The Good Doctor (24 page)

When a physician died while tending to patients, it was all the more tragic and meaningful. A journal entry dated November 26, 1993, told of the sudden death of one of my father’s Mount Sinai internist colleagues during rounds at the hospital. This doctor had frequently come to the Mount Sinai at night and on weekends when his patients needed admission, even when he was not on call. It was not surprising that my father had so much admiration for this man, who, he wrote, represented “a dying breed, the indefatigable solo practitioner who knows all about his patients and follows them himself closely and confidently until their problems are resolved.”

Depending on who the relatives or friends were, where they lived and what diseases they had, my father got involved in their care to different degrees. People loved to run cases by him, both because they trusted his medical judgment and because he knew almost the entire Cleveland medical community. On one occasion, when he went to see his mother, Pearl, who had fainted in her apartment, there were three people present who asked his medical advice on other issues. He was surely happy to provide it. It is not clear if there was a specific moment when my father decided to insert himself more directly into the care of certain relatives, but the reasons he did so seem clear. In an era of increasingly impersonal medical care, directed by doctors who were overextended and hassled by insurance companies and who practiced “cookbook” medicine, he thought he could help ensure that his loved ones received the individualized, hands-on attention that he had been taught to provide. Meanwhile, the notion that his dying relatives and friends might become the victims of futile treatment was entirely unacceptable. “My talents prolong the lives and sufferings of strangers,” he wrote in 1991. “I would never do things like this to a loved one!” Finally, there were the themes that ran throughout his journals: his relatives had shown the courage to move to the United States, had nurtured my father, and had enabled him to achieve his dream of becoming a physician. How could he—their cousin, their nephew, their son—not pay them back?

It was this mind-set that led him to get highly involved with the care of one of his first cousins, Donald, who developed prostate cancer in the early 1990s. Donald, the son of one of my Grandma Pearl’s sisters, was the first of his cousins living in Cleveland to become seriously ill. Donald was also our family accountant and, as my father often remarked in his journals, one of his favorite people. The turning point in Donald’s case came in 1992, when he developed painful metastatic disease to his spine.

The timing was particularly poignant. In June 1992, when Donald made a casual remark to my dad about the gradual loss of Jewish traditions in the family, it had “triggered an idea”: What if my father wrote a brief history of the Singers—Pearl’s very large family—in time for a family reunion, planned for September of that year? Thus was born “Cousins: The Next Generation,” a thirty-four-page booklet that recounted the journey of Chaim and Dina Singer from Poland to the United States and the fate of their plentiful offspring, which included almost fifty great-grandchildren (one of whom was me). The final product was a labor of love, and not just for my father. Throughout the summer of 1992, he spent every Sunday morning with his mother, Pearl, picking her brain about her childhood and her relatives, dead and alive. He also asked his cousins to provide information about their branches of the family tree.

The final document, replete with stories and pictures, was a big hit with my father’s cousins. I’m not sure if my generation found it as compelling, despite my dad’s hope that “the strong sense of family recalled by the cousins will filter down to their children and grandchildren, since much has been lost or diluted, at least, by the passage of time and the dispersal geographically of the close-knit family from a tiny village in Poland.” My father loved the reunion, which, he wrote, “recalled the family club picnics of my youth and an era of simpler times.” I might have helped promote family unity by attending the reunion, but Cathy and I were living across the country in Seattle during my fellowship. In retrospect, having written this book, I wish I had made it my business to attend.

It was two weeks after the reunion that Donald called my father to tell him about the progression of his disease and to discuss an oncologist that he was planning to see. By December, Donald was traveling to Detroit to try a novel combination of chemotherapy drugs. My father was becoming increasingly involved in the case, helping Donald to get a series of studies he required before starting the chemotherapy. “He’s only got a 30–50% chance of responding,” he recorded in his journals.

