What patient care tools would you construct?

I scream in frustration as the flickering screen creates another required check box.  Silently of course.  I am on the hospital ward, and broadcasting the doctor’s frustration will not help patients or nurses.  “Who created this tool?” I wonder for the thousandth time.  Why don’t doctors make their own tools?

Contemporary philosopher Daniel Dennett ponders thinking tools.  “Like all artisans, a blacksmith needs tools, but — according to an old observation — blacksmiths are unique in that they make their own tools.”  Blacksmiths may make their own tools, but not doctors.  We allow everyone else to make our tools. And when someone makes your tools, you have been defined, able to function only in the way the tool intended.  Some of the doctoring tools designed by others are incredible, and have helped me immeasurably to provide better patient care: on the technological side, the MRI machine; on the human side, the private rather than shared patient room.  But what tools would I invent?

Initially, as a profession, doctors created dissection to learn anatomy, the stethoscope to hear the internal processes of the body, then clinico-pathological correlation, and eventually evidence-based tools for creating and interpreting studies.  But now someone else creates our tools.  Insurance companies create quality metrics, employers create production incentives, and of course: software engineers create electronic records.  But if you could make your own tool in the service of patient care, would it look like any of the ones we are now given?

An “intuition pump” is a thinking tool coined by Dennett, as a “handy prosthetic imagination-extender… that permits us to think reliably and even gracefully about really hard questions.”  An intuition pump is an exercise in making our own intellectual tools, and freeing our profession from all the intermediaries who have encroached on physician autonomy over the years: third party payors, electronic medical records, patient experience consultants, quality metrics …

Dennett illustrates the concept by describing the Whimsical Jailer, who every night, unlocks all the cell doors for a few hours while the prisoners sleep.  Then he asks, “Are the prisoners free?” …Hmmm.  Busy clinicians often dismiss such speculations as trivial in the face of heart failure and cancer.  But I find that the Whimsical Jailer mirrors my own position as a doctor: the Bemused Prisoner.  The electronic record contains a pathway for entering the correct order, I know it; I just cannot usually find it.  Am I free?  Am I in control?  Am I managing the patient’s care? What does freedom mean in this setting?  The intuition pump bends current in order to free our minds from thought traps and straitjackets.

Perhaps using intuition pumps to imagine a better medical world will only serve to increase frustration and burnout in medicine.  But I believe that imagining a better world, created by providers, will be the first step in wresting control back from parasitic external controllers and financers, back to where it belongs with the front-line caregivers.  Go to your work everyday, in the clinic, or hospital, and “pump it up.”  Don’t just slog through the day, but imagine a day opening before you with the tools you need for your patients.

Medicine was at one time, or at least was once conceived, as an intellectually vigorous profession, attracting the best students who wanted to meld their hearts and minds in the service of patient health.  Medical school meant a ticket into a life of never-ending learning and inquiry.  Now, it appears to lead to a career of never-ending conformity, bending ourselves to the next outside influence so we can take our spanking.  Let’s stand up and take back the profession; don’t just complain but instead pump up your intuition.

Tackling the “hard problem”: consciousness in medicine

Why does the universe have conscious beings? The physical and biological laws of nature do not seem to explain the existence of conscious creatures such as humans.  Neuroscience has done well to explain many of our behaviors, illnesses, and medical therapies based on purely physical and observable rules.  But no one has ever measured consciousness.  And yet it appears fundamental to whether my patient will recover from their disease.

After 15 years as a physician I have become fairly proficient at the scientific aspects of treating complex medical conditions in the hospital.  I study hard, try to keep up-to-date, and read my journals.  Even so, I cannot account for patients who passively give up versus patients who fight an illness long past the reasonable time of acceptance.  I cannot account for the placebo effect.  In a nutshell, I cannot account for the consciousness of my patients that transcends their physical existence.

Philosophers and neuroscientists have divided their thinking about consciousness into the “easy” questions — an organism’s ability to react to environmental stimuli, access its own internal states, and control behavior — and the “hard problem”: explaining experience.  The “easy” questions are at least in principle answerable through measurement and study.  We use these “easy” questions clinically when we prescribe selective serotonin reuptake inhibitors to treat depression, or interpret an EEG to diagnose a seizure.  Neuroscience continues to advance these areas daily.  But the problem of subjective experience is trickier altogether.

