Medicine has four major ethical pillars: nonmaleficence, beneficence, autonomy, and social justice. In the care of vulnerable patients, the ethical scales are rarely balanced — and this is often tested in the field of oncology.
As interventions in medicine become more sophisticated, ethical issues also increase in complexity. Oncologists and indeed many other medical professionals, out of a desire to provide excellent care to patients, have to navigate weighty ethical questions such as:
"When is a lack of medical intervention justifiable?" and "How much information do I need to give a patient about their prognosis?"
Nonmaleficence means to, first, do no harm. Yet, the side effects of many cancer therapies (chemotherapy, radiotherapy, immunotherapy) can be so severe that patients are indeed "harmed," even after putting proper contingency measures in place.
Beneficence, on the other hand, translates to providing care that the medical practitioner believes is in the best interest of the patient. Yet, as the oncologist goes to great lengths to provide scientifically relevant interventions (eg, enrollment in clinical trials), there is no assurance that these harsh oncologic approaches will not result in significant harm.
Patient autonomy in oncologic practice requires a nuanced approach. Although the shared decision-making model is becoming increasingly popular in cancer care, the complexities surrounding oncology (ie, continuous research leading to newer findings and treatments) makes it difficult for even well-informed patients to make evidence-based choices when presented with varying care options. How much guidance, then, should an oncologist provide? When should an oncologist take a step back, allowing the patient to decide their care plan?
To address the question of social justice in oncology, we cannot ignore the importance of providing equitable care to everyone — regardless of skin color, sexual orientation, and social class. Staying blind to these social injustices leads to inequitable care. Unfortunately, while some patients might receive an ample amount of intervention, others might receive less than is required — not for a lack of desire but because of such disparities as place of residence and whether they have health insurance or not. In fact, 46% of cancer patients in a US study had to reduce the amount spent on necessities such as food and clothing; another study revealed cancer survivors to have severe intensity of financial worry.
In the quest to increase patients' lifespan, does medical care negatively impact oncology patients' quality of life?
Quality of life is a descriptive term referring to one's well-being and their ability to function in ordinary day-to-day tasks. As oncologists expend energy on keeping their patients alive, it can be difficult to balance the physical aspects of cancer-related care, the psychosocial impacts of cancer, and quality of life issues that these patients face. So as not to be overwhelmed, such dilemmas have unfortunately resulted in a reduced emphasis on issues surrounding quality of life in clinical environments, medical education, and research.
When Dr Nadia Chaudhri, a Montreal neuroscientist with terminal ovarian cancer, realized she had only a few more months to live, she began to document her last moments on Twitter, engaging in inspiring activities such as raising funds to support minority students and in the process, inspired millions of people across the globe. Like Dr Chaudhri, more patients with cancer should have the opportunity to spend their last moments filled with joy as opposed to dreadfully awaiting the end or feeling pressured to continuously undergo distressing or unwanted treatment. Oncologists would agree — though probably with a heavy sense of guilt that perhaps more intervention (no matter how unlikely to help) should have been offered.
Although an issue of ethical debate, when the quality of life becomes so severely impaired that living longer is unlikely to yield any significant benefits, and the patient makes an informed, well-considered decision to choose end-of-life care over further invasive treatment, the oncologist may hang his or her interventional boots without guilt. Even if the ethical scales never fully balance out, as long as the oncologist has worked jointly with the patient, offering equitable and justifiable care, allowing a patient to live out their last moments will provide them with much needed comfort and peace.
Her major clinical and research interests include cancer survivorship among marginalized populations, diversity and inclusion in clinical oncology trials, and technological advances in oncology. She hopes to contribute meaningfully to these spaces through clinical practice and evidence-based research.
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The Florez Lab, formerly known as the Duma Lab and the Social Justice League, was founded in August 2019 and focuses on social justice issues in medicine, including discrimination and gender bias in academic and clinical medicine, cancer health disparities, and medical education.
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Cite this: Oyepeju Abioye. The Oncologist's Ethical Dilemma: Can Medical Intervention Ever Be Too Much? - Medscape - Dec 06, 2022.