Friday, November 30, 2012

“Doctors don’t do hope”

“Doctors don’t do hope anymore,” my wife, herself a doctor, said to me the other day as I was leaving my oncologist’s office. I was complaining about his reluctance to discuss my prognosis. For him, the only real question is what drug I am on and what drug I might be on next. And for him the effectiveness of cancer drugs, at least at this stage of my illness, is measured in months. He would not talk about a time any longer. Pretty much the same was true for my stepfather’s oncologist. (My stepfather has a complicated form of multiple myeloma.) My wife, accompanying him on his last doctor’s appointment, asked about survival rates. She was told—doctor to doctor, no less—that she could google the question.

What seems to be happening is an ethical narrowing of the doctor’s relationship to his patient. Medicine is self-divided. On the one hand, the doctor’s responsibility to relieve a patient’s physical suffering is an ethical role. Relieving her suffering, the doctor responds to his patient as a Thou. But on the other hand, medicine’s pursuit of a certain kind of relief—an effective treatment—demands hard scientific knowledge. And when a doctor acts knowledgeably, he is pulled away from the patient as a whole person; he must treat her as an It, an objective set of symptoms and physical reactions to be grasped if she is to be treated at all.

The conclusion seems inescapable. To be fully ethical toward a patient the doctor cannot treat her partially. Medical ethics, if they are anything more than a classroom exercise and a pretext for scholarly publication, would seem to demand something more than medicine. A good doctor is more than a practitioner of medical science—he is an ethical person, that is, a person with ethical demands upon him. And perhaps what this means is that there are occasions on which he must not behave objectively and medically, but personally and subjectively—as I to Thou. But even this is not quite right. As the French Jewish philosopher Emmanuel Levinas argues, to respond to another fully is to put the I, the requirements of the self, in question. It is to risk the loss of self. But, ironically, this is also the experience of physical suffering, as described by Babette Deutsch in a poem I have quoted here before now. It was originally published in the old Commentary in 1949:

                The eyes, huger in the wasted face,
Wandered like wild things dulled by narrow pacing.
The hand was tethered to a pain, that fed
On a spreading horror.
The living are helpless to do much more than to share the dying’s look:The living stood beside the bed and waited
For nothing in the nowhere of appall,
And smiled at her, as if there were no wall
Between them and the dying. Her fate
Stood near them with eyes larger than her own,
That would not close, not even when she slept.
Its look followed after as they lightly crept
Off, waving, leaving her alone.
It seems there must be times when the ethical responsibility to relieve suffering entails an utter passivity—when you finally abandon the efforts to treat a patient, and simply respond to her. But if this is true it follows that medicine, to be fully ethical, must be founded not upon the activity of relieving suffering, but rather upon the passivity of suffering and responding to suffering. The doctor must look into her patient’s face before he takes her into her hands.

I can understand why doctors might be reluctant to do so. There are no protocols, no clear hospital directives that can be written down in black and white, to regulate and direct the doctor’s look. And doctors don’t do passivity any better than they do hope. My wife and I fired my first oncologist in Columbus because he could not look past the clinical data to the person in front of him. When my cancer returned, he gave me a year to eighteen months. (That was nineteen months ago.) “I was hoping to dance at my [three-year-old] daughter’s wedding,” I said. “I’m sorry,” he said, “but that won’t happen.” (My wife started weeping.) I can understand the impossible position in which my remark had put my doctor, but the alternative of silence—and perhaps a touch on the arm or shoulder—the possibility of anything other than a data-driven pronouncement, never occurred to him.

Because they don’t want to give the patient false hope, doctors don’t do hope anymore. What they do instead, though—ordering a treatment meted out in months—is lonelier and more frightening than no hope at all.

9 comments:

R.T. said...

Here is my diagnosis of the ethics issue: If a doctor were to offer a prognosis, he or she becomes vulnerable to litigious ne'er-do-wells who would, without blinking an ethical eye, sue the doctor when the prognosis turns out to be wrong. For example, the doctor says 12 months to live, the patient lives 9 months, and the heirs sue the doctor for a faulty prognosis. The ethics deficit, therefore, can be more properly ascribed to the U.S. tort system, upon which Americans have become entirely too dependent.

