Not long ago, I read two articles, one by a cancer doctor and another by a journalist. They both left me steaming a bit. In medicine, we talk about the science (the factual database and knowledge that we use) and the art of medicine (how we use and adapt that database to the benefit of individual and different patients). Both of these articles, the first overtly and the second more indirectly, suggested that the art of medicine is about hiding the science from the patient in order to provide hope, albeit false hope to the cancer victim. Let me state clearly, despite paternalistic instincts, dishonesty has no place in the practice of oncology.
Both of my grandmothers died from cancer. Grandma S. died of stomach cancer when I was in college. As far as I know, she was never told that her cancer had recurred after surgery. Her second husband and family wanted it that way. “Knowing that she has cancer will devastate her, let her have her hope,” we were told. When my cousins and I visited, we were under strict orders to not ask too many questions about her “gall stone” problems. She knew though. You could see it in Grandma’s eyes. But the web that had been woven kept her from being able to grieve and gave no opportunity for good byes. As she slipped away she became withdrawn and depressed.
Grandma B. was diagnosed with an aggressive lymphoma when I was just out of medical school and in my training. She was fully informed by her doctors. She had opportunity to seek second opinions. She conferenced with her children. When she chose to not leave her little ranch valley in Idaho for desperate treatments far from home, and to die in her own home, her family rallied around her in support. For six weeks, she narrated her life history, wrapping up a legacy of lasting value for her family. She was the recipient of an outpouring of love from her community and she died fulfilled, with a smile of satisfaction on her face.
The science and art of medicine are not juxtaposed against each other, but go hand in hand. The practitioner of the art must know the science well for his first job is to teach it to the patient. The artist doesn’t beat his patient up with the truth, and when the eyes start to glaze over he may wait for another day to continue the lesson, but neither does he dismiss the truth with a whitewashing of the patient’s disease and prognosis.
Moving beyond the science, the artist is able to recognize the difference between denial used as an effective coping tool and denial used as an ineffective coping tool. He allows the former to be optimistic and gently discourages the latter from pursuing treatments that may be ineffective at best and dangerous at worst.
Sometimes there is a temptation to treat the patient’s need to be treated and not the patient’s cancer. Abandoning the science to give mild, but ineffective treatments, or small and ineffective doses of an established chemotherapy, and presenting it as hopeful therapy, in order to treat the patient’s need is not art, but fraud. The real artist will be able to present an honest appraisal of potential treatments without deception, while demonstrating true concern and care for the patient. Then the fully informed patient will make his or her own decisions. They may choose to pursue a treatment against the odds, and the artist will then support their hope, doing his best to help beat the odds. The patient’s autonomy and the physician’s integrity are preserved.
There was a time, not too long ago, that cancer medicine was highly paternalistic. Maybe, “better not to know” was necessary mantra when we had limited tools with which to offer hope. But today it is a cop out for the physician who doesn’t have the will to master both the science and the art of medicine.