- Watershed and Intersections:The Doctor in the Family
"The practice of medicine in an art . . . a calling in which your heart will be exercised equally with your head."—William Osler, MD
Nowhere in the practice of medicine is this aphorism tested more than with the illness and death of a family member. In the 1970's, my exposure to the bioethics of treating and deciding for a family member was limited to: "never treat a family member." We were led to believe it was unethical. The rationale was that we could not be objective enough to treat in the best interest of the patient. Without formal readings, that was just theory. Today we understand the difference between autonomy and beneficence. The patient is, if able to do so, to be an active participant in decision making. But in the 1970's beneficence was still the norm.
My personal watershed—the moment that challenged that standard—was my father's sudden, shocking diagnosis: metastatic pancreatic cancer. For me, this occurred at the end of my demanding residency and the beginning of an even more [End Page E4] demanding fellowship. I was in the middle of another passage along the long road toward becoming a practicing physician, a continuum will little room for detours into family relationships. Medicine, the jealous, exacting lover! No diversions from complete devotion were allowed for the committed until a family crisis so dramatic that the two worlds must collide. The place that I found myself was uncharted and unguided for me. In those days, there was no mentor in bioethics to guide me.
As a physician, the challenges of death and relationships is starkest when the patient is a close family member. At home, sleeping, I was notified that my father was admitted with an acute abdomen to the ER in my hospital with my colleagues caring for him. The pancreatic cancer was yet to be diagnosed in the operating room. He was so scared to undergo anesthesia, he would not sign the consents without making me promise to be with him during surgery. This was truly ironic from a man who never really understood why a woman would want to become a physician. Yet here I was as his anchor in his sea of fear. In the words of Atul Gawande, "I was forced to realize that he (his father) might not be Immortal." So, began my reluctant position as the conduit of medical information and decisions with my family.
Without my father's strong hand to control individual family members' agendas, the lines were quickly drawn into two opposing camps. On the one side were my brother, mother and my first husband refusing to let go and accept the finality of death. They wanted debilitating chemotherapy in a man with diabetes, heart disease and terminal cancer. The other camp, me with my sister and her family, was more realistic and able to hear what the surgeon was telling them. The second camp pleaded for more information and help on giving him a dignified end of life. The first camp refused to let anyone tell my father the severity of his diagnosis! His physicians argued against not telling him. But that first camp won out. Until, one evening I was alone with my father who began to refuse his morphine. He point blank asked me to tell him the truth. By then, he had pieced together enough information to know that the end was near. So, I told him. He was so thankful. It allowed the development of another dimension of my relationship with him. It allowed him to finally accept me as a physician. It allowed him to regain his dignity and control. I felt useful and needed. Dare I say vindicated? But, it now put me even more at odds with the "do everything camp."
After the funeral, it became evident why my brother was so irrational. Unbeknownst to everyone but my mother, my father had made my brother executor and so controller of my father's monies, real estate, and businesses. It was not my father's right to control his own end of life that mattered, but my brother...