The controversy that has erupted regarding the Susan G. Komen foundation and recent decisions about funding Planned Parenthood has been hard to miss. As a specialist in women's cancers and given my general interest in women's health, I've been fascinated by this dialogue online—on message boards, Facebook, and other social media sites. As an oncologist, I have been taken aback by the misinformation being presented as facts [no—abortion is not associated with an increased risk of breast cancer
] and saddened that sites devoted to inspiring women with—and those advocating for the cause of—breast cancer have degenerated into yet another forum to debate "liberal" versus "conservative" ideas in our society.
Yet, in this ongoing "spirited" dialogue, I find the situation reminds me again of the challenge of being in health care—of professional duties in a society with so many viewpoints, and how, at times, this can be a challenge. All of us (and I include my colleagues in nursing and the allied health professions) have probably been in patient-related situations which were uncomfortable, but where the best interests of the patient called for action. For me, this drew me to considering pain control at the end of life.
When I was a medical resident at Yale-New Haven Hospital, the oncology rotation was both the most rewarding and the most challenging. I remember vividly the case of one young man in his twenties nearing death from metastatic melanoma. This situation called for pain control, and I remember my attending telling us to increase the dose of his morphine PCA so he could not feel pain. Someone on my team brought up concern that increasing morphine doses may kill him. My attending, resolute in her desire to do what was in the best interests of her patient, taught us that respiratory depression is rarely seen as a consequence of pain medication in this situation. She also taught us that even if it were a risk, the bioethical principle of double effect
would apply—that administering pain control at the end of life is (a) morally a good action; (b) intended to induce pain relief (even while respiratory depression and subsequent death could occur); and (c) directly intended to reduce pain as a direct result (not indirectly produce pain by causing respiratory depression). I have always remembered my time as a medical resident at Yale and the lessons I learned in the care of the oncology patient were initially formed there.
Many years later I found myself considering this case as an attending physician myself. It was not in the context of a patient visit but in the context of a medical school interview. The student was from a well-respected university, had fantastic MCAT scores, and was a double major in biology and philosophy. I had asked him about his majors and he explained how he felt they were "complementary" fields of studies—that biology often had ethical implications. I don't remember how we started on the topic, but I found myself discussing cancer and end of life. I recalled the experience with the patient dying of melanoma, and asked him about his impressions of pain control at the end of life—the use of pain medications to control suffering, even when the risk that it could also induce death was present. The student paused to consider this scenario before delivering his answer, "I don't think it's ever right to murder someone." Taken aback, I tried to re-frame the issue to emphasize the objective was not euthanasia, but pain control, in someone who would otherwise suffer unnecessarily, but his answer was the same—"It's never right to kill someone; but I guess a doctor would feel better using this answer to justify murder." I found myself wondering that if after four years of college as a double major in philosophy and biology he still saw the world in black and white, I wondered how open he would be to see all the "shades of gray" that underlie the practice of medicine.In medicine we should do what's right for our patients, no matter what our personal beliefs and opinions.
Fortunately, in oncology, there is no debate about pain control at the end of life—it is absolutely important
. However, the current controversy regarding Susan G. Komen reminds me that we must continually engage and educate the public at large on issues of importance to us as oncologists.
Personally, I practice oncology and share beliefs aptly summarized this week by Ellen DeGeneres. My practice in oncology is based in "honesty [with myself and with my patients], equality, kindness, compassion; treating people the way you want to be treated and helping those in need." Fortunately, I know many, many others who share this sentiment.