Has your knowledge of Becker influenced your practice as a physician? If so, in what ways?

Well, my temperament has always been open and nonjudgmental, both in medicine and life in general, but specifically with patients. I spent my summers on my granddad’s farm so I saw lots of things dying. From the get-go I tended to help people die, or at least try to keep them from unnecessary medical intervention. You hope that you have a system in place that encourages the appropriate kind of care rather than unnecessarily aggressive kind of care.

What are the biggest challenges in medicine to addressing end of life?

It used to be that we doctors would kill people in the hospital, but we would do it slowly, you know, we would gradually increase the morphine and give comfort treatment only, obviously at the patient’s desire, but the hospital itself would, of course, not “allow” that to happen, because you don’t “kill” people in the hospital, right? And in the system I practiced, every department had peer review committees and every death was analyzed.

I remember one doctor who, when he told a patient’s husband that this was all they could do for his wife, the husband said, “OK, well then, let’s end it,” so right away the doctor ordered big doses of morphine and phenobarbital and within 24 hours she was dead. So that comes to the attention of the quality assurance committee. So here we are, a bunch of us in our white coats or shirt and tie, talking about this behavior, which is clearly demonstrated in the chart. Sitting there we realized that, you know, we all do this but we do it in a way that’s culturally acceptable. We don’t just throw in the towel. So what we’re doing is we’re titrating morality! When does it become appropriate, what’s appropriate? So those are the kinds of things that we used to have to do and deal with in the hospital setting.

I do have a concern now with primary care doctors who aren’t spending a lot of time with patients and learning the patients’ stories. I think one way of summarizing life is “the story is everything.” That’s the whole thing. So somehow, we have got to tie into that and allow that to be played out in as a gentle and meaningful way as possible. And I suppose maybe hospice/palliative care is a place where this can be considered.

…we do it in a way that’s culturally acceptable. We don’t just throw in the towel. So what we’re doing is we’re titrating morality!

In medical school, what is the approach to teaching students how to talk about mortality and end-of-life issues with patients?

In medical school things are changing. I’m not there anymore but I have professor friends who are still in academia and they are teaching poetry, storytelling, and the importance of stories more than we were ever told about. All we ever learned about stories came from our grandmothers, not from professors. So they’re trying to get that into medical school.

Storytelling, poetry, palliative care treatment, etc. So, the more good kind of experience you can get in medical school, the more likely it is to carry over to your practice. And I think things are happening in the right direction.

What do you think needs to happen for Western medicine to improve its ability to have dialogues around mortality and reduce the stigma?

I’ll tell you one thing that I’m pleased about. I’ve noticed in the obituaries lately it seems to be that the most frequent thing is that people die at home surrounded by their family. And that is, of course, what you would want to have happen in most cases. What needs to evolve, and seems to be evolving, is palliative care and hospice programs. These obviously need to be a strong part of any system of medical care. But there are always people who, for whatever reasons, want to fight death to the end. This whole idea of using medical care in a military way—“he fought until the very end!”—has always sort of bothered me.

Finally, have your own personal thoughts about death changed since you first encountered Becker?

As Thomas Kent said, “Teach me to live that I may dread the grave as little as my bed.” Personally, I think reading Becker has given me a clearer understanding of how our tribal nature determines much of our behavior, which has helped me want to rise above that. Poetry has also played a big role in helping me get beyond culturally determined restriction to a freer life. We should all, not just physicians, be about reducing human suffering or misery and improving quality of care, well-being, and happiness. That’s what life should be about.

COMORBIDITY

I don’t recall ever using that word
when discussing a risky
test or treatment with a patient.

Of course I’d assess the pros and cons
before taking a big step.
Take me for example, I’d review my

being over eighty,
my heart disease and hypertension,
narrowing of my carotids.

But when, discussing plans to remove
a kidney tumor, the doctor said,
Given your comorbidity,

I was offended
―a light flickered in the deepest cave
of my mind
where I keep in chains the fear of death.

—John L. Wright