Palliative care is both a new medical specialty and an approach to patient care that is much discussed today. It is an elusive and provocative topic for patients and health care professionals alike, because its meaning is determined by which of two broad perspectives is under consideration.
One view of palliative care incorporates the traditional patient-centered role of physicians. This heritage directs doctors to address each patient one at a time, attending to their individual needs. In this way, the physician directly benefits the patient and only indirectly advances the overall health of society and the common good. From this perspective, authentic palliative care is a legitimate approach to caring for patients who are seeking assistance to alleviate their suffering. Benefit accrues to both the individual patient and the common good when practitioners of palliative care promote a medical culture that values each patient's decision-making authority.
The alternative perspective considers palliative care to be primarily a means for directly supporting the common good. This perspective strikes fear in those who realize that palliative care is misused when it becomes a tool for reducing health care expenditures by limiting patient care. They observe a palliative care system in which physicians target patients with poor prognoses and/or poor functional ability and those approaching end of life, thereby placing the elderly and chronically ill at risk.
These physicians' primary allegiance is not to individual patients, but to serving some other goal or objective. This is additionally harmful to patients when the common good begins to encompass a societal strategy that overrides the patient's right to make his or her own health care decisions in order to achieve other aims, for example, resource allocation and conservation.
The World Health Organization defines palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual."[1]
Unlike hospice care, palliative care happens while patients are receiving active medical treatment for their underlying diseases. For example, lung cancer patients receiving chemotherapy and radiation could (and should) receive palliative care. Palliative care seeks to discover and effectively treat patients' symptoms arising from their disease as well as from the treatment itself.
In fact, studies have shown that patients with lung cancer who receive palliative care while receiving standard cancer therapy have fewer episodes of depression, experience better pain control, make fewer visits to the emergency department and may even live longer than those not given palliative care.[2] Therefore, authentic palliative care done well is patient-centered and aims to alleviate all aspects of human suffering, not just physical pain. By doing so, physicians respect the inestimable worth and dignity of every human life.
Christians should neither fear nor calumniate palliative care. Rather they should work together - both professionals and non-professionals - to insure this patient-centered approach becomes the shared perspective that ends confusion about the practice of palliative care.
Christian morality teaches that each person in the doctor-patient relationship encounters the other as fully dignified and worthy of each other's respect. The patient is the one who initiates this meeting, which becomes the first step toward building a genuine, trusting relationship. The patient seeks out the professional whose assistance is necessary for addressing perceived or real threats to their health.
The physician becomes God's minister, easing suffering and dispensing God's love to the patient. For Christians, a physician's service is indeed vocational, a calling from God. The physician's "yes" in response to this transcendent call advances the physician's own journey to holiness by concretely demonstrating his or her love of God and love of neighbor.
Even nonreligious physicians understand that the service they render - caring for and curing human beings - is traditionally directed toward the individual patient. Unlike physician-scientists, whose research directly benefits society through the accumulation of new knowledge, the practicing physician, using his skills and knowledge, benefits society by focusing his complete attention on patients, one at a time. Any conflict regarding where the physician's fidelity should reside - with the individual patient or society's common good - ought to be resolved in only one way: a physician's primary ethical responsibility is with his or her patient.
This standard principle of serving patients according to their needs once informed much of the work of physicians and the medical profession. It was a norm incorporated into the system of medical education. It helped to prepare students for their work of encountering persons in need by becoming better-equipped professionals predisposed to serve others.
In 1980, Dr. Therese Southgate, then editor of the Journal of the American Medical Association, addressing a convocation of medical students at the University of Missouri School of Medicine at Kansas City, remarked, "As a physician your charge will be not to cure, but to attend your patient, a far more difficult task."[3]
"To attend" to our patients and to their needs, first consider the verb's linguistic origin borrowed from two Romance languages. The French verb attendre and the Italian verb attendere both mean "to wait for" or "to wait on." In other words, "to attend" means "to serve." It calls to mind our duty to pay attention to, to listen to, and to hear what our patients want to tell us. Therefore, the designation "attending physician" is rich with meaning, since it sends the physician on a mission that must ultimately be patient-centered.
Dr. Southgate told the students that learning the science of medicine is extremely important, but "attention is the art of receiving and that this art must be learned [too], and that both of these qualities, knowledge and attention ... are the difference between being a good physician, which is only the minimum demanded of you, and being a great physician."[4]
The very best physicians - the great ones - know this and demonstrate it daily in their patient care. They understand that competence is more than technical expertise and that their essential obligation is to pay attention to the one requesting help. This can be accomplished only by focusing on the needs of the patient, not the needs of society as a whole. Dr. Southgate emphasized this to the students when she said this is the "far more difficult task ... to meet the patient and to care for him where he is, not where you are."[5]
For Christian physicians their calling and subsequent mission comes from God; thus, their work is holy and commendable. A great source of guidance is The Charter for Health Care Workers, issued by the Pontifical Council for Pastoral Assistance to Health Care Workers in 1995. The Charter states that the health care worker's activity is "a form of Christian witness."[6] Palliative care done as "Christian witness" attends to the needs of the patient through professional competence and expertise directed toward palliating patient suffering. This meaning of palliative care is not elusive. Misuse of palliative care to create a tool for advancing some other objective ultimately creates misunderstanding and fear.
Those physicians whose primary allegiance is not directed toward serving their patients are not attentive to their patients' needs. Likewise, doctors who use palliative care directly to control expenses and the common good too often do this at the expense of individual patients' needs. They badly distort both the nature of palliative care and the essential character of the medical profession, which at one time presumed in favor of life and fought for the gift of life. Finally, these physicians also destroy the trust that is essential between doctors and their patients, further weakening the ideal of the "attending physician."
Regardless of the importance of finding a more just way to distribute precious or scarce resources, the physician guided by faith must help to lead his colleagues back to the mission of caring for each patient, one human life at a time.