Can You Handle the Truth?

And ought your doctor serve it out to you, whether or not you can “handle it”?  For that matter, is it for your doctor to decide whether you can handle it?

One of the most basic human cravings is for certainty.  We spend enormous amounts of time, energy, and wealth on efforts which all come down to knowing the future or controlling it, which is just the second verse of the same song.  Illness, serious illness for which there exists no known cure beyond cutting out part of one’s body and hoping the doctor cut high enough (to borrow Jennie Churchill’s injunction to her own doctor, although that was gangrene), is about as diametrically opposite to certainty as you can get.  Even if you’ve just been plucked off the street by Stalin’s NKVD, there’s actually a human will on the other side of your dilemma, and you can know something about that will and how it’s likely to deal with you.  Cancer has no mind, no will, and very little predictability.

So how long do I have, doc?  What are my chances?

Is it ethically more defensible to give someone a hope to cling to, when in one’s mind and heart one knows that hope is nearly certain to be blasted?  Is it more proper to speak in terms of “percent” chances, when those percent chances are derived from sample sizes in the tens of thousands, and you have exactly one patient in the consulting room?  I mean, this patient either will or will not live more than six months.  As a statistical proposition, I do not have a “60% chance” of dying within six months.  Of all people diagnosed with my same cancer at approximately the same stage as mine, 40% may live longer than six months, but that really tells me nothing.  Where am I in that sample?

I’m not a doctor and I’ve never sat in on a conversation like the ones described in the article.  But it strikes me that the doctor and the patient are talking about two completely different things.  The doctor says, “Six months,” by which he means something along the lines of “half of the people diagnosed in your condition will be dead no later than six months post-diagnosis”; in other words, he’s talking about the median survival period.  The patient hears, “You will die roughly six months from today.”  One is statistically correct but irrelevant to the specific patient and to what the specific patient wishes to know.  The other is almost assuredly incorrect.

Serious illness, especially when not of a kind correlated to the patient’s own behavior (e.g. lung cancer for the life-long heavy smoker, or cirrhosis for the incorrigible drunkard), has to be perceived as, among other things, a monstrous injustice.  This is not supposed to happen to me.  I was good.  I did all the “right” things.  I ate my damned broccoli, after all.  I went to the gym; I ate whole wheat bread; I bought “organic” fruit; I skipped dessert.

How is it helpful to someone in that condition, who’s just been handed what’s tantamount to a death sentence for something neither he nor anyone else did, to add to his burden of injustice?  Three months out and I’m dying.  The doctor said I had six months.  This is not supposed to be happening to me!!  I’m not asking to get well; I’ve come to understand that.  But I just want those three months.  Why can’t I have my last three months?  At this point to sit the patient down and explain that well, them’s just the breaks, doesn’t seem to be doing much kindness.  They were always the breaks; all you as the doctor have now done is defer the point at which the patient confronts that fact until a time at which the patient may not have the energy, the psychical strength, or even the simple time to come to terms with it.

I will answer at least one question which Dalrymple poses, and that to the effect that the patient must in the end own his disease and its treatment.  The duty to think clearly about oneself and one’s life is universal and without caveat.  “Tell me what I want to hear,” is an unacceptable position to present to any advisor.  If I had a nickel for every time a client kept asking versions of, “But if I ‘incorporate’ I can’t be sued, right?” I wouldn’t have to keep lawyering much longer.  Same for people who want me to tell them all they’ve got to do is “go to the courthouse and file some papers” and the walls of their personal Jericho will come crashing down.  Or when I explain that, assuming the facts as they’ve told them to me are correct, the outcome of any particular legal dispute ought to be X, but that they should not assume their particular dispute will have outcome X.  But that’s the law!!  That’s right, and you need to understand how frequently a legal dispute’s outcome is only moderately predictable with reference to demonstrable facts and known rules of law.  The client must confess, as it were, to his own degree of risk (in)tolerance, both in an absolute sense (how likely is an incorrect versus a correct outcome?) and relatively to that outcome (can the client bear the financial burden of achieving even a correct outcome?).  Clients who will not confront that question honestly, or who give you some version of, “We’re just counting on you to protect our interests,” (which is to say, we’re looking for someone to sue if we don’t like how this turns out) are to be gently shown to the door.  They will absorb, burn up, all the energy you would otherwise devote to those clients who are willing to engage with the uncertainties of their existence.  And that is deeply unfair to those clients.

Which is to say that I come out on the side of telling the patient everything that I can know about his specific situation, and to be extremely careful about how I present statistical statements.  You as the doctor do have a duty to treat a patient consistently with that patient’s stated desires (up to a point).  You cannot, however, grant absolution from death, or numbers.  To present oneself as an oracle when one knows one is not and cannot be such is to deceive the patient about one’s role.  Shade the facts, “spin” the truth?  How can that help?  That is not to say, however, that you must present all information to every patient in the same way.  With a little bit of luck you can pick up sufficient clues about how this particular patient perceives things that you can sense to what extent he is given to hearing what he wants to hear, or to have his worst fears confirmed, no matter what you say.  If you’re lucky.  But even if you haven’t been permitted sufficient time with this particular patient to have any idea of how he’s likely to respond to any particular factual statement, at some point he’s a grown-up and is morally chargeable with the ability to listen carefully and to think clearly.  This is not a duty you as the doctor ought to assume, even if you could.  Your burden is enough, just figuring out what’s wrong and what’s the most likely to make it better, without presuming to think for your patient.

Yours are the healing arts, after all.  Deceit does not heal.

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