Cancer & Conscience

Cancer, a deadly disease that the doctor has to attack with inadequate tools and insufficient understanding of the cause, gives the medical profession its two most painful problems of conscience: Should life be prolonged, even at the cost of pain to the patient, if the doctor is convinced that the patient is dying? And should the doctor tell the patient that the disease is cancer as soon as the diagnosis is certain? Last week 1,000 medical scientists and 450 laymen at the annual meeting of the American Cancer Society in Manhattan heard an eloquent answer to the first question, and a helpful statistical answer to the second.

How Long to Prolong? A vigorous defense of what he called "aggressive or extraordinary means of treatment" to prolong life came from Dr. David A. Karnofsky, of Sloan-Kettering Institute for Cancer Research, who was recently called in as a consultant on the treatment of House Speaker Sam Rayburn.

As the patient continues in a seemingly inexorable decline, said Dr. Karnofsky, "the state of dying may be protracted by expensive and desperate supportive measures, and the patient is rescued from one life-threatening situation only to face another. Many objective observers, in contemplating this dismal scene, plead with the doctor to let the patient go quickly, with dignity and without pain."

With rising indignation he continued:

"Withholding of aggressive or extraordinary treatment can be urged and supported by state planners, efficiency experts, social workers, philosophers, theologians, economists and humanitarians. For here is one means of ensuring an efficient, productive, orderly and pain-free society, by sweeping out each day the inevitable debris of life." Roundly rejecting any such advice, Dr. Karnofsky said that life must be prolonged on the ground, among others, that there is always the hope during a temporary reprieve that science will find a more effective and longer-lasting treatment.

Temporary relief can be stretched a long way. Dr. Karnofsky cited the case of a patient with cancer of the large bowel. A colostomy relieved an intestinal obstruction. A recurrence of cancer nearby was relieved by X-ray treatment. When the abdominal cavity began to fill with fluid, radioactive phosphorus checked the process. Bronchopneumonia was cured by an antibiotic. Cancer spread to the liver, and again X-rays were used. As liver function progressively declined, many medical measures supported the patient. If some of these treatments had been withheld, said Dr. Karnofsky, the patient would have died within weeks or days. Successively, they kept him alive for ten months. Dr. Karnofsky asked, "When should the physician stop treating this patient?" and answered: "I believe he must carry on until the issue is taken out of his hands."

How Much to Tell? Dr. Victor A. Gilbertsen described a research follow-up on the attitudes of 298 patients who had been surgically cured of stomach or intestinal cancer from five to 20 years ago at the University of Minnesota Hospitals in Minneapolis. Only 13%, including some mental patients, had not known that their disease was cancer. Of the 87% who knew, the vast majority had been told by their doctors, a few by relatives or friends, and a handful had found out by reading hospital charts or insurance reports, and by overhearing doctors' talk. Of those who had been told the truth, 83% advised telling it to other patients; of the same opinion were 70% of those who had not known the nature of their disease.

To make sure that these results were not biased because the patients had been cured, the Minneapolis researchers checked 92 current patients with far advanced disease. Among the 75 who had been told they had cancer, the proportion who favored telling the truth was almost the same as among the cured.

From working with such patients, Lutheran Pastor Granger E. Westberg of Chicago concluded: "The minister has his tongue tied by well-meaning relatives who insist that he never mention anything about death to the patient. The minister is held back from helping his parishioner in this moment of crisis. So the minister is forced to limit his conversation to the weather and the activities of the ladies' aid." Happily, said Pastor Westberg, more and more patients understand the nature of their illness and freely discuss their prognoses. They quickly come to the point with their pastors: "I know what I have, and I would like to make the best use of the time I have left."

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