What is the experience of being someone?  There is something it is like to be a conscious organism, as the issue has been stated.  There is something it is like to be my patient with heart failure.  Whatever this experience is, it determines her fate as much as the dilated cardiomyopathy I see on the echocardiogram.  The “hard” problem in neuroscience has not been explained by the purely physical process of neurons firing in complex networks.  How many neurons does it take to be conscious?  Humans are conscious, sure, but are cats?  What about trees, or the E. coli living in my colon?  Can you be a “little bit” conscious?  As an eager medical student I used to laugh at these questions, likening them to medieval monks debating how many angels could dance on the head of a pin; I had more important subjects to tackle, like the Na-K ATPase in the distal tubule of the nephron — concrete, physical, and measurable.  Now as I round on my patient with heart failure, or in the ICU on my patient who is in a persistently vegetative state after hypoxic brain injury, I see that the hard problem of consciousness haunts all my work.

Will we someday be able to explain consciousness via physical processes, when our science of complex systems has advanced far enough?  Or will we find that spirit, not matter, is the fundamental building block of the universe?  If so the problem of metaphysical consciousness will not be a problem at all, just a recognition of the true non-material nature of reality.  Many patients have already resolved these questions in their minds.  Some will have never even considered them.  The same is true for physicians.

We all know patients who have resolved the question of consciousness by deciding that everything is spiritual.  These patients resist material explanation of their condition and resort entirely to non-scientific therapies: gemstones, homeopathy and whatever is popular on Google.  We also know patients who have resolved the question entirely in favor of materalism.  These people want the studies, the facts and the percentages.  I find that they are usually deluding themselves into ignoring the impact of illness on their lives.  The best medical outcomes likely appear through balancing our physical processes with our consciousness.  Not too spiritual, not too material.

Good medical care takes into account the “easy” problems of the human body, correctly diagnosing the physical ailments, their etiologies and their remedies.  But excellent medical care tackles the “hard” problem: what is it like to be this patient?

The metric, the dialectic, and the chart electric

There is no document of civilization which is not at the same time a document of barbarism.                      -Walter Benjamin, Theses on the philosophy of history

It is 1940 and the Nazi horror is bearing down on Europe.  France has fallen, and refugees are streaming out, fleeing to safety through neutral states and America.  Walter Benjamin, a Jew and a German philosopher, joins a small group being guided through southern Spain with the hope of making it to Portugal and safety.  He has just completed his manuscript that would reverberate through modernity with its insight into how rationality brought us civilization and Nazism at the same time.

“Enlightenment was supposed to involve the use of reason to help humans free themselves from myth and superstition.” Scientific thought abolished foolish superstition, yet somehow the over-reliance on measurement and mechanization also had a downside.  The Enlightenment project, dominant in Western thought since the Medieval Age, created a new scientific future where mechanization and measurement improved innumerable lives.  Yet, the elimination of magical thinking also created a sterility of thought that enabled Nazism in Europe.

Benjamin’s colleague Theodor Adorno, a German Jew who succeeded in escaping to America, later expanded the ideas on the duality of development in The Dialectic of Enlightenment.  Here he details how the enlightenment project “has always aimed at liberating men from fear and establishing their sovereignty… the dissolution of myths and the substitution of knowledge for fancy.” But the other side of the dialectic also ends up with “men paying for their increase in power with alienation from that over which they exercise their power.”  For example, as we control the natural environment by building cities, we become alienated from authentic communion with our natural world.  As we harness social media to stay connected with people, we may become alienated from authentic human interaction.  So goes the dialectic of enlightenment and progress.

Western scientific medicine epitomizes the enlightenment process as it replaces superstition with rational diagnosis and treatment.  As modern medicine measured more and more with the goal of improving health, we also created the “quality metric”.  Rather than being subject to the vagaries of non-standard care, rather than individual doctors perpetuating treatment myths, we created the temple of evidence-based medicine, and measured the dimensions of the temple with quality metrics.  The electronic record then burst open the dam of myth in medicine and allowed us to measure, well… everything.  We now know what being a good doctor means because we measure blood pressures, and we know if patients have less than 140/90.  We know if you are talking to your patients about flu shots because it is in the electronic chart.

And yet… Benjamin’s eerily prescient warning about progress has also come to pass.  “For the Enlightenment, whatever does not conform to the rule of computation and utility is suspect.”  The art of medicine, whatever that might mean, is not measurable, and teeters on the verge of extinction.  Increased control over the body ended up bringing about domination over bodies: paternalism, futile end-of-life care, polypharmacy… and pay-for-performance. Pay-for-performance promises the quantification of the entire patient-physician relationship and then its optimization as providers become rational profit-maximizers.  Rather than the comforting hand of the healer, the invisible hand of the market will guide improved patient care.  So goes progress.

