In her excellent book, Ordinary Medicine, on how advances in technology and payment continue to create treatment expectations into old age, Sharon Kaufman relates a conversation with a patient regarding a liver transplant:
“At his age, it’s difficult to say if transplant is best… So it’s trading risks. It is controversial. That is, everyone will have an opinion about it. Do you want a transplant if we find you eligible?” Mr. Chin responded, “If that’s the best option, of course.”
All conversations clinicians have with their patients today follow this paradigm. The doctor presents a set of options with their risks, then frames the debate in terms of “no right answer,” and inquires about what the patient wants. The patient responds by asking for the best choice. We have a mismatch of fundamental orientation: the ethical versus the philosophical.
The philosophical register corresponds to the age-old quest for stable truth, truth in speech, thought and action that conforms to some underlying, often hidden, reality. Ethical thought, particularly in our postmodern world, coincides with an implicit concession that of a lack of underlying truth leads to relativism. Ethical statements always could be otherwise, in a different circumstance, with a different person, in endless ways. Philosophical statements exclude other possibilities in order to pin down the truth.
Rigorous medical training leads doctors to always consider the possibility that diagnoses are wrong, that prognoses are uncertain, and that biological systems are complicated and therefore fundamentally precarious. Yet our patients have little interest in this ethical ambiguity. They are asking for the truth in a situation for their lives. Nothing is ever ambiguous for the patient: I can choose to use warfarin to prevent a stroke or I can take aspirin. I can have the surgery or not have the surgery. And so on.
Our perspective mismatch is never more apparent than at the end-of-life. We approach medical care near the end-of-life from an ethical perspective, that is, we try to understand what is the right thing to do. We use ethics to inform us on “the line between enough and too much intervention.” (Kaufman). I wonder if we might try harder to understand what is true, that is, use a philosophical perspective.
As hospitalist medical director I have coaching conversations with my team of doctors. During the last one I heard, “Patients seem to prefer it when I am a little more paternalistic.” I think he was referring to a move out of the ethical register and into a more philosophical one. In other words, paternalism in his mind equates to truth-telling, rather than concerned, caring, and patient-centered, all of which are ethical modes.
Why have doctors retreated from truth into ethics? Perhaps it reflects a legitimate retreat from scientism and paternalism. Statements of truth in the face of value questions have a medieval ring to them today. As doctors, and as world citizens, we no longer believe in value-free facts. The public is so accustomed to high-decibel controversies in abortion and climate change that “spin” is part of any scientific fact or philosophical statement. Perhaps this was an inevitable sequela of Kant’s 18th century Critique of Pure Reason; humans have no subjectivity-free access to objective truth. And so, after 200 years of modernity and postmodernity, we have abandoned the quest for objectivity entirely. But we often forget that Kant himself had no doubts as to the validity of philosophical, truth-bearing, speech. He just desired a more careful approach to the problem.
A careful path to truth is surely required, particularly at the end-of-life. However, as my partner has discovered in his conversations with patients, they expect physicians to still be able to speak “truth.” In a jaded populace, the medical profession is one of the last ones still trusted to transcend “spin” and endless ethical relativism. Let us not be afraid of the philosophical mode. Is it ever untrue to say, “Your loved one (or you) are dying?” Somehow Americans have forgotten this fundamental fact, the fundamental fact, that we are born to die. As a statement of truth, this statement of the inevitability of death is accurate. There may be circumstances when it is misguided to say, “You are dying,” but it is never not true. Doctors have worried so much about being wrong that we often do patients a disservice by avoiding the truth.
Kaufman, Sharon. Ordinary Medicine: Extraordinary Treatments, Longer Lives, and Where to Draw the Line. Duke University Press, 2015.
Kant, Immanuel. Critique of Pure Reason, 1781.