To Treat or Not to Treat

"Kostoglotov! Twelve sessions of x-rays have turned you from a corpse into a living human being. How dare you attack your treatment? You complain that they gave you no treatment in the camp or in exile, that they neglected you, and in the same breath you grumble because people are treating you and taking trouble over you. Where's the logic in that?"
"Obviously there's no logic." Kostoglotov shook his shaggy black mane. "But maybe there needn't be any, Ludmila Afanasyevna. After all, man is a complicated being, why should he be explainable by logic? Or for that matter by economics? Or physiology? Yes, I did come to you as a corpse, and I begged you take me in, and I lay on the floor by the staircase. And therefore you make the logical deduction that I came to you to be saved at any price! But I don't want to be saved at any price! There isn't anything In the world for which I'd agree to pay any price!"
Alexandr I. Solzhenitsyn, Cancer Ward

There are two ideas about what the role of the physician is: One holds that the role of the physician is to preserve life; the second, which I consider to be more rational, is that the proper role of the physician is to alleviate suffering. My reason for preferring the second is that we all die and there may well be things that are worse than death. The thought that keeps people alive in the middle of extreme physical pain or mental anguish is that at sometime in the future, things will be better. If a person were sure that he would spend the next year in extreme physical pain, ending in his death, it might be rational to consider suicide. Many older people have decided to forego treatment when properly informed about the probability of surviving, for how long and in what condition.

There is an aphorism in the medical profession that says that "any physician knows when to treat; the good physician knows when not to treat".

The final decision as to whether a patient receives treatment is best left to the patient. Someone with cancer should have the option of saying "I will take the treatments," or "I will let nature take its course." In many cases, however, the choice is really made for the patient; because, the moment the physician says "you have a chance of being cured" the patient thinks "I can take a good deal of suffering if it means that I can live for a long time." The question of the morality of telling a patient that he has a chance of being cured depends on what those chances really are. If the odds are one in ten, then it is clearly worth taking a chance. But what if the odds are one in 100, one in 1,000, or one in 10,000; or what if the odds are about the same as that of a miraculous spontaneous recovery. At what point should a physician hold out hope of a cure? And at what point should he say "My treatment is practically worthless, but miracles do happen and you might get well?"

If you or your child is the cancer patient that the surgeons have declared untreatable, it's up to you to make the decision about further treatment. It is not necessary to feel guilty about letting nature take its course. Some very knowledgeable physicians have made just such choices about their own lives. It's your life and the choice is up to you. Insist on knowing the odds of the treatment being effective. Some people don't figure that long shots are worth it, if you calculate the cost in prolonged suffering against the merit of a quick death. It takes the ultimate in maturity to meet death without struggling. It does little good, as Dylan Thomas said, to "rage against the dying of the light." While I understand the fighters (die with your boots on), my admiration goes out to those who accept the end with serenity. I doubt that the fighters live longer or happier than the resigned. It might even be the reverse.

The therapist's values of "life at all costs" should not be the determining factor. Whether or not we wish to admit it, there are things that are worse than dying. Prolonged and painful illness exerts a profound effect on the patient and on those who love him.

Every time that experimental medicine has a success it makes the front pages: the first successful kidney transplant, the first successful heart transplant, the first few children with acute leukemia who survived beyond the expected period. and so on. This has led the general public to expect miracles as a matter of course. They do not take into account the many people who have been treated in the same way and have died; sometimes more painfully than they otherwise would have. A surgeon who has been doing kidney transplants for the past eight or ten years suggested to me that he was beginning to have his doubts about the value of what he was doing. Not that the transplants don't work, nor that he has not prolonged the lives of many people; he has. Because of his efforts, a number of people who ordinarily would have died at young ages have been living for at least five or more years. He told me that if his own kidneys failed he's not sure that he would undergo the treatment. His reason for this is the inspiring example of the few patients he has had who have refused treatment and have peacefully gone to their death. For a man who has devoted his whole life to "fighting death" to admire people who allow themselves to die is a rare and fascinating phenomenon. Young physicians almost always feel that death is the worst of all possible events. When they get older, and wiser, they sometimes come to the realization that death is not the worst thing in the world. Young physicians will often fight for days and weeks and months, to preserve the last remaining spark of life in a dying human being. Older physicians come to realize that everyone dies, and that death may well be preferable to some of the alternatives.

Several years ago I had a badly shattered leg. I was in constant pain for five months and managed to get my sleep in two or three hour spurts. When the sleeping pills and pain killers wore off, I was caught in the dilemma of remaining awake and in pain, or being drugged and not in pain. Most of them time I choose the first alternative, because I like to feel alive, even though at that time I was more or less faking it. What kept me going was the assurance that the leg would heal and the pain would eventually cease, which it did. There were moments when I wished that I could die for a little while. I think that if I believed that the rest of my life would be like those few months, I might very well have considered ending it all. It is a tautology to say that pain is painful, but it's true, and there is nothing quite as bad as hurting badly.

I have seen things which I consider to be worse than dying. I have seen people in unremitting pain who had no possibility of recovery; I have seen people whose brains were destroyed, who are not even able to keep themselves clean, feed themselves, or have any awareness of who they are.

While working on this book, I went to a chemotherapist to check out some information. He took me by the hand (like a child does who has just done something that he considers praiseworthy) and said, "Come, this is something that you must see!" In the examining room was a woman in her sixties. All of her hair was gone; her equilibrium was disturbed, and she was very unhappy; but in a dull way. He said, "She has lung cancer. You should have seen her a month ago. She was in coma and barely alive. Look at her now." When we left the room, I asked him "How much time does she have?" He replied "If we're lucky, maybe six months." I asked myself "How is she going to die?" "What will the rest of her life be like?" She had had a metastasis to the brain, and a brain tumor is usually a fairly painless way to go. Before the therapist treated her, she was in a coma, and it would have been a short time before she succumbed. He had brought her back to life. How is she going to die now? How much pain will she suffer? How much is she suffering now? I know of a famous pathologist who found that he had cancer of the colon. He refused any treat ment and allowed nature to take its course. A surgeon once told me that he doesn't even send his patients to the chemotherapists or radiation therapists unless there is a chance that they can do something substantial; not just prolong life for a few months.

The other side of the coin is that I have a dear friend who had breast cancer. After surgery, she developed a metastasis to the brain which she had treated with radiation. The doctors thought that she had a maximum of six months. Eight months after the treatment, she tells me that she is re building a cottage, putting on some weight, and feeling fine. I am glad that she had the treatment and is still alive, as are her husband and children. She is happy with her decision.

Bromides such as "always treat" or "always let them die peacefully" are not the answer. Each person should be allowed to decide for himself. It is also advisable to make the decision before being incapacitated because, once in a coma, the decision, by default, goes to someone else.

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