Mark Athitakis said...

It doesn't speak to your situation exactly, but Andrew Solomon's new book, "Far From the Tree," suggests just how endemic this problem is. Confronted with medical issues that are out of the ordinary (in the context of Solomon's book cases like severe autism, dwarfism, deafness, etc), doctors seem to habitually respond in ways that are inept or unthinkingly cruel. (I lost count of the number of times I wrote "Bad doctor!" or "Bad therapist!" or "Bad institution!" in the margins.) Doctors appear to be less trained---or untrained---in how to merge their diagnostic skills with their ethical, human selves, and the biggest shortcoming of Solomon's book (which I highly recommend) is that it spends little time looking into this problem.

D. G. Myers said...

When advising an undergraduate the other day—he had come to dispute a grade, of course, worried that it would keep him out of medical school—I urged him to stop obsessing about grades, about polishing the right image to get into med school, and to start obsessing about how to become the kind of man who would be a good doctor.

He looked skeptical, and who could blame him? It was useless sentimental antiquated advice from an old square.

D. G. Myers said...

Patrick Kurp passes along the following:

”It is seldom that we find either men or places such as we expect them. He that has pictured a prospect upon his fancy, will receive little pleasure from his eyes; he that has anticipated the conversation of a wit, will wonder to what prejudice he owes his reputation. Yet it is necessary to hope, though hope should always be deluded; for hope itself is happiness, and its frustration, however, frequent, are less dreadful than its extinction.”

Samuel Johnson, The Idler #58

R.T. said...

Do you really think that medical schools' admissions committees give much if any attention to polished images among applicants? Or do they first and foremost give attention to applicants' transcripts? I would like to believe in your point of view--I myself have given students similar advice--but I am now cynical enough in my advancing age that I think my advice and your point of view are fast becoming obsolete and absurd.

ghostofelberry said...

i've noted that i can receive more or less the same medication from two doctors; and with one there's no improvement, with the other i'll be markedly better in days.

i believe that "something" is transmitted depending on the personality & force of the doctor. i wouldn't say it's merely a placebo - for one thing, in one case i genuinely didn't expect anything to happen and only got the meds from the pharmacy days after seeing the doctor, when i'd more or less forgotten about her. My father was also a doctor and had a near-miraculous influence on many patients. You could put it down to diagnostic skill and so on but at some point the pattern of results seems, in statistical terms, highly improbable.

i think the placebo effect is a very crude and superficial way of looking at it.

R.T. said...

Well, ghostofelberry, do you not think that people, in surprisingly large numbers and in mysterious ways, can and do heal themselves? Yes, there are plenty of exceptions, and people can argue about the effects that can be attributed to differences in doctors and medicines, but there is plenty of scientific and anecdotal evidence in support of the notion that a patient's frame of mind (and spirit) has much to do with the patient's future.

PMH said...

When did it occur to doctors--for whatever reason, legal, professional, personal--that somehow prognostication and the offering of that knowledge most useful to human beings--expectation--to be outside of their work? I'm troubled that those professionals in the best position to be honest about the future would choose silence, and would somehow believe that silence (which can be awful) is preferable to a meaningful exchange. And what is wrong with giving hope if it understood as that and not as a promise? Everyone knows the therapeutic value of hope, so it should be one of a possible range of therapies.

ghostofelberry said...

RT,

Indeed, self-healing is also possible. i would say, you cannot force healing on someone but you can find how they will accept it, and cajole or nudge them in this way. And sometimes a man can as it were find a deep resource within himself, from which he may work & do much. Sometimes, the proximity of death is itself a source of tremendous strength & rejuvenation.

Trouble also lets you know who your friends are. Some people with power are on Mr Myer's side right now, because of his character, where he stands, and so ultimately it comes down to one's own heart.