"First, do no harm.” This Hippocratic Oath is practically the initial we hear when we graduate from medical school and are set loose on patients as real doctors. In fairness, I think it hits very few people in that moment what that oath is about. You think you know what you’re saying—you certainly don’t plan to hurt anyone, and you are hoping to help many. In my case, as an oncologist and hematologist, I am focusing specifically on helping children.

On my last 10 days ever on the inpatient service (as a trainee), and after 4 years of medical school, 3 years of residency, and 3 more years of fellowship, I still often don’t know the right answer. Medical ethics are so complicated. We are a team of attending doctors, experienced nurse practitioners, fellows, residents, and medical students. We teach medicine, we learn, we make rounds, we examine patients, we place orders, and we ask for help when we don’t know the answer—sometimes from the pharmacist, other times from the research personnel, sometimes from the social worker, or sometimes from another specialist.

Everyone, at every level, is checking, rechecking, thinking, researching, asking questions, discussing, analyzing, and trying to help patients. We go home and read, we contact world experts, we search through the latest medical literature to see what is available; we try as hard as we can. We work in shifts so there is never a drop in momentum—sometimes 12 hours or sometimes a week. It depends.

What do you do when you have the best mentor and cutting-edge therapy, and yet nothing you do is working? The cancer and all its associated illnesses are leaving people literally broken, in multiorgan failure, with rare but very deadly syndromes and with rapidly enlarging tumor burden. You have to make decisions with your teams, both quickly and correctly. What’s the right thing to do when you know, medically, nothing short of a miracle is going to heal this person? “Do no harm.” Is it more unethical to not offer something that is medically available when the family is willing to try anything, because you do not think it will work (and no one has ever survived the treatment)? Sometimes these ethical dilemmas seem like they have an “of course” answer to them. The answer is easy if it is well researched and people know the benefits and the risks and aren’t just making decisions based on desperation. But what if it’s an experimental drug? It has worked in “10% of rats,” and the adverse events can kill your patient much faster than their disease. Do you roll the dice then? “Do no harm.”

Maybe the ethical thing to do is to help a family understand when it is time to focus on the quality time that is left available rather than try to offer something that will likely not work for various reasons and achieve what is, unfortunately, medically impossible. The patient (in this case the child) is suffering, sometimes consciously, with issues such as severe pain and difficulty breathing.

Just recently, one of our little angels who went to heaven was literally gasping for each breath in her final few days because of her tumor-filled lungs. However, she wanted to fight. “I’m not worried about myself, but I don’t want to leave my mom behind,” she said. “Are you saying there is nothing else you can give me so she’ll have more time with me?”

And sometimes, even when the patient is no longer conscious, the next ethical issue becomes, “In the midst of trying to help this person, am I doing things for them or to them?”

You overhear one supervising (well-intentioned) doctor make a decision to try yet another drug, and you see the sadness on the training residents’ faces as they look down and shake their heads because they feel it’s the wrong thing to do. Along with the dedicated bedside nurses, they’re the ones who spend day and night in the hospital trying to bring comfort to the patient and their family.

Who is right? The person with the expertise who thinks, “This could work,” and wants to give the patient another shot—or the person who has watched all the suffering and wants to stop prolonging what everyone knows, in their gut, is the end of the game? Plus, it’s important to factor in what the family believes is in their child’s best interest. There is no correct answer.

What complicates the ethical issues even more is when a mom looks at you and begs you not to give up hope on her child. I have heard about “maternal guilt” and, admittedly, don’t know what that feels like. However, I certainly know what “doctor guilt” feels like.

You wish you had something that worked. You’re hoping for a miracle just like the patient and their parents. But you see which direction this is going, based on lab tests, imaging results, and your experience. You are praying and hoping, too. You do your best to try not to cry in front of the patient and their family because they need someone who is composed and has a plan, not someone who is a crying mess (so you wait until you get to your car and you cry all the way home).

You understand they are angry, and they remark that they wish they had sought a second opinion. They wish you had told them they had only a few days to go (but you didn’t think that was right, either, because you’re only a human, not God, and the fact is, you were hopeful for more time, too). You hear, in their voice, that they came to you for help and, despite your best efforts, you just couldn’t deliver. That hurts as deeply as the kind of hurt of your worst broken heart—the one that leaves you a little broken forever because it never made sense to you. The same hurt as one where you still can’t even walk by the exact spot you were when it happened, because it makes you sick.

The only word I have to describe how it feels when someone says they are excited about college, and you know they’re likely not going, is sick. Or in another instance, they are not ready to die because their worry is, “But that means I won’t see you guys at the hospital ever again.” Or they plead with you to try something else (but there is nothing else).

We take care of many children with various problems, 2 of whom are currently the sickest kids I have ever seen in my entire career. Both with loving families, both who are just…sad. Who are we to strip people of their last hope? But on the other hand, is it fair to offer a solution that will have the same poor outcome, only with more suffering and less quality of life? Isn’t it our moral obligation to tell the truth without trying to either give or take hope? Easier said than done. All these questions are obviously not meant to be answered, because there is not one correct solution, especially when no part of it is clear-cut. That’s why they are ethical dilemmas.

