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Primum Non Nocere 65 à la mort. Cependant, la formation en Primum Non oncologie met l’accent sur le trait- ement du cancer et fait très peu de Nocere: place à la relation d’aide en prépa- Reflections of a ration à la mort. Des médecins tels Bahá’í Oncologist que l’écrivain Atul Gawande veulent ramener le sujet de la mort dans la about Treating the conversation entre le médecin et Dying Patient le patient. De plus, bon nombre de religions, dont la foi bahá’íe, peuvent aider à examiner comment les mé- AARON ALIZADEH decins perçoivent et abordent le sujet de la mort. Dans le présent article, je Dedicated to Carley Elle Allison traite de mon expérience personnelle en tant qu’oncologue et en tant que July 18 1995 - March 31 2015 bahá’í en ce qui concerne le sujet de la mort. Abstract Medical oncology is a subspecialty of Resumen internal medicine that focuses on the Oncología médica es una subespecialidad treatment of cancer. Cancer is the sec- de la medicina interna que se encarga en el ond leading cause of mortality in the U.S. tratamiento del cáncer. El cáncer es la se- Therefore death is a frequent subject for gunda causa de mortalidad en los Estados oncologists. However, oncology train- Unidos. Por lo tanto la muerte es un tema ing emphasizes cancer therapy with little frecuente para los oncólogos. Sin embargo, guidance on counseling in preparation for la formación oncológica enfatiza el trata- death. Physicians such as the writer Atul miento del cáncer con poca orientación en Gawande are working to bring back the la preparación para la muerte. Médicos, topic of death into the physician-patient como el escritor Atul Gawande están tra- conversation. Furthermore, many reli- bajando para traer de vuelta el tema de la gions, including the Bahá’í Faith, can help muerte en la conversación entre el médico to address how death is perceived and dis- y el paciente. Además, muchas religiones, cussed by physicians. The purpose of this incluyendo la Fe bahá’í, pueden ayudar a article is to review my personal experience hacer frente a cómo la muerte es percibida as an oncologist and as a Bahá’í, as it re- y discutida por los médicos. El propósito lates to the topic of death. de este artículo es de revisar mi experien- cia personal como oncólogo y como bahá’í Resumé relacionando el tema de la muerte. L’oncologie médicale est une sous-spécialité de la médecine interne I sit across from my patient (we’ll call axée sur le traitement du cancer, qui him Mr. Smith) in an 8x8 ft. exam est la deuxième principale cause de mortalité aux ÉtatsUnis. Les onco- room. We have previously reviewed the logues sont donc souvent confrontés fact that his pancreatic cancer appears 66 The Journal of Bahá’í Studies 25.3 2015 incurable with the presence of liver commonplace. Patients whom I saw and bone metastases. His demeanor is regularly in clinic regularly would calm, even serene. He speaks eagerly stop showing up. The transition could as if I am his confidant, the only per- be sudden and unexpected, making it son to grasp the precious news that he difficult to believe they had actually will soon die. died. It soon dawned on me that the He quickly divulges that he does practice of oncology took place on not fear death, but he is afraid of pain. the “ceiling” of this world—a portal When he pauses I try to reassure that between the physical world and death. we have good medicine to alleviate As an oncologist, was I to serve as a pain. I also begin to introduce chemo- spiritual gatekeeper of sorts. therapy options, but he waves me si- According to the American Can- lent. He has made up his mind to start cer Society, the five-year survival rate hospice care. He wants to spend his re- for all types of cancer in the U.S. is maining time with loved ones in peace. approximately 68%, a substantial in- No chemo side effects, no long waits in crease from the 49% of the mid 1970s. doctors’ offices, no vein punctures, CT Yet in my experience (and I suspect scans, IV drips. None of that. Just pure most other oncologists feel similar- time at home and with the people he ly), death and the practice of oncolo- loves. He expresses sadness and mild gy remain inseparable. Death hovers guilt about leaving them, but he also subconsciously in the conversations makes it clear that he is ready for this. we have with our patients, wheth- The subtle joy in his tone surprises er in the discussion of the causes of me. I leave the room feeling a little let cancer, the treatment, the side effects, down by his decision, yet his serenity the prognosis, the surveillance, the