Tuesday, November 22, 2016

The Oath and Killing

My dad received his M.D. from Temple University School of Medicine in 1931.  He died suddenly, though I now realize from the perspective of time, not unexpectedly, in July 1974.  I was in the last two weeks of my junior year at the same medical school.  (Though irrelevant to everything that will follow, I can never express my gratitude to two late deans at Temple Medical, M. Prince Brigham and Hugo Smith, for the kindness and compassion they extended in allowing me to take the surgery final, scheduled the week of dad's funeral, when I felt ready to take it, and for considering my six-week internal medicine rotation complete after the four weeks I'd already finished.). 

Dad's death and the timing of that death was a wound that took several years to heal.  Eventually, like other wounds, it scarred over.  Were you to look at my soul today you could still see the scar. It occasionally gets a bit inflamed.  That inflammation is not something to fight against but rather to be gently rubbed, acknowledged, and soothed.  It was a hard-won scar on both dad's and my parts.

As we were planning the funeral I wanted, indeed, had to have, a copy of the Hippocratic Oath next to the crucifix in his coffin.  Dr. Steve Wartella, a radiologist and tremendously kind man, was very helpful getting a copy in those days before computers made it easy to find and print a copy suitable for framing.  It was held in a brown fake wood frame from Woolworths. That copy of the oath, in the same $7.57 (plus tax) frame, has hung in my apartment, office, or room ever since.  At the moment it is packed in a box at Campion Center along with the rest of my stuff.  Should I return to Slovenia I will ship it over.  It meant a lot then. It means even more today. 

All of this was triggered by an item from the Catholic News Service that popped up on facebook.  The headline is:  Cardinal Dolan urges stronger effort to stop physician assisted suicide. 


Dolan makes an important point that I hadn't considered.  "The legalization of doctor-assisted suicide creates two classes of people: those whose suicides are to be prevented at any cost, and those whose suicides are deemed a positive good."  In an American society that has become extremely hypersensitive to 'isms', 'ists', a panoply of 'phobias' and in general insists on pounding any round peg possible into a square hole of discrimination, this seems to be a widely ignored thought.  The cardinal described the situation well, “We remove weapons and drugs that can cause harm to one group, while handing deadly drugs to the other, setting up yet another kind of life-threatening discrimination . . . ”

The Oath Attributed to Hippocrates has a long history.  It was never universally accepted by physicians, even in ancient times.  While reading some history of medicine a few years ago I learned that not all physicians took or abided by the oath.  The ones who did were deemed "Hippocratic Physicians."  By now, however, the "Hippocratic Oath" has become traditional at medical schools, generally upon entering and at graduation.  The question is whether the bowdlerized oath means anything at all today.  Should it even be called The Hippocratic Oath or perhaps changed to something like, "The Doctor's Promise" or "The Medical Code Based on Hippa and Medicaid?" I was stunned when the "oath" we pronounced less than a year after dad's death bore no resemblance whatsoever to the copy in dad's coffin.  I cannot recall the exact words in the graduation program which, like the framed oath, is in a box at Campion.  I do recall searing disappointment that we pronounced what seemed at best a pseudo-oath.

There are now many versions, none of which seem to include a proscription against killing a patient, none of which include forbidding abortion, and most of which no longer caution against having sex with a patient or member of the patient's household as did the original oath quoted as follows,   "Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. . . . I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free." 

Cardinal Dolan notes that, rather than being abandoned to the ease of being killed by a lethal combination of drugs or poisons, the dying require care.  They require intense symptomatic management.  They must be assured that they are not a burden or a bother.  What Dolan and many others call for is not easy.  Almost forty years practicing first internal medicine (fourteen years) and then geriatric psychiatry (twenty-six years) allow me to say that it is not easy by a long shot.  It requires compassion (from the root words for 'to suffer with'), it requires physical and emotional stamina on the part of the physician who is confronting his own mortality every time he enters the patient's room or, ideally sometimes the patient's home.  It requires a very certain and detailed knowledge of physiology, pathology, and pharmacology, not just good intentions and a few prescribing trees that instruct "if this then this."  Care for the dying demands knowing the patient as a living being.  Perhaps it is this last part, knowing the patient, that is being destroyed in American medicine. 

