The task of my project is to explain how and why medicine can (and must) enhance the life of the dying. One of the reasons that hospice and palliative care are often neglected, both by the medical profession and by policy makers, is that these services sometimes are conceived of as peripheral to the practice of medicine. This misconception, in turn, may be due to the fact that physicians, medical educators, policy makers, and patients have failed to reflect on what medicine actually is at its most fundamental level of meaning.
I define medicine as a free, professional, ameliorative response, in love, to the suffering occasioned by the physical finitude of the human. This definition is, admittedly, a mouthful. It is intended to be sufficiently basic to cover everything from shamanism to 21st century neurosurgery, but it requires some explication. By free I do not mean without monetary charge (although sometimes physicians should give their services free of charge, an admonition dating back to Hippocrates!). Rather, I mean that people do not need medicine the same way they need air, food, and water. Medicine is not a necessity, but an enterprise born of human freedom. It is a response, made out of other-regarding concern (love) towards those suffering from illness and injury. As opposed to informal care, medicine is an activity of a specialized group of persons socially sanctioned to carry out this work (i.e., professionals). Lastly, medicine is ameliorative in its aims. It is this word, “ameliorative,” that I want to expound upon in this blog.
I prefer to use “ameliorative” in my definition of medicine rather than more familiar words such as “healing” or “beneficent”, both of which have baggage that a less familiar word such as ‘ameliorative’ does not carry. To some, putting the word “healing” in the definition of medicine can seem tautological, and to others who are more skeptical, it only shifts the definition to a question of what “healing” means—not a helpful way to define a term. “Healing” can also sometimes be confused with curing, and I will later explain how not all of medicine’s ameliorative acts are curative. Others interpret “healing” so broadly as to convey spiritual themes. These themes are important, and ought to be part of a holistic response to agent-narrative suffering, but the spiritual aspects of healing are far wider than medicine.
Likewise, “beneficent” might be a more familiar word, having become part of the medical lexicon in the wake of the 20th century’s principlist approaches to medical ethics—but this word has drawbacks as well. It is a term of art in ethics, and its use in the definition of medicine already presupposes a view of medicine as applied ethics—moreover, with consequentialist philosophical associations. These are all contestable themes, while “ameliorative” has none of these associations. “Beneficent” is also too general, since there are duties of general beneficence towards everyone, while medicine must be understood as a form of specific beneficence. The word “beneficent” also lacks both the sense of urgency that medicine requires, and an understanding that medicine is a response to something that is wrong—important features of the word “ameliorative.” One can be beneficent towards someone who is already well-off, whereas medicine, in its most fundamental sense, is a response to those for whom something has gone awry, or threatens to do so. For these reasons, “ameliorative” seems a more suitable word to use in the definition of medicine than either “healing” or “beneficent.”
Medicine is an ameliorative enterprise. To ameliorate means to make better. The word typically applies to conditions rather than to things or to kinds of things, and so it seems especially apt for medicine, since diseases, disabilities, and terminal states are conditions in which individuals find themselves, not “things” in a strict, realistic, ontological sense. The word ‘ameliorate’ also carries a bit of a sense of the urgency proper to medicine. It further suggests that conditions are presently out of proper order and need to be improved back towards a normal level of operation. Amelioration is a form of enhancement, but the enhancement that medicine, per se, can offer to anyone is, thus, rather restricted. The enhancement medicine can offer is important, significant, often profound, but it operates within limits. Medicine ameliorates—it makes a bad situation better. Medicine aims to make people well—not better than well—but well. Medicine aims to ameliorate not the person himself or herself but the sick or injured person’s dysfunctional biological conditions, so as to enable that person to flourish more robustly. Medicine serves the whole person, but does so in and through the biological aspects of the person. Aristotle counted health among the basic conditions for human happiness: People do not flourish as best they can under the conditions of illness or injury. Medicine ameliorates these conditions so as to enable the person better to flourish.
Every medical school applicant declares his or her desire to “help people,” but medicine is a specific, circumscribed way of helping people. Medicine’s ameliorative aim is to re-establish or maintain—to the extent possible—the biological conditions that enable human beings to flourish as the kinds of things that they are.
Yet human beings are physically finite kinds of things. Therefore the amelioration that medicine offers necessarily will be incomplete. Medicine is imperfect—it is finite, like the persons to whom the craft ministers. The aim is to help, but medical action carries with it unintended consequences and failures. The aim is ameliorative, but sometimes the intervention fails to make conditions better, and sometimes medical interventions have side-effects that can make conditions worse. This is the meaning of the Hippocratic aphorism, “Make a habit of two things: to help, or at least do no harm.” This is a corollary of medicine’s ameliorative aim.
A traditional medieval aphorism encapsulates medicine’s ameliorative aims: “To cure sometimes, to relieve often, and to comfort always.” This tri-fold aim covers care at the end of life, as well as the beginning and middle. When the ameliorative aim of medicine results in a complete and durable restoration of the biological conditions that enable flourishing, we say that the patient has been cured. Yet sometimes medicine’s amelioration is only partial: a prosthetic leg might improve ambulation, but would not represent a cure for the gangrene, vascular insufficiency, or diabetes that caused it. This would be aptly described as relief—not a cure.
Finally, even relief is finite and ultimately transitory. Relief might be so incomplete that function is not improved and life can no longer be prolonged. A time comes when cure has become impossible, and relief far from perfect. Under such conditions, symptom control may be all that one can do to ameliorate the patient’s situation. The amelioration that comes through comfort and symptom management is extraordinarily valuable in any illness, and ought not to be neglected at any time in a patient’s life—but as life draws to a close, symptom control may be all that medicine can do that is ameliorative. For example, a patient might have an incurable liver cancer, and might have tried chemotherapy, which now has failed, meaning that even life-extending treatments are no longer be possible. In such a situation, medicine has not failed. Medicine is a finite craft, but when cure is impossible and relief attenuated, medicine still can make the situation better. The comfort of having one’s pain and nausea mitigated might allow that person to do such things as to say goodbye to loved ones, to come to terms with her finitude, and to plan for the well-being of her survivors, thus flourishing within the limits of her finitude. Medicine can, in such ways, enhance the lives of dying persons.
The suffering occasioned by the finitude of the body is manifested not merely in physical symptoms. Patients suffer, not only in a neuro-cognitive sense, but also in an agent-narrative sense—as whole persons embedded in a nexus of relationships and traversing a narrative arc through life. Thus illness, injury, and the dying state can bring not only symptoms such as pain and nausea, but can bring also the suffering occasioned by fear, loneliness, guilt, despair, and other agent-narrative modes of suffering. These states, too, can be ameliorated—not by medicine in a strict sense, but by the interpersonal efforts of physicians, other members of the healthcare team, family, friends, and clergy. There is no pill for loneliness and no surgical procedure for guilt. Yet while physicians cannot address these states with the usual tools of their trade, they nonetheless have an obligation to recognize these forms of suffering, to speak words of compassion and love, to make medical decisions motivated by this holistic sense of the person’s suffering, and to make referrals as needed so that others can provide the care for agent-narrative suffering that is beyond the scope of medicine per se. To be freed from guilt, assured that one is not suffering alone, and helped to find meaning and hope in one’s last days is to have one’s life enhanced even as one is dying. Good medicine is mindful of what it is at the most fundamental level (as I defined it above). Good medicine cannot forget what it is.
Medicine does not cease to be medicine when caring for the dying, and we can make use of medicine to enhance the lives of those who are approaching death. Through its ameliorative orientation, medicine can help the dying to flourish, within the bounds of what they are, as finite beings coming to grips with their physical finitude.