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

professionalism from doctors, but I wonder if this is really true. Leadership and professionalism involve confronting unpleasant truths, and sometimes denying people what they want (or think they want). Many doctors routinely over-diagnose, over-investigate and over-treat; these doctors are invariably described, approvingly, by their patients as ‘thorough’. Inevitably, the ‘thorough’ doctors eventually leave their dying patients mystified and abandoned when there is no chemotherapy left, no scans to order.
    Sherwin Nuland bitterly regretted his funking of his duty to level with his brother when he was diagnosed with advanced colon cancer: ‘With this burden on my shoulders, I made a series of mistakes. That I made them with what seemed like the best of intentions does not mitigate how I feel about them in retrospect... I could not deny him a form of hope that he seemed to need.’
SENTIMENTALITY AND THE LIE
    Much of the behaviour of people around the dying is characterized by sentimentality and evasion. This can take many forms: at its simplest, there are the relatives who conceal from the dying person the fact that he or she is dying. Then there are those – relatives, friends and doctors – who encourage a deluded optimism about the benefits of medical treatment. This deluded optimism is usually disguised as ‘giving hope’. Friends and family may genuinely believe in the delusion, which then becomes even more difficult to deflate. Doctors generally know what is truth and what is fantasy, yet some cynically peddle lies to their patients. This may be done with the good intention of ‘maintaining hope’; others become addicted to the hero-worship given by their adoring patients. Then there are the charlatans and money-grabbers – and they’re not all on the fringes.
    Many dying people inhabit a world of histrionic pretence. David Rieff’s memoir about the death of his mother Susan Sontag, Swimming in a Sea of Death (2008), is a vivid depiction of such a world. Having twice survived cancer, Sontag was diagnosed with a form of bone-marrow cancer, myelodysplastic syndrome, at the age of seventy. Rieff describes his mother’s terror of death, and the bizarre denial she maintained almost to the very end. Rieff clearly knew that his mother was dying, but could not summon the courage, or find the opportunity, to discuss this with her, and the memoir is filled with regret for this failure.
    The journalist John Walsh, in his memoir of his Irish immigrant parents, The Falling Angels (1999), expressed outrage that his doctor father, when diagnosed with leukaemia, was told that it would be fatal. Walsh describes his parents’ disastrous decision to retire to their native west of Ireland, after half a lifetime in London. They found it difficult to settle, the new Ireland unrecognizable to them. Walsh’s father’s specialist, knowing his medical background, told him the unvarnished truth: ‘“You’re a doctor, Martin,”’ he said. “You know how these things go. Check your will, say goodbye to a few friends and accept it. That’s it, I’m afraid.”’ Not, I’m sure, the approach they would recommend in a Breaking Bad News workshop, but I think I understand what this doctor was trying to do: speaking frankly to his patient, a colleague talking to a colleague. Walsh was appalled: ‘I could never forgive the cold-hearted scumbag for saying such a thing to my poor father.’
    So – there is little reward, professionally or emotionally, for doctors who tell patients the truth, but the Lie is heavily incentivized. Nearly all families, and many patients, prefer the Lie. I try to engage with the dying patient with the intention of being honest, but the path of the Lie often looks so much more inviting. And no one has ever complained to me for taking the path of the Lie. Doctors, like their patients, are human and flawed, and the easy path of the Lie is the road commonly taken.
    Ivan Illich wrote scathingly of