Six months after dad's death I began a cardiology rotation.  The name of the hospital is irrelevant.  I was assigned to a group of six or seven cardiologists.  They were excellent at what they did.  And they were very nice guys who treated me well.  My qualm was how they practiced and made rounds.  Every morning I walked into a patient's room with a different doc.  The dialogue went something like this, "I'm Dr. Harrison.  You don't know me but I work with Dr. Miller who admitted you.  He told me all about you."  The following day Dr. Wilson repeated the same things mentioning both Harrison and Miller.  Eventually during the recitation of four or five names who handed off the patient, I realized I was the only consistent presence in the patient's room all week.  I swore I would never do that to my patients.   

Caring for the dying is physically, emotionally, and spiritually demanding. It is exhausting work.  Sitting at the bedside of a twenty-something year-old patient as he approached an unpreventable death from devastating and terminal heart-lung disease, I screamed "WHY?" at God, a prayer that was greeted with silence at the moment.  Despite his physical struggle to breathe and the wracking coughs that brought up dark red blood clots, I never had the thought to kill him in the name of compassion and relieving his suffering.  God knows it would have been easy enough with a slight adjustment of medication.  He got through that awful crisis.  When he did die a few weeks later he was home.  Watching a football game.  That angry WHYYYYY? hurled at God was answered. 

The question behind Cardinal Dolan's talk is whether physicians are willing to do the hard work needed.  Are they willing to be compassionate, to "suffer with" in down and dirty fashion?   Are they willing to stay when they desperately want to flee the room or punch a wall?  Are they willing to be what they think to be an ineffective presence (presence is never ineffective) seeming unable to do anything to relieve the suffering?  Would they rather be in a bioethics seminar room making pronouncements about short-circuiting suffering rather than fighting sleep at 3:00 AM while sitting in a chair next to the bed, perhaps scared out of their minds?

In 1977 I had the immense privilege, a life-changing privilege, of working as a house officer for six weeks under Dr. Cicely Saunders at St. Christopher's Hospice in London.  One day, in my uncomprehending youthful state, I asked what she thought about what was then called "euthanasia" assuming agreement. Dr. Saunders was a tall woman.  She crossed her arms under her ample bosom, made herself even taller, her halo of white hair like a cloud above me, and almost thundered her response.  It was not pretty.  Her philosophy was that pain could always be controlled.  It wasn't always easy or without risk but it could always be controlled.  Killing a patient was never the answer.  That is quite a difference from the Dutch who are considering physician assisted suicide for those who are simply tired of living.

Another of Cardinal Dolan's remarks is a fitting end to these thoughts, “Patients need our assurance that they are not a burden — that it is a privilege to care for them as we ourselves hope to be cared for one day. A compassionate society devotes more attention, not less, to members facing the most vulnerable times in their lives.”

The above thoughts were triggered by something that popped up on facebook (yes, I had to bite the bullet).  Scary, especially the Dutch and/or Beligans who are thinking of allowing those who are simply tired of living rather than terminally ill, be administered "physician assisted suicide."  Ditto for Alzheimer's patients who didn't request it.  Obviously given at the behest of the family or the physician ('the inheritance is going to run out' or 'I need a bed on Monday').  

Attached are a few more photos from Piran.  Sunday morning Robert took me up to St. George's Church, bell tower, and baptistry, each of which is a separate structure.  There was sun.  

Robert checking out the catch with two fishermen.

Morning fog is rare in Piran.  This was one of those rare days.

Forty minutes earlier we sat under the white canopy at the upper left corner of the square with coffee and croissant.

The pink house in the corner of Tartinijev trg is 'the Venetian House.'  

Heading to the boats with coffee

+Fr. Jack, SJ, MD


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