To Cure Sometimes, to Relieve Often, to Comfort Always

A conventional view of medicine holds that doctors work toward the health of their patients. When healing a disease is not possible, then physicians strive to relieve unpleasant symptoms that similarly threaten health. Doctors follow the adage, “To cure sometimes, to relieve often, to comfort always.” And this is what patients want. Time and time again, patients in my primary care practice assert that they want a physician who will stick with them in sickness and in health, will advocate for them, and will help them feel better, even when no treatment is possible.

But competing aspects of modern life may challenge the orientation of medicine toward health, and, consequently, threaten the possibility of dying well. Before we talk about dying, however, let’s consider aspects of life and medicine that disrupt a professional commitment to health.

First, technological advance has vastly expanded options for doctors and patients. Now more than ever, consumer patients can request services, and doctors can do or prescribe services that aren’t necessary to help people recover from illness. Although quack healers have always peddled goods of questionable benefit, technology has made possible options, that while not oriented toward health, are recognized as legitimate by the profession of medicine.

For example, breast reduction may be necessary for some patients to lessen chronic back pain—a health-oriented good. But is all breast augmentation with the aim of improving health? Certainly not. Examples doubtless come to the reader’s mind in which such surgeries represent little more than consumer and provider choices. This is not a judgment, just a fact. The consumer (patient) desires breasts of a different size or shape, and the provider (surgeon) is financially rewarded and thus happy to oblige. Of course, this concept of medical interventions-as-choices could be extended to many other surgeries or procedures, e.g., facial surgery to repair cleft lip versus facial surgery to satisfy a consumer’s choice to look younger.

Such an expansion in options coincides with the rise of self-determination, which represents the second challenge to medicine’s commitment to health. The last five or six decades have issued unprecedented support for the idea that the individual is master of her own universe and beholden to no one. Within medical ethics, the notion of patient self-determinism developed as a counter to physician paternalism-run-amuck. And while it has been appropriate and beneficial to patients to challenge physician authority, the pendulum has swung too far.

Recently I spoke with an older friend who described an experience of talking with a heart doctor about blockages in the arteries. He explained, “The cardiologist basically said to me, ‘We can put in a stent or do open heart surgery. Obviously, heart surgery has more risks. Think about it this weekend, call me Monday, and let me know what you want to do.’”

On the one hand, my friend’s scenario represents the cardiologist’s regard for my friend’s autonomous decision-making. On the other hand, I would argue that such a scenario represents the cardiologist’s wholesale abdication of his responsibility to accompany his patient. From the Latin docere, doctor means “to teach.” The cardiologist should carefully explain the risks and benefits of both interventions, his own experience of performing them, expected outcomes and long-term prognosis, and deliberate with the patient until a decision is made. By contrast, the approach my friend recounted represents a sort of abandonment.

The third factor in modern medicine that can affect physicians’ commitments to the health of their patients is money. Economics can affect nearly all aspects of the modern medical enterprise. Doctors are beholden to the generation of RVUs, or relative value units, and all interventions and services are assigned a certain number of RVUs. It doesn’t matter how well a doctor takes care of her patients, if she doesn’t generate enough RVUs, she’s out of a job. Similarly, it is difficult to justify to health care leadership any new approach that is not at least cost-saving, if not cost-generating. This means that physicians’ orientation toward the health of their patients may be constantly challenged by economic factors. To riff on another old proverb, “One cannot serve both patient and mammon.”

The way doctors have traditionally viewed their patients is fundamentally different from the way retail clerks view their customers. Medical students and trainees are taught that the patient-doctor relationship is essentially sacred, covenantal—the doctor’s responsibility is fiduciary, not financial in nature. But medicine has in part become about service providers reaping payment for indulging consumer whims for interventions not related to health. And while this may be all that some patient consumers want from the profession, it is not in my experience how most patients want to relate to their doctors. And with an aging population, the question of how patients want their doctors to accompany them to the end of their lives becomes even more pressing.

It is beyond the scope of this post to expound upon the ways that consumer-driven medicine might affect the art of dying. For a longer explanation, I refer readers to my book The Lost Art of Dying: Reviving Forgotten Wisdom. But the following questions are worth considering:

1. Options. How will patient consumers navigate the expanding menu of options at the end of life? Will they die at home, in the hospital, or at hospice? Will they die naturally, or elect to hasten death in states where assisted suicide is legal?

2. Self-determination. Will patients seek the advice of their doctors or family members? Will doctors accompany their patients to the end, or will they effectively abandon them for the sake of efficiency, or abandon them by passing the baton to experts in hospice? And does passing patients off to hospice constitute “abandonment”?

3. Economics. How many patients will choose to hasten their deaths because of economic drivers? How many doctors will encourage patients to consider treatments that are unlikely to help but are highly remunerative for physicians themselves?

This post is clearly not exhaustive. Challenges to good patient care are myriad, and the impacts of such challenges on the care of the dying are even more complex. But we as a society ignore these issues at our peril.

Technological advances and societal shifts make it possible for us to “deliberate sometimes, choose often, and consume always.” But we must also hold fast to practices in medicine that cure, relieve, and comfort. Especially at the end of life.