Three months later, my dad was even more involved. “I suddenly find myself taking care of my cousin Donald,” he wrote. He described how this had occurred. Donald’s primary oncologist was in Detroit, and even though he also had one in Cleveland, Donald had let my father and his physician-brother, Allan, know that he was happy to rely on them for ongoing medical advice. This new responsibility was one reason that my parents canceled their annual trip to France. My father approached the task with trepidation. Although he was “glad to be able to help” because it gave Donald “a little more control” and allowed him to “avoid unnecessary treatments” and minimize visits to doctors, he feared that when Donald deteriorated, it might force my father “to make some hard decisions.” Doing so as both a treating physician and a “cousin and good friend” was a potentially fraught conflict of interest.

The bioethicist in me, reading this passage, wishes my father had simply articulated these concerns to Donald and elicited his end-of-life preferences. Taking care of one’s cousin was iffy enough. Indeed, this relationship probably made it even more crucial that the patient’s autonomous wishes be identified and honored. But given my father’s paternalistic leanings, this was unlikely to occur, at least while Donald remained semi-stable. Nor did Donald seem uncomfortable letting my father (and his brother) run the show.

Five months later, during the summer of 1993, Donald was much worse. His rapid deterioration, my father wrote, was “startling,” even for someone like himself who had witnessed these types of cases many times before. By this point, Donald had made his wishes known: he wanted to die at home and not be readmitted to the hospital.

Even though the plan was to make Donald comfortable, my father was impatient. “I am most concerned that his suffering end as soon as possible,” he wrote, “so we can remember him as he was, the Donald we all knew and loved so much, not the Donald who suffered so at the end.” My dad planned to speak to Donald’s wife and children “as soon as possible” to encourage them to ask Donald’s Cleveland oncologist—who had once again become his primary physician—“to ease his way out of this terrible suffering.”

As usual, with this sort of language, my father was pushing the envelope, suggesting a level of comfort with euthanasia that was not shared by most physicians or society. Ultimately, Donald availed himself of some of the evolving technologies for treating the pain of dying cancer patients, such as an indwelling epidural catheter used for administering strong analgesic medications. Happily, my father wrote after Donald’s death, his final days had actually been quite peaceful, and his loving family had had ample time to say good-bye.

My parents had decided to euthanize our dog Lily shortly before Mickey’s death, and, in an ironic twist, they had to put down Lily’s successor, Sabine, just as Donald began to worsen. My father once again remarked on how dying animals experienced more humane deaths than humans did. Perhaps charting new territory in the world of bioethics—should doctors treat their own pets?—my dad had actually taken over Sabine’s care after he grew impatient with the veterinarian’s inclination to order additional tests for what was apparently a hormonal abnormality known as Cushing’s disease. “I decided,” he wrote, “after doing my own literature search, to initiate treatment myself.” Although there was some initial improvement, Sabine later worsened.

It is hard not to think of Jack Kevorkian when reading my father’s thoughts on death. Kevorkian was a pathologist who championed the rights of terminal patients to request assistance in dying. Between 1990 and 1998, it is estimated, he sped the deaths of 130 people. In order to ensure that patients themselves—as opposed to doctors—initiated the process of euthanasia, he developed machines that delivered lethal doses of gas or chemicals when the patient pressed a button.

Although he appeared to be an advocate of patients’ rights and of death with dignity, two concepts promoted by bioethics, Kevorkian was loathed by most ethicists. First, by encouraging physicians to help patients kill themselves, Kevorkian was asking them to violate the Hippocratic oath, a section of which prohibited doctors from giving “deadly medicine.” Second, investigations into Kevorkian’s cases suggested that some of his patients had not been terminal and that others had not been appropriately referred for assessment of their psychiatric states or for pain management. Eventually, in 1999, a Michigan court convicted Kevorkian of second-degree homicide in conjunction with a death aired on TV’s
60 Minutes
.

My father was no fan of Kevorkian either, criticizing his “misguided actions.” But, he wrote, Kevorkian was “filling a major void in our society—the need to address the issue of death and dying.” My dad favored legislation, which eventually passed in Oregon and a few other states, that legalized physician-assisted suicide, a carefully controlled process in which doctors could supply terminally ill patients with enough pills for them to end their lives at home.

