By PETER A. UBEL, M.D
Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.
Not long ago, as part of my hospital duties, I cared for a man who could no longer swallow. This dysphagia was his only medical complaint, one that had sneaked up on him over the course of a month. He simply couldn’t find the muscular strength to propel food and liquid down to his stomach.
After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.
While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life — small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but the best we could offer.
On rounds the morning after he received a feeding tube, I stopped by to see how he was doing — checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.
I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical or a social question. It was his wife who replied — angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business.
She looked toward me for support — I was the physician, after all — and I found myself in a common medical quandary.
Was it my duty to tell this patient what to do or, instead, to give him the medical information he needed to make up his mind?
Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient’s preferences.
Should a middle-age woman with mildly elevated cholesterol take a statin, for example? That depends on whether she thinks the pill’s benefits outweigh its burdens, burdens that only she can judge: costs, possible side effects and the inconvenience of taking medications.
Should an elderly man have knee-replacement surgery? That depends on how much he is suffering, how much he cares about the risk of surgical complications and how willing he is to undergo lengthy and painful rehabilitation.
According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options.
So going by the book, I should have informed my patient about the pros and cons of tobacco. But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.
I advised him to smoke.
“You two obviously love each other very much,” I said. Then I turned to his wife.
“I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker,” I continued, as I recall. “But those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax. What matters is that you two stick together, because these next few months are going to be really difficult.”
I reminded them that the cancer wasn’t curable, that we were hoping to improve his quality of life, and that the best way to do that was to spend quality time with the people he loved.
Every situation is different, of course. But my duty as a physician is to improve my patients’ lives. And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do.
Even if it means encouraging them to smoke.
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