of the decision to work or liability, long term financial damage might not concerns the individual: your duty of ensue because of passengers switching care to the patient or the passengers (can I airline. In medicine no anaesthetist or intencope with routine work, let alone the sive care doctor wants their patient to die. emergencies, in a safe and efficient way?) But there are obvious differences between and to yourself (will worrying about whether their situation and that of the pilots. When I can cope today harm me as well?). patients die doctors survive. Doctors have an Perhaps we should have guidance individual responsibility to the patient, makon what constitutes acceptable and unacing it difficult to say, “I am sorry, but I am ceptable levels of disturbance. Who should going to cancel the operation you have write the guidance? Perhaps the GMC, as waited so long for because I was woken last the regulating body in the UK. However, the night and I feel tired today.” The operating Medical Act, which sets out the GMC’s role, team would also find it difficult to accept does not give the GMC power to regulate such a decision, partly because of an ethos of doctors’ hours. Perhaps the act needs muddling through and a macho culture of changing so it does have the power to stop not accepting tiredness as an excuse. Then patients being exposed to tired doctors? there is the management, driven by governOtherwise it is left to the medical ment imposed targets. They don’t take “trade unions,” but it seems wrong for kindly to operations being cancelled unions to be involved in matters of patient because the anaesthetist is tired. safety. Why should passengers, pedestrians, The pilot told me that he found it and road users who are at potential risk difficult to make the decision to cancel the from tired pilots and lorry drivers be flight but asked himself whether he could protected by the law but patients be cope, when tired, with certain scenarios: left to doctors’ organisations and employengine failure during take off, depressurisaers, who may have other, competing tion at altitude, diversion en route because interests? of a passenger being taken ill. Equivalent scenarios in my profession might be G R Park consultant, The John Farman Intensive anaphylaxis during induction, massive unexCare Unit, Addenbrooke’s Hospital, Cambridge
[email protected] pected bleeding, and pipeline failure. BMJ VOLUME 331
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d I had not heard of the Tuskegee Syphilis Study—a research programme under which adequate treatment for syphilis was withheld from a group of poor black men with the disease—until I read the contribution from the US Centers for Disease Control and Prevention (www.cdc.gov/nchstp/od/ tuskegee/time.htm). Although the Alabama based study was ethically unsound, it lasted for 40 years, from 1932 to 1972. This web page is a clear summary of this disturbing case, which led to a change in the rules governing research on human subjects. There is information about the background of the study and the subsequent investigation, followed by a timeline ending in an apology from President Clinton in 1997. d The web has a wonderful selection of free software available for download. One such offering is a word processor called AbiWord (www.abiword.org/). As with many of the programs created by volunteers, it is free, and users are encouraged to improve on it and pass it on. It can work on operating systems other than Windows. The website demonstrates what the program is capable of, and some of the features are impressive, such as dictionaries for more than 30 languages. d Want to find out more about evidence based medicine (EBM) and don’t know where to start? http://pedsccm.wustl.edu/ EBJ/EB_Resources.html is a site that is full of resources for practising EBM. It may not suit everyone—it is a large and detailed site—but many visitors are likely to find it is a well stocked launch pad to finding EBM resources on line. This substantial collection comprises journal articles and websites catalogued in a single page. To prevent people getting lost as they scroll down, the main subject areas—for example, “What is EBM?” “EBM databases,” and “Medline search strategies”—repeat themselves every so often.
Harry Brown general practitioner, Leeds
[email protected] We welcome suggestions for websites to be included in future Netlines. Readers should contact Harry Brown at the above email address.
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reviews
Will modernised medical careers produce a better surgeon?
