Intended for healthcare professionals

Editorials Christmas 2011: Editorial

Death can be our friend

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d8008 (Published 21 December 2011) Cite this as: BMJ 2011;343:d8008

Re: Death can be our friend

I am in broad agreement with the philosophical arguments in favour of embracing death (1). But I do have concerns about the proactive promotion of such a view in clinical practice with the ultimate aim of reducing futile treatments. It all boils down to a simple question –‘Who defines futility?’

For example, Cancer patients are keen to accept toxic chemotherapy with minimal benefits. More importantly, patient’s views on this issue are discordant with those of general public and doctors themselves.(2).

I buy the national lottery tickets. I am aware of the extremely small odds of wining the jackpot but I still buy with hope (3). I am also 100% certain that the chance of winning the lotto jackpot is zero if don’t buy the lottery ticket. Similarly, if an ‘ expert patient’ after being advised of the very small chance of treatment being effective, elects to have the treatment, is it ethical to deny treatment and advice patient to ‘embrace death as a friend’.

Furthermore, the state of incurability is not permanent. There are many diseases which were deadly in the past but not anymore. For example, Tuberculosis and some childhood cancers, which were in past associated with high mortality, are now curable with chemotherapy.(4)(5).

Advances in medical treatment are quite often evolutionary rather than revolutionary. Researchers build upon previous good as well as bad experiences in clinical trials. A systematic review of published literature examining patients' motivation to participate in clinical trials found that self interest is a more common reason for participating in clinical trials rather than altruism (6). So without hope, there might be less recruitment to clinical trials and consequently possible delay in advancement of medicine.

Waiting in a queue at a supermarket till for even 15 minutes can test the patience of many (7). Imagine waiting for death for many days or weeks. Some patients would not want to sit still and twiddle their thumbs while waiting to meet their maker (or biological degradation and recycling if one is not religious). Instead, some patients might choose to fight the disease every day and every minute of their remaining life. We, as autonomous individuals, quite often make diametrically opposite choices all our life. Shouldn’t we be respectful those choices? If healthcare costs are the main problem, shouldn’t we be more explicit about rationing?

References
1. Enkin M, Jadad AR, Smith R. Death can be our friend. BMJ. 2011;343:d8008.
2. Slevin ML, Stubbs L, Plant HJ, Wilson P, Gregory WM, Armes PJ, et al. Attitudes to chemotherapy: comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ. 1990 Jun 2;300(6737):1458–60.
3. How to win the Lottery [Internet]. BBC. 1999 Nov 12 [cited 2011 Dec 28];Available from: http://news.bbc.co.uk/1/hi/uk/515481.stm
4. Murray JF. A century of tuberculosis. Am. J. Respir. Crit. Care Med. 2004 Jun 1;169(11):1181–6.
5. DeVita VT Jr, Chu E. A history of cancer chemotherapy. Cancer Res. 2008 Nov 1;68(21):8643–53.
6. Edwards SJ, Lilford RJ, Hewison J. The ethics of randomised controlled trials from the perspectives of patients, the public, and healthcare professionals. BMJ. 1998 Oct 31;317(7167):1209–12.
7. Maister D. The Psychology of Waiting Lines. [Internet]. 1985 [cited 2011 Dec 28];Available from: http://www.davidmaister.com/articles/5/52/

Competing interests: No competing interests

30 December 2011
S SUNDAR SANTHANAM
Consultant Oncologist
Nottingham University Hospitals NHS trust
Hucknall Road, Dept of Oncology, Nottingham NG5 1PB