The Cancer Experience

The doctor, the patient, the journey.

Is the Importance of Physician Beneficence Overrated?

The patient's best interest must dictate all decisions.

Discussions of beneficence have historically been sparse in the medical, and even the cancer-specific medical literature. However, because of shifting societal attitudes, especially as they apply to the practice of medicine, important basic changes have occurred. Emphasis on patient education, their rights, their autonomy and self-advocacy have become the norm, and despite a continued deficiency in the relevant literature, the word, as well as the concept of beneficence seem to have become essential to contemporary medical dialogue and thinking.

The word comes from Latin roots, and basically connotes the doing of good – and in the genre of medical care, refers to doing what is in the best interest of the patient. Pursuance of other definitions involves generalities that all circle around this basic concept – it is that which improves patients’ circumstances, and ideally leads to improvement and wellness. Important, however, is the realization that it is more about the intent, and as such, not limited to specific pathways of improvement; obviously such goals are not always achieved, especially in the world of cancer. This play with words is a subjective distinction that is the manifestation of the caregiver’s intent to do a good thing, no matter the outcome. Put another way, from an ethics standpoint, the judgment or the decisions of a physician may not always be correct, but if the planning and the intent that led to them were based on beneficence, the action or series of actions are morally correct; and although not always without legal consequences, the unintended outcome is more defendable.

In the first paragraph, I eluded to the dynamism of both the concept and the usage of the word in our evolving society. This is especially reflected in the attitude of contemporary physicians compared to their predecessors of a bygone time in which patients were treated paternalistically, often being left in the dark about the reality of their condition and circumstances. I strongly believe that generation of physicians cared as much as we do today, and they did in fact want to do good for their patients – but in their naïveté, sometimes hedged on the truth, withheld information about potential unpleasantness or poor outcomes, and in general presumed to believe that they knew best what the patient and the family was capable of dealing with. Thankfully, these practices are longer the standard, and I would venture to say that the new climate of tailored realism and forthrightness is better for both doctors and patients. In looking back in time, and judging by today’s standards, no matter how well intended, what was meant to be acts of beneficence actually constituted a type of unintentional betrayal. In fairness to those doctors, this was the attitude of an era, and was not limited to the medical profession, but permeated the typical family and other social units. I readily concede that some doctors are poor communicators whose words often belies reality, and unfortunately in some, indifference. I stand firmly by my contention that indifference is the antithesis of what a physician should offer. 

There is so much subjectivity in all of this, and it is largely within the heart and mind of the doctor - that is to say, in the extreme privacy of their thoughts – in which the true intent of a course of action is known. As a means of illustrating this concept, I cite an personal story that I detailed in my recently published book (1), The Cancer Experience: the doctor, the patient, the journey, where I described a case in which I probably made an judgment error that led to an unfortunate consequence. My self-revelatory misgivings did not concern the possible error in judgment (most physicians are guilty of this at one time or the other), but was more about the motives and personal failing that may have led to that possible error. I asked myself then, and I continue to question whether my motives were beneficent rather than stubbornness and/or professional immaturity. I’ll never know the truth, but the question haunts me. On the other hand, if I were certain that my motives were unselfish and beneficent, I would have long ago caste away my concerns.

The subjectivity mentioned in the preceding paragraph serves to underscore what I have spoken of in recent blogs concerning truth, trust, and absolute physician integrity. The most basic and important theme in the doctor/patient interaction is the patient’s ability to trust their doctor’s unselfishness in giving only that advice which is in the best interest of the patient; that is to say, based on a beneficence premise, as opposed to scientific or personal convenience or curiosity. The important question to ask your doctor, therefore, and the most important question for your doctor to ask him/herself is “what would be recommended if this was a member of your immediate family”? Once that is answered with certainty, the decisions in cancer management for instance - radiation v surgery, both, chemotherapy, no therapy and acceptance of death, and so on – are far easier to make.

Over many years of dealing with patients, I have come to believe that most oncologists don’t begin to realize how powerful their influence really is. Frightened patients are especially vulnerable, and when a trusted physician pushes, real power is in play. Essentially, an enormous responsibility has been de facto bestowed on the physician by the patient. This is what I was referring to several paragraphs back by saying the true intent was within the heart and mind of the physician – and for the patient to buy into this transference is the sine qua non of trust, and at a minimum, the betrayal of this by a physician is a grave moral breech.

Reference:

(1) The Cancer Experience: the doctor, the patient, the journey by Sessions, Roy B.; Rowman and Littlefield Publishing, Inc; 2012

Roy B. Sessions, M.D., is retired but still teaches head and neck surgery at The Medical University of South Carolina.

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