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was asked to use this question as the So, a great deal should be possible in the topic of a talk for a recent interview for a shortened MMC training period. This tallies specialist registrar post in general with our common experience of surgical surgery. Getting to grips with the topic protraining. We gain great confidence quickly vided some scary insights into the future of when training is structured and when we training and led me to think about how have the opportunity to repeat procedures training would need to be structured to proseveral times under calm and patient supervide surgical services into the future. vision. But anyone who has worked as a surThere is now a consensus that the gical senior house officer will know all too Department of Health’s modernising mediwell the profusion of wasted opportunities: cal careers initiative (MMC) will shorten surtime spent assisting in procedures we really gical training. Under the old system, our should have done ourselves and time spent predecessors worked long hours for an filing or doing menial tasks while missing average of 13 years between qualifying as out on opportunities in theatre. preregistration house officers and starting If we are to become competent surgeons work as consultants. This amounted to a of the future, we must use our training time training time of more than 30 000 hours. more effectively. All stakeholders (trainees, Alarmingly, the combined effect of the trainers, and trusts) must come to see trainEuropean Working Time Directive and ing hours as a finite resource, legally limited MMC will reduce the by the working time direcnumber of hours of surgical tive and MMC. Wasted training to at most 15 000, Wasted training training opportunities must or 50% of what it used to be. opportunities be audited and avoided. Add to this the greater Trainees and trainers number of trainees sharing must be audited are already converts to the a static caseload, and it and avoided cause of training. All senior seems hard to imagine how house officers have been we will get the kind of traintempted to blame their ing our predecessors took for granted. trainer for not giving them cases, but we It would be reasonable to assume that need to look at the wider picture governing with such abbreviated training, we, tomorour work. Unsurprisingly, routine surgical row’s surgeons, will be condemned to being procedures such as laparoscopic cholecysundertrained and underqualified for our tectomy take considerably longer in the work. On the other hand—although it may hands of trainees than consultants. With seem a tacky comparison to draw— limited theatre time and a constant emphaastronauts are trained in 12 000 hours sis on quality and quantity of service (www.esa.int), and pilots are deemed fit to provision in the here and now, training often work as captains on long haul flights after has to be shoehorned into a busy schedule. just 5000 hours (www.balpa.org). If they can Until the whole hospital infrastructure do it, why can’t we?
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30000 25000 20000 15000 10000 5000 un Me de di r o ca ld l tr sy ain st ee em M ed i c un al de tra r M in M ee NA C SA as t ro Lo na ng ut ha ul air lin ep ilo t
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supports the efforts of trainer and trainee, the situation seems unlikely to improve. In an NHS that is, rightly, governed by quality standards and detailed targets, it is inevitable that hospitals think rather in the short term. I imagine that the need to train junior surgeons to meet healthcare needs 20 years hence probably seems distant to clinical managers. Moreover, the government’s important policy documents lack any targets for training. All concerned need to remember that training now is a prerequisite of service provision in the future. Although it is not surprising that trainees may take longer than their consultants to perform given procedures, it has been consistently shown that training does not prejudice the quality of surgery. The most forward looking units have begun to audit consultants’ training performance in terms of percentage of cases given away, alongside their morbidity and mortality figures (Heart 2001;85:454-7). It is not always the trainer’s fault when training opportunities are missed; trusts too should be subject to audit of their training performance. From my perspective as a junior hospital doctor it seems that hospital managers respond first and foremost to health department targets. For sustainable surgical services to be given sufficient priority, data from training audits will need to be the subject of such targets. Incorporating training audit targets in the Commission for Health Improvement’s assessment structure that is used to decide hospitals’ star ratings may be the only way to motivate trusts to create environments in which training will flourish. Will MMC produce better surgeons? Unless the whole organisation comes to recognise the need for high quality surgical training, it seems unlikely.
NASA
Do surgeons really need more hours’ training than astronauts?
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Luke Devey Medical Research Council and Royal College of Surgeons of Edinburgh clinical research training fellow, tissue injury and repair group, University of Edinburgh
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reviews
SOUNDINGS
Dilemma of a surgical trainee