Adorno famously died before writing his views on the possibility of synthesis between progress and domination.  Perhaps he never meant to write such an essay, not believing it was possible to become civilized without also losing the humanistic values of civilization.  The ability to measure “quality” practically defines what it means to be “scientific”; science is that branch of human knowledge which measures things.  I fear that pay-for-performance represents the enlightenment run amok, “scientism” rather than science, with the loss of the realization that medicine is ultimately a humanistic profession, and not scientific.

My medical school each year granted a “Humanism in medicine” award to some deserving students.  The rich irony of the need for this award has only now, years later, begun to sink in for me.  The criteria for winning must have been more than simply being human, or even being A human.  I would forlornly hope that we would all have won this award, or even better, that there would be no need for such an award at all.  I recall that I won the award, by what criteria I know not, or have long forgotten, but I write this as a humanist, as a recognition of the potential barbarism of pay-for-performance everywhere.  

The day is not far off when the economic problem will take the back seat where it belongs, and the arena of the heart and the head will be occupied or reoccupied, by our real problems — the problems of life and of human relations, of creation and behaviour and religion.

-John Maynard Keynes

I have not heard a better apology for the “real problems” that preoccupy doctors than what the economist Keynes describes, and we might do well to heed his warning about economics taking the back seat. Is not medicine by definition “humanist”?  Will we succeed in merging the scientific and the relational, or will medicine end up separating patients and their healers?

Two quality metrics walk into a bar…

One demands, Give me the best beer you’ve got!  The other asks, Give me the second-best beer you’ve got.  The bartender pours the beers and states, You can have them both for free if you can tell me why this one is better than that one…

Quality metrics were invented to quantify the ineffable, such as the taste of a fine lager or IPA.  I see that my neighborhood pub now lists “International Bitterness Units” (IBU) for all its beers.  I wonder if this has helped me gauge which pint I should choose?  At least it gives me something to talk about while enjoying the beer.  

Just as listing the IBU is new in beers, metrics did not always exist in medicine.  The moment we really got serious about quality is often cited as Caper’s 1988 article “Defining quality in medical care”.  Even as medicine invented quality in the 1980’s, Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and instead using three terms that correlate to desirable medical outcomes: efficacy, appropriateness, and the caring function.  We know that certain interventions are efficacious in certain conditions; we can measure that.  We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this.  And we know that patients want “caring providers”… We likely cannot measure this very well, but it may be the most important of all the factors.  But, the “quality” of care is more than all of these factors and perhaps quite different entirely.

Despite the prescient warning, we have not abandoned “quality” and its continued use has created an entire jargon: quality, measurement, and value.  Quality creates value.  We are all preoccupied with creating value now.  The term is rarely defined but often used: creating value to insurers, for payers, for health systems, even occasionally for patients.  It appears to have a vague but unacknowledged relation to quality.

No one used to ask whether they got value when they went to the doctor’s office.  We might have discussed whether we had a good doctor, but never whether the experience was valuable.  When I buy a car, I sometimes wonder whether I got a good deal and whether the exchange had “value”.  But when I sit with my friends for a beer at the pub I have never asked whether I got a good value out of the experience.  The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor”.  

Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.”  Nor do I ask whether my evening at the pub was “quality time”, and rarely whether I just drank a “quality” beer.  Remember “quality time” spent with our loved ones?  Once we started asking this about the time with our children, it already represented an unacknowledged loss of the inherent relational component of life.  Just so, once we started using “quality” and “value” in medicine, we had already lost its primary relational component.  Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.

Quality itself relates to the humanistic function of medicine, and not to its scientific trappings.  As such it is describable but not measurable.  As an individual patient, whether my A1C is less than 9% correlates only tangentially with the quality of the care my physician provides. I might do better to have a lower A1C, but the factors involved in lowering my A1C, and how I perceive the care I have received, are not measured by the A1C itself.  Presumably the A1C captures the “efficacy” of the care received.  It is a gross injustice to label this as “quality”.  Substituting “quality” for “efficacy” defines patients as lifeless objects rather than in accordance with their characteristics as human beings.

