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C H A P T E R F I V E DOCTORS AND DEATH They Comfort Me If it is true that an underlying cultural attitude about death’s inherent wrongfulness has fueled past medical abuses against dying patients, the reformist move to patient self-determination would not be a reliable corrective, because dying people themselves would be prone to mirror the relentless hostility of their physicians. The stage would thus be set for reiteration of past abuses, embraced by patients in collaboration with physicians. There is, moreover, a further element in medical practice that gives added impetus to this malign possibility. Physicians’ mistreatment of dying patients has arisen not simply from their condemnatory attitudes toward death but also as an expression of misgivings, of deep-rooted but ordinarily denied ambivalence, about the moral status of medical practice itself. On its face, this observation may seem utterly implausible. Medical practice has bestowed great advantages on vast numbers of people; the physician’s office is still a prized place of benevolence in our society. But this benevolence has the same status as the secularized rational conception of death: it is a clear truth widely understood as such; and yet, at the same time, there is a strong undercurrent of disbelief, a powerful contrary attitude, that remains in persistent contrapuntal tension with these rationally apprehended truths. As with the claims for patient selfdetermination , the existence of this ambivalence is not a reason to reject belief in the virtues of medicine or its professional practitioners. It is, however, a reason for caution, and for especially intense skepticism where some medical practice is ostentatiously dependent for its acceptability on unalloyed good motives among physicians. 87 The goal of this chapter is to set out grounds for ambivalence among physicians about the moral status of their professional enterprise and to identify the potentially malign consequences of this ambivalence for their patients. I mean by this ambivalence much more than the familiar complaints about greed or incompetence among physicians, which are really about some disputable number of proverbial “bad apples” in a fundamentally well-cultivated estate. I mean deeper misgivings about the moral worth of the entire enterprise of medicine—misgivings that are often glimpsed by the general public but that are felt with special intensity , and frequently denied with great adamancy precisely because of this intensity, by physicians themselves. From the discussion of the sources of this fundamental ambivalence in medical practice, we can then turn in the next chapter to consider the claims for—and the special vulnerabilities for abuse of—physician-assisted suicide, where the interlocking themes of patient self-determination and physician benevolence have come together most powerfully in the contemporary reform agenda. In his classic observational study of surgical practice, the medical sociologist Charles Bosk was impressed and “surprised” at the ambivalence of surgeons who worked in elite hospitals on the most difficult cases with a correspondingly high fatal outcome. Bosk reported: I was surprised at the degree that informants sought me out to relate stories of practice that they disagreed with. . . . I knew that observers were often sought by organizational malcontents; what surprised me was that all my informants were at one time or another malcontents. . . . Disfiguring palliative operations, patient discomfort, and the openness of communications among the [surgical] ranks were the most common complaints. As a “sounding board,” I was implicitly asked to play a quasi-therapeutic role: to listen without judging and to understand. The fact that I was asked to play this role so often by so many speaks . . . to the deep feelings that physicians repress as a matter of course. As a rule, we, as medical sociologists, have not concentrated enough on how fragile physician defenses are, what events disturb them, and how primal the existential material they are dealing with is. Birth, life, death are not questions that one works through definitively. We need to pay more attention to the provisional nature of the resolution physicians make to the conflicts such subjects present. . . . Like house officers (although the opportunity arose less frequently), [senior] attending [surgeons] unloaded themselves on me. It is worth noting here that I was ten years younger than the youngest attending, so the fact that they used me as a “sounding board” points to ways in which the surgeon’s role remains disturbing even to those who have practiced it all of their adult lives.1 One of the ways that this disturbance expressed itself was...

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