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comprising mostly hernia repairs and n finishing my basic surgical varicose vein surgery. This would have training and after gaining membeen ideal for a junior surgical trainee like bership of the Royal College of me to gain experience in carrying out these Surgeons, I was keen to proceed in my choprocedures, with a consultant available at all sen career in general surgery as quickly as times. possible. I was shortlisted for specialist interA few months ago trainees became views in early summer and offered a training increasingly worried about the decline of number in the Oxford Deanery. Everybody exposure to surgical procedures and time who has been through this process can spent in theatres as a result of the European imagine how happy I was. Proud of my working time directive. This directive led to achievement, I was looking forward to my the introduction of shift systems all over the training as an SpR. country, as well as the introduction of surgiMy first appraisal went well. I am cal care practitioners (SCPs), who were currently attached to the vascular firm, but thought to reduce training opportunities for since I am not aspiring to a career in vascudoctors even further, as they are meant to be lar surgery and I am at the beginning of my trained in the same basic surgical procetraining, the targets that my trainers dures that junior surgical trainees need to identified for me include genuine surgical become competent in. experience: By the end of my vascular The problem that I face at the moment attachment I “should be able to expose the is not the dilemma of whether to go home groin vessels unsupervised, to have refined instead of to operating the performance of comtheatres after a night shift, mon femoral anastomosis, or having to compete for and be capable of perform- How am I every operative procedure ing primary long saphen- supposed to with an SCP—it is that I ous vein surgery and inguinal hernia repair unsu- become a simply don’t have a theatre pervised.” consultant and be list to go to at all. During my previous Varicose vein surgery training as a senior house expected to operate and hernia repair are officer I had already per- on complicated so-called index operative formed varicose vein surprocedures, specifically gery and hernia repairs cases when I am highlighted in trainees’ logwith varying degrees of not trained to books as markers of comsupervision, so it seemed a petence. As a trainee in logical and manageable perform the general surgery I am constep to move on to do these primary cerned that I will not gain procedures unsupervised. appropriate exposure to Unfortunately, a few procedures? training in these two basic weeks into the job, just after surgical procedures, if, as my appraisal, the Thames Valley priorities the statements of the Thames Valley prioricommittees (Oxfordshire primary care ties committees suggest, these procedures trusts) issued two policy statements on elecare from now on only carried out as an tive surgery for the treatment of inguinal exception rather than as part of a surgical and umbilical hernia in adults and surgery routine in my deanery. for varicose veins. These stated that the surHow am I supposed to become a gical treatment of inguinal and umbilical consultant and to be expected to operate on hernias in adults as well as the surgical treatcomplicated cases of recurrent varicose ment of varicose veins was a low priority veins and strangulated hernias when I am treatment and that patients would not not trained to perform the primary procenormally be offered surgery. dures? I welcome any views and advice As from the beginning of November all about this. The only answer that I don’t want patients on waiting lists for these operations to hear is “surgical skills laboratory.” have been withdrawn. They are now awaiting assessment by an independent Bettina Lieske specialist registrar in vascular party to see whether they fall into the surgery, John Radcliffe Hospital, Oxford category of patients who need surgery
[email protected] because of, in the case of hernias, sufficient pain and disability to affect their normal daily living, and, in the case of varicose veins, We welcome submissions for the personal view persistent ulceration secondary to venous section. These should be no more than 850 words stasis, recurrent phlebitis, or significant and should be sent electronically via our website. haemorrhage from a ruptured superficial For information on how to submit a personal view varicosity. online, see http://bmj.com/cgi/content/full/325/ Meanwhile several operating lists have 7360/DC1/1 been cancelled, including a day case list, BMJ VOLUME 331
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Man’s best friend Dysorganophilia (Farrell’s syndrome): excessive affection for an abnormal body part. When I was a lad I had a papilloma on my left upper arm, and had no need of thumbsucking or a security blanket; I had Bob to twiddle, and we went everywhere together. “Isn’t he a gorgeous little thing?” girlfriends would say, admiring the elegant stalk, the smooth bulbous head, but as I grew older, more mature and sophisticated, and conscious of the importance of physical perfection, I became embarrassed by Bob. Even on nudist beaches, where I was unashamed to let everything else hang out, I would hide Bob with a bandage. Eventually I decided Bob had to go. Distinctly I remember it was in the dark of December, and the razor felt cold, ice against my skin. The vorpal blade went snicker-snack and a drop of blood welled up like a last tear—had I heard a sad little sigh? I left Bob dead and with his head I went galumphing back to the world of normal people. But years later, I found I was not alone. Joe refused to have Norm removed, as he had become rather inappropriately fond of his hydrocoele. As I had worn the T shirt, I could empathise; Norm was cheaper and less troublesome than a pet, didn’t leave a mess, didn’t need a licence, didn’t need to be taken for walks. Every so often, when Norm became so large that Joe required an extra seat on the bus he would let me drain off a few gallons, but it was a procedure that caused him considerable distress. “Ah, look at the poor wee thing, don’t be taking too much now,” he would say. “No more, no more, for God’s sake hasn’t he suffered enough?” “There, there,” I would say, as counselling is so important; sometimes I think I care too much. Joe would then stand shaking himself for a few moments, getting used to his altered centre of gravity. His mood would also be altered, but as the weeks passed and the implacable forces of physiology forced vibrant life-affirming fluids back into the temporarily flaccid Norm, Joe would regain his jaunty good humour. “And Norm gives my girlfriends such a scare,” he said, grinning evilly. “I don’t know about your girlfriends,” I said, like the Iron Duke reviewing his troops before Waterloo, “but by God, he scares me.” Liam Farrell general practitioner, Crossmaglen, County Armagh
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