A minister writes:
What is the role of the minister or chaplain in telling a parishioner that his illness is hopeless and death is imminent?
A chaplain answers:
The minister must always remember that the doctor is committed to keeping life going. He will do nothing that will cut down the force of wanting to live. The doctor never wants to call any case hopeless—and neither should a minister. Many older doctors recall that during the period of their practice they have seen a number of "hopeless" diseases like diabetes, diphtheria, pneumonia, and smallpox become curable. Some of the patients who were being starved to death in the old manner of treating diabetes were actually kept alive long enough by this somewhat brutal method to be miraculously healed by the discovery of insulin.
If to "tell a patient" means to imply utter hopelessness then a minister will certainly not encourage such telling. If, on the other hand, it is thought of as being in the same category as telling the T. B. patient in order that he may work cooperatively with those who could help him, then it serves a valid purpose. The suspected T. B. patient who is waiting for the diagnosis usually says that even though the news may be bad he can hardly wait until he gets a definite answer. Living in doubt and uncertainty is worse than knowing the truth. Once he knows he has T. B. he learns to face it realistically. If all malignancies were contagious then patients would have to be told and perhaps the problem confronting us would be quite different.
Most of us would agree that the decision to tell the patient that his illness appears to be hopeless lies with his family. Our guess is that seventy-five per cent of doctors would rather that the patient not be told he has a malignancy because it might cut down his ability to fight against it. They suggest this to the family and soon they all enter into a conspiracy of deceit. Unless the patient presses his family or the doctor for a specific answer, contacts with him are on a superficially cheerful basis. He is treated as if he were a small child and conversations are confined to small talk which often means inane trivialities. Obviously there are many patients who are not fooled by this ruse. There are others who desire to be fooled, and it is not at all easy to tell in advance what attitude is best to assume around any particular patient.
Facing Up to the Problem
The minister finds himself in some sort of dilemma at this point because he has always been opposed to deceit in any form. Yet the majority of the so-called hopeless cases with which he deals are handled by the deceit method. This naturally irritates him in that the mood created runs contrary to the Christian concept that it is always best for man to face life and death realistically. But most ministers have shied away from facing up to this problem. We think there are at least three reasons why they have.
a) They do not want to be like a very small percentage of ministers who are guilty of seeming to take delight in making people squirm by holding over their heads the threat of death, judgment, and hell.
b) They respect the tremendous advances in scientific medicine and want to work closely with the doctor and so have been willing to abide by his orders even though the matter of telling patients the truth may not be solely in what might be called a medical category.
c) They know that the family puts more trust in the doctor during illness than in the minister.
Because the minister has not been at all sure of his value in the sick room he has been too timid even to question some of the customs dictated by a materialistic culture.
Now that people in general are beginning to appreciate what a minister can accomplish through pastoral care he has taken courage to ask whether deceit is ever justified—even in a sick room. He wonders if it is quite fair to expect a man to fight against the most difficult of foes, the unknown. He has long believed that if a problem is repressed it will cause the person more real suffering than if it is taken out of its hiding place and faced with the help of loving friends. If it is true that children can bear and handle all sorts of tragedy much better than they can handle lies, deceit, and pretense then perhaps the same can be said for adults.
All this gives the impression that I personally believe every patient with a malignancy ought to be told. I doubt that I shall ever say "every," for I can immediately think of a number of patients who I am sure could not have handled it. But I think there are more people than we realize who would have had a more meaningful last few months if they had been treated like adults. Some of them have confided to ministers that they "played the game" because their doctor and family wanted it that way.
Is there anything that can be done about this problem? We think there is. We are now in a position to ask medical and theological educators to meet together from time to time to address themselves to the many problems which they face in common. The patient is the center of attention of both of these disciplines. As they both attend to the needs of the patient they cannot help seeing how these professions overlap. In the give and take of such discussions new insights are bound to develop and new ways of dealing with particular problems will be explored. It is to be hoped that such discussions will stress the wholeness of man and see in problems such as this more than the physical dimension.
Some Principles to Follow
If we are to set down some principles for ministering to those whose illness is apparently hopeless the following things might be said.
I) The minister must always think of each patient as an individual for whom the usual methods of pastoral care may not be appropriate.
2) The minister must consider each problem in the light of his own personality. If he tends toward being the brutally frank type he must attempt to understand the dynamics underlying his behavior. If he is often overly cautious it may be that he never has sufficient conviction on any issue to stand up and be counted.
3) The minister must be willing to take the time to talk over with responsible members of the family the religious and psychological implications of facing the future realistically.
4) If the minister believes it would be best for the patient to know the truth, then he ought to convey this information to the doctor. If sufficient medical reasons can be given to show that this course should not be followed then at least it is clear that the withholding of the truth has been decided upon with the patient's best interest in mind.
5) If religious and psychological reasons for telling the truth seem to outweigh the medical reasons for not telling it, it is to be assumed that the physician will understand this.
6) If the family, the doctor, and the minister are in agreement that the patient should be told there will, of course, be no formal announcement. If the patient asks if he has a malignancy the answer is simply, "Yes" with an immediate description of all the possibilities for counteracting it.
Where an atmosphere of honesty prevails, the air seems much clearer. All conversations carried on in the patient's presence are free, easy, and open. No one has to be on his guard to remember the last lie told the patient. The minister is his same hopeful self, encouraging and strengthening the patient with the resources of the Christian faith. He is no longer fettered by being unable to discuss with the patient all aspects of the Gospel. He does not have to avoid certain passages of Scripture which deal with death and the hope of life eternal. He now speaks frankly of both life and death with the realism so characteristic of the early Christians. He is a minister of the religion best equipped to help people die victoriously. It would be unkind to withhold such a faith from most terminal patients.
GRANGER E. WESTBERG, Chaplain, University of Chicago Clinics, Chicago, Illinois
A doctor writes:
It is unlikely that early in the course of any but a few diseases should the word "hopeless" be used. At the time the average incurable disease is recognized, with few exceptions, "hopeless" is the wrong word. There is always hope for relief of pain, for palliation, for daring surgery, for unusual reaction to drugs, or even for the advent of a drug that can control or cure.
Life can be called an incurable disease. The cardiac or the diabetic or the hypertensive is more incurable than the cancer patient. Each knows with more certainty than the rest of us what will be the likely cause of death. Although it is true that such knowledge is hard to bear, uncertainty is intolerable.
Although any patient will experience anxiety when he has to face the reality that he is not immortal, he really has always known this—and his faith can be a powerful support at this time.
GEORGE V. LEROY, M.D., Associate Dean, University of Chicago Medical School, Chicago, Illinois
