“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.