Free The Way We Die Now by Seamus O'Mahony Page A

ethos of customer-friendliness has all but silenced other, dissenting, voices. There is now an insatiable appetite for medicine: for scans, for drugs, for tests, for screening. This appetite benefits many professional groups, industries and institutions. It is difficult to call ‘enough’, but a good doctor sometimes has to tell patients things they do not want to hear. Regrettably, it is much easier, in the middle of a busy clinic, to order another scan than to have the Difficult Conversation.
    Doctors have a duty beyond that of pleasing the individual patient, a duty to society at large. The US has many so-called ‘concierge’ doctors, private physicians engaged by the wealthy, who are always on call to minister to the needs of their fastidious and demanding clients. The annual fee per patient is said to be as much as $30,000. The ultimate concierge doctor was Conrad Murray, the late Michael Jackson’s personal physician. Murray’s willingness to prescribe almost anything, including the general anaesthetic agent, propofol, for his wealthy and manipulative patient, eventually led to Jackson’s death.
    Axel Munthe’s autobiography, The Story of San Michele (1929), is, in part, the story of a concierge doctor. Munthe, a Swede who had studied medicine in Paris, developed a lucrative practice, first in Paris, then in Rome, treating wealthy neurotics. Like Murray, he eventually had just one, wealthy and powerful patient, the Queen of Sweden (who was also his lover). Munthe, who had a brilliant start to his career as a medical student and young doctor, was filled with regret for the direction he had taken. Describing another concierge doctor working in Rome, Munthe wrote: ‘That I considered him an able doctor was of course quite compatible with his being a charlatan – the two go well together, the chief danger of charlatans lies there.’
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    Patient autonomy now trumps all other rights and obligations. Autonomy, however, is a useful card to play when, as often happens, particularly with the diagnosis of cancer, I am ambushed by well-meaning relatives, urging me not to tell the patient, because ‘it would kill’ them. Relatives have no formal rights as such, but commonly dictate medical care to those doctors keen on a quiet life and willing to be leaned on. Inevitably there will be instances, such as in the case of patients with dementia or those of very advanced age, where giving a diagnosis of cancer is of no benefit to them. But in most cases I believe it is my duty to tell the truth.
    The difficulty, however, is this: Kieran Sweeney’s acceptance of, and confrontation of, his situation, is the exception, not the rule. He was both advantaged and disadvantaged when he was given the diagnosis of mesothelioma. As a doctor, he knew immediately what the future held in store for him, but this knowledge precluded all hope. Many of my patients lack the educational background or knowledge to fully absorb a diagnosis of something like mesothelioma. Apart at all from this ‘cognitive’ aspect, many simply do not want to know the grisly details about survival statistics and what the future might hold. As the case of Sherwin Nuland’s brother shows, it is not only relatives who wish to have the truth concealed. Many patients do not want to have the Difficult Conversation.
    The entire modern hospital system conspires against those doctors willing to have this dialogue: the relatives, the chaos and noise of the environment, the techno-juggernaut of modern hospital care, the customer-friendly doctors who are happy and willing to dole out false, delusional hope, and sometimes the patients themselves, who may not want to hear what the doctor has to say. The temptation to opt for the quiet life, to avoid the Difficult Conversation, is overwhelming. And no one will ever complain. The relatives will be content, and the dying will soon be dead. Why give yourself the grief?
    Society at large purports to want leadership and