What does it mean to care for a patient in today’s world?

‘To care’ is a concept we all use and as long as we are not asked to define it all is well. However, to care for, say, a dying patient will be very differently defined depending upon the fundamental beliefs of the patient as to the meaning of life. Our problem is that the secular view of the world, which presumes no ultimate, transcendent meaning, is not only providing its version of caring but increasingly demanding that we accept their tacit definition without any adequate discussion of whether they might be wrong.

We ought to sympathize with an aspect of this: whoever speaks about ‘care’ is speaking of something good. Is medical care not good? The Supreme Court of Canada thinks so. When earlier this month it opened to door to euthanasia the Court identified the law’s prohibition of killing as a barrier to “medical care”, thus bad:

[To] prohibit physician‑assisted dying for competent adults who seek such assistance as a result of a grievous and irremediable medical condition that causes enduring and intolerable suffering … denies people in this situation the right to make decisions concerning … medical care….

But the advocacy of good has justified great harms in the past. Christians once executed heretics (as defined by us) in the name of public welfare. ISIS does it now and considers it good and therefore a form of caring for society. Marxist dreams in the last century killed untold millions in the service of a state created for the welfare of the people.

What the Supreme Court has done is to drop on us yet another permutation of care. But what does it mean to care for a patient?

The difference between groups is most often subtle, a difference in priorities or in philosophical terms in the ordering of the goods. C.S. Lewis contrasted the classical Christian position with the modern one. Traditional Christian beliefs make obedience to the teaching of Christ the primary objective of life. The modern concern, however, is to conform the world to our desires by the manipulation of words, laws, and actions using technology as the means. The recent Supreme Court decision on assisted suicide is a prime example of the modern approach:

•  there are no absolutes to guide us –

An absolute prohibition on physician‑assisted dying is rationally connected to the goal of protecting the vulnerable from taking their life in times of weakness…. However,… the evidence does not support the contention that a blanket prohibition is necessary in order to substantially meet the government’s objective….

•  the government sets the objectives;

•  and these objectives have to do with individual autonomy (the god to whom the law bows, choice being the trump card) –

The prohibition denies people in this situation the right to make decisions concerning their bodily integrity and medical care and thus trenches on their liberty.

I believe we are naïve if we do not recognize that this trend will work to remove or at least emasculate any rights of religion. Already this can be seen in the habits of so-called progressives who refer to rights of worship  rather than rights of religion.  Worship is a private right without public standing. Thus when we say that we have our rights of religion, which include rights of conscience, the opposition say to themselves, ‘Yes, at present, but we intend to change that.’

The Supreme Court decision reads,

Nothing in this declaration would compel physicians to provide assistance in dying.

But how will things stand when killing a patient who wants to die is understood to be care?

This is where care needs definition. If it is to be patient-centred – a service of the needs of the patient – then it must take into account the patient’s beliefs. These may be somewhat incoherent, as with Christians who say that the right to life is God’s prerogative yet don’t believe it in practice. Nevertheless, at the end of their lives they will in most cases want to die as ‘default’ Christians.

Polling data based on a false dichotomy – ‘Do you wish to die in terrible pain or do you wish to legalize assisted suicide?’ – don’t help us to face the actual scenario of our own mortality, which it would be good to do well in advance of the sobering encounter with imminent death. Sadly, most patients muddle out of life as they muddled through it. The risk now is that they may be shuffled out before they sober up!

Medicine is practiced with patients who are individuals and on these issues there is no possibility of compromise. It seems to me that we need two distinct practices of medicine with the difference being moral commitments, but a shared technical expertise.

The Christians Lewis described have hardly gone away: there are two quite different moral outlooks alive in this country.

•  The 2011 National Household Survey conducted by the Canadian government tells us that Canada is 67 percent Christian;

•  in all but two provinces over 70 percent of the population call themselves Christians, while in five provinces over 90 percent do.

Twenty-five hundred years ago, Hippocrates and his colleagues took a very similar situation and changed the nature of medicine in the opposite direction to our Supreme Court. In those times physicians killed for profit, easy money. The conundrum that faced Hippocrates et al. was how to improve the practice of medicine given that they had very little effective therapy. They realized that relieving a patient’s anxiety was one powerful tool in their kit and it could be enhanced by promising the patient that the physician they engaged would never be the cause of his or her death.

This approach worked and in conjunction with more attention to the patient’s story became the dominant mode of medicine – one that flourished even more with the arrival of Christianity. The essential insight that medicine is a deeply interpersonal and moral profession in which the physician is the guardian of a long tradition of trust – the trust of this patient in that physician ­­– lasted until reductive scientistic views of what constitutes a human being emerged in the eighteenth century. What do you think was then removed from the doctor-patient relationship?

We have now reached the point where “measureables” are the new means of assessing the efficiency of medical practice. W.H. Auden understood what was happening when he wrote at the end of his own life a description of the physician he wanted at his bedside as his life came to an end.

Give me a doctor partridge plump,
Short in the leg and broad in the rump.
An endomorph with gentle hands,
Who will not make absurd demands
That I abandon all my vices,
But with a twinkle in his eye,
Will tell me that I have to die.

There are not many billable items in this description but we all want the same attention at the end of our lives.

Whatever legislation emerges (12 months have been allocated by the Court for Parliament to set in place safeguards for terminating life) it ought not to necessarily involve physicians in doing this deed.

The linguistic ingenuity of the Supreme Court should not fool us:

The prohibition on physician‑assisted dying infringes the right to life, liberty, [etc.]

Physicians will be asked to do something  and ‘dying’ is not a transitive verb (dying is something that happens to you). What the Court is talking about is killing, though it refused to use that word. It is not ‘physician-assisted dying’ that the law prohibited; that is what we already have in place, as a mode of care.

If ‘assisted death’ is really thought needed it would be better to involve someone other than a doctor (maybe lawyers, judges, and other progressive folk). After all, ten years of medical school are not required to inject a lethal drug. Nothing should be done that could in any way diminish public trust in doctors.

There is a solution to these problems but our pluralistic society is not going to bite the bullet easily. What will be required is the recognition that what is at issue is not a small thing and both sides of the argument must be accommodated. The bureaucratic involvement in the funding of medicine will need to come up with just funding formulae that will allow the two groups to compete and see who cares for whom. The patients will vote on ‘care’ with their feet.

John Patrick

SOURCES Carter v. Canada, (Attorney General), 2015 SCC 5 (6 February 2015)

Evangelical Fellowship of Canada, “EFC Deeply Disappointed in Supreme Court Carter Decision” (6 February 2015)

Statistics Canada, 2011 National Household Survey

Statistics Canada, Census of Population (2001)

Pie chart: Wikipedia, “Religion in Canada”

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