It was more than just his cousin Donald that caused mortality to be on my father’s mind. By the early 1990s, he was actively involved in the medical care of three octogenarians who were very dear to him and all of us: my grandmother Jessie (my mother’s mother), my grandmother Pearl (my father’s mother), and Aunt Gertie, my grandfather Meyer’s older sister. Although he described them as “tough, stubborn, argumentative women” who “snipe and interrupt and expostulate,” they were very much his “three angels.”

In point of fact, all three women were in pretty good shape—“remarkably intact mentally, and even physically.” Jessie was losing her vision and hearing, had heart disease, and had survived a colon cancer fortuitously discovered at the time of an operation for diverticulitis. But she had been well enough during the late 1980s to accompany my parents on several of their summer trips to visit my uncle Mark (her son) in France. Pearl had high blood pressure and pretty bad arthritis but was extremely active, driving her own car well into her eighties and traveling to weddings and other family events across the country. She even made the trip to Israel that she and Meyer had begun planning just before he died. In 1991, Pearl and Jessie accompanied my parents to visit Cathy and me in Seattle during my Robert Wood Johnson fellowship. It was not a prescription for relaxation. “There have
never
been two such badly matched traveling companions,” my father wrote. “One is hard of hearing and the other doesn’t listen so we’re constantly repeating and repeating so the two of them are on the same wavelength.” Gertie continued to work part-time at a local dry-cleaning store well after she turned eighty.

I vividly remember when Cathy and I would visit Cleveland in the middle and late 1990s with our son, Ben, and, eventually, our daughter, Nina. The three women would sit in the den of my parents’ house, reminiscing and bickering. Sharing my father’s sense of family history, I recall thinking what a gift it was to have three women born into poverty in Poland in the early twentieth century who were still going strong in the upper-middle-class suburbs of America as the century came to a close. I also loved that I was well into my thirties and still had two grandmothers and a great-aunt doting on me, the first grandchild on both sides of the family. Even better was that they doted on the kids. As a toddler, Ben, in particular, had ample opportunity to interact with his great-grandmothers and Gertie, and he still remembers them well. Ben was “friendly and most solicitous of the older crowd,” my father proudly recorded, which was a “blessing.”

Jessie was the first to begin to deteriorate. When she fell asleep at ten o’clock on New Year’s Eve in 1993, at the age of eighty-six, my mother “wondered, out loud, how many more, if any, New Year’s Eves, we’ll be together.” It was the beginning of a series of premature predictions of Jessie’s demise, most of which would be made by my dad. Nevertheless, she had a remarkably large number of ailments, which my father compiled in 1995: worsening blindness and deafness, coughing spasms, stress incontinence, “horrendously itchy” eyes, back pain, hip pain, and chronic diarrhea due to the removal of part of her colon. By the next year, she could not see her great-grandchildren’s faces. Meanwhile, she was developing a humped back and had increasing trouble standing up straight. Jessie had also become alarmingly outspoken, showing little or no inclination to censor her thoughts. Over the years, she had heartily criticized my sister Dana’s boyfriends, told one of Dana’s African American friends that “Black is beautiful!,” and once asked me when I was home from college whether I was still a virgin. Such statements and questions always generated considerable laughter, which probably only encouraged her. Even though my mother was the subject of many of Jessie’s criticisms, she remained a remarkably dutiful daughter, increasingly putting her life on hold to assist her mother. “I must make note of R.’s extraordinary courage with and devotion for her mother,” my father wrote.

Given Jessie’s increasing debility, it came as a surprise in 1997 when Pearl, age eighty-eight, died first. Pearl’s main medical problems had remained high blood pressure and arthritis. She had also developed what is now called diastolic dysfunction, a condition resulting in a hypertensive patient’s lungs filling with fluid if his or her blood pressure gets too high. Over the years, my father had regularly visited Pearl on Sunday mornings for some “venting and gossiping.” Pearl was not the warmest person and could be brusque and negative. But she got along well with both my father and his brother, Allan, who also kept close tabs on her. As Pearl’s medical problems worsened, my father gradually became more involved, particularly in monitoring Pearl’s high blood pressure, which was hard to manage.