Pay-for-performance takes medical quality metrics to the next level by using them economically. Yet in our medical system they are not working to improve care; why?  Because the metric does not incentivize doctors to be more human.  Instead it rewards treating patients as commodities and lifeless objects.  Doctors resent this incentive because commodification is dehumanizing.  As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately  attempt to pull them back towards a humanistic ideal.  Satisfaction itself is now a commodity and subject to the rules of the market – massive, absurd inflation everywhere!

However, what does not work on an individual level, can work on a group or institutional level.  Some payors, government and private insurance, reimburse hospitals more or less depending on how they perform on various metrics.  With some exceptions, this tactic appears to overall have improved medical care in America. Companies should be held responsible, or rewarded, for the quality of their products.  Corporations have always responded well to financial incentives; it’s why capitalism works!  
The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives”.  This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans.  Be careful with your jargon, and be wary of individual metrics.

What was the hypothesis in pay-for-performance?

Quality metrics and pay-for-performance have now been in existence long enough to start accumulating some efficacy data.  And the picture does not look good.  Paying doctors to improve their quality metrics does not, in general, improve those quality metrics (Ann Intern Med. doi:10.7326/M16-1881).  Like all good scientists, we can now either question the data, or discard the hypothesis.

Most payors and administrators appear to be reacting to the lack of efficacy data on pay-for-performance by questioning the data.  I certainly do not see any sign of a lessening of the fervor of belief in these quality metrics, or the promotion of their use to guide physician payment.  Instead, I hear excuses like, “we haven’t put enough money at risk,” or “we just need to do a better job with measurement so it is more transparent to providers.”

But what really was the hypothesis with pay for performance?  Did the medical community have a hypothesis when we embarked on this experiment?  Were we asking how to improve the quality of patient care, or rather could we incentivize professionals to change their behavior for more money?  Let’s look at a typical pay for performance plan in a medical group: 15% of physician compensation is “at-risk” under the plan, the rest is productivity from wRVUs.  The at-risk amount is subdivided into three equal quantities based on performance: percentage of diabetics with A1C<9%, percentage of patient visits where medication reconciliation was performed, and percentage of visits where tobacco cessation was discussed.  What noble goals these are!  Surely all doctors should be performing these basic tasks with their patients and thereby earning the last 15% of their salaries.

The rationale behind paying for improvement is that physicians are economic actors.  They are economic creatures who obey the fundamental rules of rational economic behavior.  We maximize personal gain based upon our own personal goals and predilections.  This behavior is why free-market capitalism, ebay and Amazon all work well.  Under this theory, as a doctor I would rationally calculate what the 15% of my salary is worth compared to the pain of complying with the measures.  As a primary care physician, if I make $180,000 per year, then each measure is worth $9000 over a year.  Fortunately I am a smart doctor, and I realize that I have 4000 patient encounters per year, so for each one I could earn $2.25 by doing what is required.  In essence, we are asking, “Doctor, can I pay you $2.25 to have a conversation and click a box?”  You see why administrators think there needs to be more money at stake!  While sitting in the room with my patient, the pay for performance incentive is laughable.  At the end of the month it may add up to something, but at that point we can only gnash our teeth and grumble about Medicare and administrators.

So what if we increased “at-risk” pay to 50% under these three quality measures?  That ought to be enough to coax us to improve!  And likely it would be, since everyone wants to get paid.  You can be absolutely sure that there exists an amount that would ensure 100% compliance with those three measures.  But what sort of doctors would you then have?  What sort of care would you then get?  As a patient, knowing my doctor was paid in this crude manner would be horrifying.  Can you imagine the patient-physician relationship, and what the visit would consist of?  I want my personal doctor to do more than check a few boxes in my chart.

We are stuck with an impossible dilemma with quality measures.  We can make them small and simply an annoyance, or we can increase them to the point they intrude on physician consciousness, thereby ensuring compliance, but also robotic care. The dilemma highlights the absurdity of the assumptions behind medical pay for performance.  Physicians are not economic actors maximizing their profits.  Yes, many doctors like to get paid well, and will even switch jobs for a better income.  But that does not translate into the reason why they are physicians.  If I were a clever fellow and wanted to maximize my income these days I would not go into medicine at all!

