Heal sometimes, relieve often, comfort always
According to a conventional view of medicine, doctors work for the health of their patients. When the cure of a disease is not possible, doctors strive to relieve unpleasant symptoms that also threaten health. Doctors follow the adage: “Sometimes heal, often relieve, always comfort”. And that’s what patients want. Time and time again patients in my primary care practice say they want a doctor who will stay with them in sickness and health, who will stand up for them and help them. to feel better, even when no treatment is possible.
But competing aspects of modern life can challenge the orientation of medicine towards health and, therefore, threaten the possibility of dying well. Before talking about dying, however, consider the aspects of life and medicine that disrupt a professional commitment to health.
First, advances in technology have greatly expanded the options for doctors and patients. Now more than ever, consumer patients can request services, and physicians can perform or order services that are not needed to help people recover from illness. Although quack healers have always peddled goods of dubious benefit, technology has made possible options that, while not health oriented, are recognized as legitimate by the medical profession.
For example, breast reduction may be necessary in some patients to alleviate chronic back pain, a health-oriented good. But is all breast augmentation intended to improve health? Certainly not. Examples no doubt come to the reader’s mind in which such surgeries represent little more than consumer and provider choices. This is not a judgement, just a fact. The consumer (patient) desires breasts of a different size or shape, and the provider (surgeon) is financially rewarded and therefore happy to oblige. Of course, this concept of elective medical interventions could be extended to many other surgeries or procedures, for example, facial surgery to repair a cleft lip versus facial surgery to satisfy a consumer’s choice to appear more young.
Such an expansion of options coincides with the rise of self-determination, which represents the second challenge to medicine’s commitment to health. The last five or six decades have brought unprecedented support to the idea that the individual is master of his own universe and beholden to no one. Within medical ethics, the notion of patient self-determination has developed to counter the paternalism of physicians. And while it was appropriate and beneficial for patients to challenge physician authority, the pendulum swung too far.
Recently I spoke with an older friend who described an experience talking to a cardiologist about blockages in the arteries. He explained: “The cardiologist basically said to me, ‘We can put in a stent or do open-heart surgery. Obviously, heart surgery carries more risks. Think about it this weekend, call me on Monday and tell me what you want to do.
On the one hand, my friend’s scenario represents the cardiologist’s respect for my friend’s autonomous decision-making. On the other hand, I would say that such a scenario represents the total abdication of the cardiologist from his responsibility to accompany his patient. Latin docere, doctor means “to teach”. The cardiologist should carefully explain the risks and benefits of both procedures, their own experience performing them, the expected results and long-term prognosis, and deliberate with the patient until a decision is made. On the other hand, the process that my friend describes represents a kind of abandonment.
The third factor in modern medicine that can affect doctors’ commitment to their patients’ health is money. The economy can affect nearly every aspect of the modern medical business. Physicians are accountable for generating RVUs, or relative value units, and all procedures and services are assigned a number of RVUs. No matter how well a doctor takes care of his patients, if he doesn’t generate enough UVR, he loses his job. Similarly, it is difficult to justify to health care management any new approach that is not least cost-economy, if it does not generate costs. This means that the orientation of doctors towards the health of their patients can be constantly challenged by economic factors. To use another old proverb, “You cannot serve both the patient and Mammon”.
The way physicians traditionally view their patients is fundamentally different from the way salespeople view their customers. Medical students and interns learn that the patient-physician relationship is essentially sacred, conventional – the physician’s responsibility is fiduciary, not financial. But medicine has partly become a business of service providers raising money to satisfy consumer whims for non-health interventions. And while that may be all some consumer patients want from the profession, it is not, in my experience, how most patients want to relate to their physicians. And with an aging population, the question of how patients want their doctors to support them until the end of their life becomes even more pressing.
It is beyond the scope of this article to outline the ways in which consumer-driven medicine might affect the art of dying. For a longer explanation, I refer readers to my book The Lost Art of Dying: Reviving Forgotten Wisdom. But the following questions are worth considering:
1. Choice. How will consumer patients navigate the expanding menu of end-of-life options? Will they die at home, in hospital or in hospice? Will they die naturally, or will they choose to hasten death in states where assisted suicide is legal?
2. Self-determination. Will patients seek advice from their doctor or family members? Will doctors accompany their patients to the end, or will they abandon them for the sake of efficiency, or will they abandon them by handing over to experts in palliative care? And does sending patients back to hospice constitute “abandonment”?
3. Economy. How many patients will choose to hasten their death due to economic factors? How many doctors will encourage patients to consider treatments that are unlikely to help but highly rewarding for the doctors themselves?
This post is obviously not exhaustive. The challenges to good patient care are myriad, and the impacts of these challenges on the care of the dying are even more complex. But we as a society ignore these issues at our peril.
Technological advances and societal changes allow us to “deliberate sometimes, choose often and always consume”. But we also need to stick to medical practices that heal, relieve, and comfort. Especially at the end of life.