A Doctor's Deathbed: The Burden of Knowledge

My dad did not approach his illness in a fatalistic way. He was deeply involved in his treatment: he read the medical literature on it, grew his tumor in rats at Roswell Park, and sponsored stem cell research on his cancer in a national lab. On one occasion, he even took control of his treatment from Dr. Park, choosing the oral version of a drug over its intravenous alternative.

As she reminded my father, there are always outliers.

My father's expectation and acceptance of his cancer's recurrence appear to have been grounded in objective reasoning. When he was diagnosed, the cancer had spread to his lymph nodes, putting his odds at avoiding recurrence at only 35 percent. It is unclear to me where my father would have based any hope of rebuilding his body. For many people, religion might be the source of such optimism. Though he had been raised as an orthodox Jew, my dad had adopted a secular, though culturally-Jewish world view. While near death, he had described his religious attitudes to me by saying, "I was always agnostic, but now I am verging on atheist."

My father might also have found comfort in statistics. During his recovery from the surgery in Buffalo, a long time friend of his from California named Sarah visited. Although in her late sixties and very visibly affected by multiple sclerosis, Sarah spoke with my father of bell curves. As she reminded my father, there are always outliers.

This use of statistical metaphors would have had special appeal for my father. I remember walking into my dad's home office as a child and seeing multiple computer screens filled to their edges with charts and data. Although he was very successful in obtaining research funding, including many highly coveted National Institutes of Health grants, my father was a notorious procrastinator. He was often two or three hours late for afternoon meetings, let alone those in the morning. This was due to his habit of working in bed late into the night, stopping long after my mother had given up admonishing him and had fallen asleep. I once asked my father about this lateness and, at first, he deemed it a habit he had picked up from his mother. Thinking more, he explained how he had always viewed his existence as fleeting and uncertain; why worry about a meeting when life may end moments before?

Despite this apparent nonchalance, my dad approached his work with an intense scientific rigor. This mimicked his attitude toward his disease. Given his proclivity for analyzing data, he certainly understood the true meaning of a bell curve: in a perfectly shaped bell curve, for every extraordinarily long-lived survivor, there is a tragically early death. As I listened in to him and Sarah speaking, it was difficult to not hear the uneasiness of his professed optimism.

He was deeply involved in his treatment: he read the medical literature on it, grew his tumor in rats at Roswell Park, and sponsored stem cell research on his cancer in a national lab.

Beyond statistics, ignorance can also function as a basis for hope. Many patients, and those around them, opt for an uninformed optimism by leaving medical decisions to their physicians. I certainly followed this route; it was not till many months after his death that I knew more than the name of the disease. For my father, a translational researcher specializing in oncology, this was not an easily available option. This scientific knowledge had allowed my dad to devise new technologies to fight skin cancer. Yet during his own illness, this understanding led to anticipations of recurrence and, given his awareness of the biomedical literature, probably death. These expectations may explain his average outcome.

Since Harvard anesthesiologist Henry Beecher's studies in the 1950s, it has been clear that placebos, apparently innocuous procedures, can have demonstrable effects on human physiology. Despite the subsequent discovery of endorphins and other advances in our biological understanding, locating the specific mechanisms behind the response has proved difficult. This is especially true in areas besides analgesia, or pain relief. Certain variables have been identified as triggering the placebo effect. They have expanded the conception of placebos from a patient's finding succor in sugar pills to include factors like cultural attitudes toward disease, the branding of pharmaceuticals, and a patient's confidence in their doctor. For example, in one study on coronary heart disease, a high adherence rate to medication was linked to better survival, regardless of whether the pill was active or inert. These psychosocial variables can have therapeutic effects, or they can trigger suffering and even death.

Derived from the Latin verb nocere, to hurt, the nocebo (literally meaning: I shall hurt) stands as the noxious counterpart to the placebo, which means, I shall please. Just as confidence in a doctor's ability can bring therapeutic benefits, anxiety, fear and a strained marital relationship have all have been shown to negatively affect health. Recent studies have demonstrated, for example, that people experience increased pain when told to expect it, such as with the interruption of morphine. The most extreme example of the nocebo effect might be the phenomenon of "voodoo death." Investigated by Harvard physiologist Walter Bradford Cannon in the 1940s, these sudden deaths occurred among people from South America to New Zealand who had not suffered any apparent trauma or had any underlying physiological condition. Cannon found that the pointing of a bone was sometimes all it took to kill a seemingly healthy individual.

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Benjamin Oseroff is a writer based in New York City. He focuses on medicine, health, and society.

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