The New York Times today has an interesting profile of Dr. Desiree Pardi, a palliative-care specialist in New York who was diagnosed with breast cancer in her early 30s, and refused palliative care – while still working in palliative care professionally – during her prolonged and painful death.

Dr. Pardi had gone into the field because she thought her experience as a patient would make her a better doctor. Now she came face to face with all the ambiguities of death, and of her profession.

She remembered patients who complained to her that she did not know them well enough to recognize that they were stronger than she had thought. Now she discovered that she felt the same way about her own doctors. “I think they underestimated me,” she said in an interview last summer.

She came to question the advice she had been giving. She thought about quitting. “I just decided I have to believe in what I’m saying,” she said.

It’s tempting to see her treatment choices – demanding extensive low-probability and experimental treatments – as being in some way hypocrtical for someone who had made a point of encouraging others not to continue with therapeutic treatments near death. At times she was quoted expressing anger at doctors who recommended palliative care or hospice, and at times she is described by others as being “in denial” about her own condition – much in keeping with her own attitudes toward palliative care and patients’ beliefs, as seen from her professional perspective. The article at times seem to imply that there is in fact a contradiction there.

But I think, and I think most people in the field would agree, that there is no tension between active therapy and palliative care – that both are available options that different people will choose for different reasons, or even that a given patient will choose under differing circumstances. The idea that some patients would reject palliative care is hardly new; the fact that one such patient would turn out to be a palliative care specialist is merely a coincidence, ironic at most, and hardly that. (Nobody claims that palliative care is right for everybody.)

From that perspective, I was a bit annoyed with this article, because it seems to imply that there really is something wrong in the way Dr. Pardi practiced as a physician, or worse, that there is something wrong with palliative care – that it “underestimates” patients, that it is something that palliative care workers try to impose on others but reject for themselves, or even that it is the sort of “death panel” that the insane right wing keeps conjuring up. Also annoying is the tone attributed to Dr. Pardi herself (she was dead when the article was written): that palliative care was in fact something to be avoided; that she herself questioned whether it was right for her to offer it to her own patients. It’s not clear how authentic this is, but I hope Dr. Pardi was not as much “in denial” about her own profession – let alone her health status – as the article seems to imply; if not, the problem then is not that there is something wrong with palliative care, but that a doctor in that field had not thought deeply enough about what is right with it before it became an issue for her personally.

The meaning of the piece for me was that people’s personal choices are unique and not always predictable, and that this is the reason patients must be allowed to choose the terms of their own treatment. (Dr. Pardi – an MD/PhD with extensive experience – chose to allow her husband to be the point of contact with her own caregivers, and never knew the extent of her own disease, though she was adamant in her choices about how aggressively to treat it.) There is a reminder here of the degree to which aggressive treatment might serve some patients’ needs (Dr. Pardi’s final course took barely a year and a half from her last remission to her death, but it is likely that she extended that period somewhat by refusing palliative-only care and insisting on a high-calorie diet) – though that hardly renders palliative care unnecessary, or argues for returning to the days when painful aggressive treatment was the only option available.

Dr. Jack Cassell, in Florida, is getting press today for the cranky, obnoxious note he posted on his office door:

If you voted for Obama . . .
seek Urologic care
elswhere

Changes to your healthcare
begin right now
not in four years

He apparently also fills his waiting room with anti-Obama literature, signs about what “the morons in Washington have done to your healthcare” (NB: nothing has changed about any of his patients’ healthcare; he is the only one who has done anything so far), and explicit instructions on who they should vote for.

In response to concerns that he might be politicizing his care just a tad, he argues “I’m not turning anybody away — that would be unethical. But if they read the sign and turn the other way, so be it.” So of course he’s not actually doing anything to make patients feel uncomfortable by explicitly telling them to leave his practice because he disapproves of their politics; they just happen to choose to seek another doctor for reasons unrelated to his behavior or his treatment of them.

There’s been commentary over whether this infringes any laws or principles of medical ethics. His supporters claim he is justified in behaving this way because doctors, like everyone, have a right of free speech. There’s a lot to be said about that – most notably that the whole point to medical ethics is that professional practice and the professional relationship impose standards more stringent than those  incumbent on ordinary citizens. Simply having a right of free speech does not justify acting like a jerk toward your patients; the treatment relationship is one-sided, predicated upon the doctor’s commitment to service of the patients’ needs, not their approval of the patients’ politics; admission as a professional is predicated upon acceptance of those standards, and a willingness to put one’s personal inclinations aside in the professional arena.

But aside from that, what strikes me about this situation is the general attitude it reveals. Not only does this doctor fail in the face of any of the above standards, but it seems obvious he simply conceives of medical practice as something that does not in fact entail the authority of such standards or commitments. Doctoring is apparently a job, to him – something he can do if and as he chooses, and which does not impose on him any obligations he does not happen to want to meet. He is – to all appearances – essentially the doctor in Ayn Rand’s Atlas Shrugged, who joins with the amoral capitalist runaways to form a free-market society founded on hard money and ethical egoism. Being a doctor does not require him to do anything for anyone if he doesn’t feel like it, and it doesn’t require him to accept as a patient – or even keep as a patient anyone he has already accepted – who does not personally agree with him on any matter of his choosing.

What I fear, but perceive, is that this attitude is becoming more widespread. Doctoring is just a job, it seems, in the minds of more and more doctors, and in the minds of the right-wingers who are so afraid that Obama is going to destroy healthcare by making it less capitalist. (As usual, facts are of no moment to the right-wing panic apparatus: it is this doctor himself who is “changing” healthcare for his patients – his own sign says so  – but he still manages to blame it on Obama. And it is this doctor who has made healthcare hostile and unwelcoming for his own patients – he is, not a death panel exactly, but a one-man jerk panel to his personal caseload – but they deserve it, he seems to think, because they voted wrong.) Whatever the consequences of Obamacare, I fear that it will be simply impossible to destroy medicine in the US because there will be no medical profession left to destroy – just a bunch of entitled, self-absorbed jobsworths whining about how much less they like their jobs now that the glamor and remuneration has started to fade and they’re left with nothing more than providing better care to more people, which is such an imposition.

Democratic Congressmember Alan Grayson, who represents that district, was notorious for (accurately) characterizing the Republicans’ healthcare policy as “Die quickly”. He notes about Dr. Cassell: “Maybe he thinks the Hippocratic Oath says, ‘Do no good.’” That’s about the size of it.