in- lingers. heritance pattern. Death is a silent yet I decided to sub-specialize in oncol- omnipresent backdrop. Its beckoning ogy during the third and final year of remains fixed in my mind as I tend to my general internal medicine residen- my patients. Death comes for all. It cy. I was enticed by the burgeoning has already and will continue to call field of molecular science, along with for my loved ones. It will call for me. the gravitas of treating cancer. Oncol- Yet, despite its centrality in the field ogy offered me an opportunity to prac- of oncology, death is seldom discussed tice medicine with serious diagnoses openly. If so, it is often mentioned in a and weighty decision-making. But I hushed, quick voice, a dirty five-letter was not yet fully aware that death was word—the less articulated, the better. the ultimate source of the gravitas. Siddhartha Mukherjee’s The Em- In my previous three years of in- peror of All Maladies describes itself ternal medicine clinic, very few, if any, as a “biography of cancer.” Its bril- of my patients died. Once I started liance lies in its ability to portray man- my oncology fellowship, death became kind’s long struggle with the dreaded Primum Non Nocere 67 disease. Mukherjee chronicles the his- and able to endure this grievous price? tory of humanity’s experience with Having lost many battles, I am ever cancer, starting in 1000 BCE with the aware of the strength and elusiveness Persian queen Ahoshta’s breast tumor. of my foe. I witness the physical and He portrays mankind’s evolution in emotional devastation that cancer studying, understanding, and treating causes on a daily basis. My skills as an cancer over the last three thousand oncologist are honed on treatment of years, and the book culminates with cancer, so the greatest challenge, for modern-day oncology and the devel- me, is when and how to tell a patient to opment of “targeted therapy”—the stop fighting. When Mr. Smith decides so-called “smart bomb” medicine. to forego treatment for his cancer, it A central focus of the book is Pres- is difficult for me not to experience ident Nixon’s “War on Cancer,” which disappointment, even when I clearly started with the National Cancer Act recognize the wisdom, and even the of 1971, the political history of which heroism, of his decision. is discussed in detail. The “war on can- Several months after my discussion cer” becomes not only a central theme with Mr. Smith, I meet Mr. Jones, who but also a metaphor throughout the has advanced colon cancer. He too book. Mukherjee makes it clear that has multiple liver metastases, but he we are at war with cancer on multiple is only fifty-four years old—twenty levels: cellular, personal, familial, and, years younger than Mr. Smith—and ultimately, social. The main theater of is already on his third line of therapy this war is the oncologist’s office. since the initial diagnosis some sixteen From their early days of training, months earlier. oncologists adopt the “war on can- We avoid mentioning the obvious, cer” mindset. They study how to fight that his cancer is rather resistant to cancer and defeat it. Like a general, chemotherapy. I am keenly aware that a good oncologist is always thinking once the current regimen stops work- about outcomes: What strategy will ing, there will only be one additional I devise when the current therapy FDA-approved chemo regimen I can stops working? What will be the third offer. This is in the forefront of my line of defense, fourth line? Perhaps mind throughout our consultation, but a clinical trial with novel therapies I sense that he does not want to discuss will make the difference in this case. his prognosis. Here is where I cannot Chemotherapy’s potential for toxicity be merely a clinician, I must somehow is factored into the decision-making. develop the skills, the instincts and in- But while the physician may view the tuition of a spiritual counsellor. None dreaded side effects as unavoidable—a of this was taught to me in my medi- collateral attrition to achieve the goals cal training. at hand: reduction in tumor size, re- Ever optimistic, Mr. Jones makes mission, cure—is the patient willing repeated references to how well he is 68 The Journal of Bahá’í Studies 25.3 2015 tolerating the chemo. When we dis- steadfastly society seems bent on cuss the neuropathy (nerve pain) he denying the obvious fact that no has developed because of the chemo, exercise regimen, however inge- he emphasizes the point that it does niously devised, no amount of not limit him on the tennis court.
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