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Talking About Death: Medical Care Or Breaking An Unspoken Covenant?

A recent New York Times Health Section article [1] reported Medicare’s plan to reimburse doctors for talking with patients about whether they wish to be kept alive if they cannot speak for themselves, quoting the chief medical officer as saying that “[w]e think those discussions are an important part of patient- and family-centered care.”  It is tough to argue against the idea that doctors ought to have more critical discussions with patients and their families about such important issues.  In the past, most people died in their homes, surrounded by loved ones as well as their doctors and nurses.  Over the past century, as medicine and technology advanced, death moved to an institutionalized setting—though we have seen some more-recent trends back towards the home with the growth of hospice care (Werth & Blevins, 2005 [2]).  Still, some are rightly concerned that societal pressure and misplaced values may influence some doctors’ discussions with patients and families, pushing them in a negative, coercive or even lethal direction.

The American Hospital Association has estimated that in the 1990s as many as 70% of deaths were “somehow timed or negotiated, with all concerned parties privately concurring on withdrawal of some death-delaying technology” (Webb, 1997 [3]).  Wesley J. Smith at the National Review cites [4] a litany of ways in which such “discussions” can go awry – for healthy couples, disabled babies and the mentally ill – based upon actual events in Oregon [5] and parts of Europe: evidence not only of killing, but also of the harvesting of organs and the offering of payment to accept assisted suicide rather than more expensive treatment options.

Hope In The Oath

An alternative approach, and a ray of hope, is offered by Dr. Grazie Pozo Christie, who reminds us not only of the Hippocratic Oath’s famous decree to “do no harm” but also of another lessor-known precept: “Nor shall any man’s entreaty prevail upon me to administer poison to anyone; nor will I counsel any man to do so.”  This bespeaks a solemn covenant, which Dr. Christie reflects in her article [6], is based upon a foundation in inalienable human dignity manifested through a dyadic relationship of trust (of the doctor to act in the patient’s best interest) and respect (for the doctor’s integrity).  She calls the covenant unspoken, because it was always unquestioned, even among the prison population she served, a population which experienced little respect for its dignity and showed little trust in others.   She laments how this covenant will be harmed by some physicians’ actions to provide poison, going so far as to warn that doctors becoming involved in the ending of life portends the end of medicine as we know it.

What Is Best Said

While there will be those, I suppose, who out of misguided compassion choose to utilize their power and authority to steer people towards a life-ending option, there is a way in which counsel at the end of life can be helpfully offered.  Yet, one must be careful when reading the professional literature on such matters, because the strong influence of those who would unnecessarily hasten the end of lives permeates much of what is otherwise sound advice (e.g., patients and families need information, strive to find meaning in death, require care and support, etc.).  Current professional psychological literature tends to see dignity as characterized by two values: autonomy (including choosing how one dies) and social belonging (ensuring that social isolation doesn’t precede physical death).  While the latter is certainly laudable, the relativism of the former opens the door to the possibility of some morally-disturbing ‘discussions’ between health care providers and their patients and families.

As with other issues, language can be utilized in a way that confuses and distracts, rather than clarifies: dignity and choice are, not surprisingly, common refrains (Werth & Blevins, 2005 [2]).  For example, the recommendation that pain should be alleviated in a manner consistent with the person’s values and preferences is seemingly not controversial, nor the idea that “dying persons and their families should be cared for in a manner that respects inherent dignity.”  Properly understood, these standards can be a great support for those in the final stages of their journey towards death and for their loved ones as well.  However, the proliferation of efforts [7] to legalize suicide and recent highly-publicized and lauded instances of assisted suicide amply demonstrate just how society’s sense of dignity, can be grossly distorted and manipulated.

So long as the medical profession adheres to the Oath and its covenant to respect and defend life, the psychological benefit of discussing death and its impact on loved ones is surely a good to be pursued.  However, when the covenant is broken by a refusal to celebrate [8] life as a gift, even when it is suffering, unpredictable and painful, then medicine ceases to be care, and compassion – no matter how strongly asserted – ceases entirely.  The word compassion means “to suffer with.”  When we kill the patient, compassion is not possible.