I predict using quality measures as a tool for pay-for-performance will fail in the goal of improving patient care.  Or worse, it will succeed because we lack the imagination to create something better, and we will destroy the master clinicians and replace them all with “clerks,” who can be incentivized to click boxes for money.  Instead, I want to start talking about what does make “master clinicians,” and how we can cultivate that.  I want to start the dialogue with doctors about high performance, because that is why young men and women go into medicine.  They want to be high performers in the face of others’ suffering and illness!  Doctors yearn to provide quality care; they do not need to be incentivized.  Our broken medical system should instead incentivize the creation of pathways so quality care is possible.  Instead of penalizing providers with metrics, we should invest in coaching to help providers rediscover their inner passion for quality.  Instead of creating “clicks” for quality, we need to invest in ways of removing the “screen” between doctors and patients to allow for genuine interaction; that is real quality.
Stay tuned next week for suggestions on how to actualize these ideals…

What is a true “encounter”?

“Every present consciousness is discovered to be exceeded by a horizon of perceivability which confers on the world its strangeness and abundance.” –Paul Ricoeur

I am probably crazy.  I ride my motor scooter to and from work at the hospital.  Some consider it unsafe.  Perhaps it is, but feeling the wind and rain, the unfiltered elements, after 12 hours inside a controlled environment is too refreshing to pass up.  So at 2am Friday night I am zooming (you always zoom on a scooter…) through the industrial district after a tiring admitting shift.  I see some kids messing around on bicycles, one pulling a trailer, all laughing and yelling.  The road is otherwise deserted.  “Joyriders,” I think, “out for fun on Friday night.”

I passed them by and was soon home in bed.  But the late night encounter sticks with me because of the way it showed how my medical mind worked.  As a hospitalist I never know what patient encounter awaits me until the pager buzzes from the emergency room.  Similarly, zooming down dark streets, my mind is empty, receiving the unfiltered stimuli of breezes, smells, and lights.  A vision impinges on my consciousness, bicycles with trailers, screaming kids.  I have no idea what they are really doing there on a deserted street in the warehouse district at 2am.   Just so, the ED doctor presents a case: fevers and trouble breathing.  My brain reacts the same way to both phenomena, I categorize a direct experience into some digestible: joyriders and pneumonia.  The human brain does not deal with pure experience very well, or for very long.  We love to categorize and digest.  Once classified, I pigeonhole the experience and am able to keep moving down the dark street, or entering admission orders.

The phenomenologists were philosophers who worried a great deal about humans’ propensity to categorize prematurely.  Phenomenology can be seen as a reaction to Descartes’ proclamation, “I think, therefore I am.”  That phrase was intended to start philosophy with the only stable, unshakable, preconceived notion: rational thought.  Starting with a basis of a human as a rational, thinking machine, Descartes deduced the existence of God and a whole lot more as well.  According to Cartesian thinking, which dominated Western philosophy for two hundred years, pure reason alone will yield up truth.  Instead, the phenomenologists wanted to focus on what we have to do prior to using reason.  We have to confront the “things in themselves,” the experiences prior to interpretation.  “Perception never ceases to reveal how living goes beyond judging,” is the phrase used to describe this never-ending cycle of perceiving and judging.

Medical practice relies on the doctor’s ability to make judgments.  When I make a diagnosis and start treatment I have assembled a jumble of perceptions into a coherent judgment, a classification of some kind.  Without this act of labeling, my patient would remain a pure individual, with an uninterpretable unique set of occurrences and symptoms.  I would be powerless to act.  Yet, treating a person as a label is dehumanizing and objectifying.

Many healthcare workers are familiar with the AIDET tool, coined by the Studer group to help provide better patient experiences.  It is an acronym for Acknowledge, Introduce, Duration, Explain, Time, and functions as a mnemonic for us to remember to humanize interactions with patients.  Examples of using AIDET include greeting the patient, introducing yourself, explaining why you are interacting with them and how long it will take.  This tool eases patient anxiety about the uncomfortable experience of interacting with healthcare.  In truth, AIDET is nothing but a method of putting phenomenology into practice.  Instead of jumping straight to the categorization of a patient, labeling them as “the next xray,” or the “the diabetic,” we acknowledge the direct experience of the other person.  Rather than “joyriders,” the kids on their bikes and at night are left as simply that, kids on their bikes at night, a wonderment to tired eyes, surging up on a deserted street.  

Every patient — every human — needs to be first a welling up of an experience, a consciousness of an other without a judgment.  Everyone has had their moments of zooming down dark streets at night, with a tired rational brain at idle, directly feeling the wind without analyzing it.   How can we let patients surge up into our consciousness?  And after this pure experience of another human, how can we then move on to the categorization we need to do as medical professionals in order to diagnose and treat?

Are you afraid of the truth at the end-of-life?

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.