Like any other person, I feel grief. But I then have to turn around and walk into the next patient’s room, as the patient’s doctor, not a grieving person, because they deserve the same care and my full attention, too.

The doctor guilt creeps right back in when wellmeaning loved ones say things like “I don’t know how you do it.” You feel guilty because you didn’t actually do much. You hope you did the medically and ethically responsible thing, but you didn’t change the outcome for that person. Overall, I’m at the balance between being thankful that I’m not too jaded to feel nothing (if I ever get there, something is wrong with me) and, simultaneously, wanting to run.

I looked down today and realized my white coat pocket pretty accurately sums up my life in the past 2 weeks: a mangled, coffee-stained reference book, a stethoscope with a dinosaur that lights up, a full beeper, a Sheraton pen, and an emergency fork. “Do no harm.” Many times I do not know what that means after all

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Everyone, at every level, is checking, rechecking, thinking, researching, asking questions, discussing, analyzing, and trying to help patients.

Medical Ethics in Pediatric Oncology

As a surgical oncology fellow, I have had the privilege and the opportunity to treat patients afflicted with malignancies of different etiologies, mostly within the abdominal cavity. Variety is one of the primary reasons I was attracted to my specialty: On any given day, we perform a liver or pancreatic resection or an extremity sarcoma excision or deliver heated chemotherapy into the abdomen for advanced peritoneal malignancies.

My interests and training are solidified by the collaborative relationships we have with multiple specialties, such as medical oncology, radiation oncology, and therapeutic interventional radiologists. Through this complex approach to oncology care, I am challenged by the patients referred to us following a devastatingly new diagnosis of cancer with hopes of a cure.

The breadth of surgical oncology introduces us to the wide spectrum of gastrointestinal malignancies, melanoma, sarcoma, etc. Within each specific cancer stage, I have learned that the biology of each cancer can be highly variable, and patients can recur having already received neoadjuvant or adjuvant chemoradiation as treatment for locoregional or distant metastasis. The personalization of cancer care is more elaborately expressed in multidisciplinary tumor conferences and clinical trials.

Starting the Process: I’m Sorry We’re Meeting Under These Circumstances

The truth is, we don’t have the answer yet. There isn’t a magic pill, vaccination, or preventive treatment to get ahead of every type of cancer. The approach we most commonly advocate is behavior modification and screening modalities that detect cancer earlier, such as regular mammography or colonoscopy screenings. Often there are some tumors that present at such an advanced stage that surgery is no longer an option. It is difficult to present that reality to a patient who may very well still feel healthy, and knowing that disease progression is inevitable can quickly transition that conversation to focus on quality of life.

When patients are referred to a surgical oncologist, there has been very little opportunity for them to accept a recent cancer diagnosis. The denial, the rationalization of blame, compounded by any attempt to explain to their loved ones what may be going on, is only about to become even more complicated. I firmly believe it’s important to take a step back, recognize there is a person in front of you, and address any obvious misconceptions before proceeding.

You Can’t See It All: Decisions for Surgery Are Complicated in Oncology

A reassuring interview tone versus one of judgment is a formidable foundation for trust in patient—physician communication. Being able to professionally address barriers to health literacy or delays in care is an important quality of any patient advocate. During my first few months of fellowship, I was dumbfounded by how long patient symptoms persisted without intervention, how physicianled work-ups spiraled, and how patients were inappropriately treated. It didn’t take long for me to reflect on my training in public health to quickly recognize that the disparities among my patients were also a reflection of the inadequate referral patterns and poor follow-up in our healthcare system.

Following any cancer diagnosis, patients understandably seek consultation and sometimes second or third opinions to see if they can undergo surgery to remove their cancer. A subtle distinction between surgical oncologists and other surgical specialties is our underlying training in oncology that marries the technical feasibility with an understanding of the biology of the disease.

There’s nothing more disappointing than operating on a patient who recurs or presents with metastases on their 3-month surveillance imaging. It’s unjustifiable, and surgery is not without considerable risks in these complicated cases. The psychological impetus for any patient is to “get the cancer out, now!” We commonly explain that certain aggressive cancers, albeit resectable, may benefit from treatment with chemotherapy or radiation up front instead of surgery. A treated cancer, which is now smaller with regression from nearby vessels or lymph nodes, makes for a greater likelihood that the surgical oncologist will remove all visible disease. More important, it allows for earlier treatment of cancer cells that may have already escaped the operative field to distant organs, such as the liver and lungs. Without our being able to guarantee a treatment response with upfront chemotherapy, patients can also progress despite treatment, and the reality is that they probably would have suffered all the risks of surgery without any real benefit.

Every surgeon will occasionally make an emotional decision about whether to proceed with an operation because of a patient. The current recommendation for the majority of stage IV or metastatic cancers is typically ongoing chemotherapy or enrollment in a clinical trial. Surgery is offered infrequently in these situations, depending on the type of cancer. When a young patient presents with an advanced cancer, the heroic efforts of a surgeon or other treating physicians may conflict with the standard of care, particularly if that patient shows some degree of stability or treatment response despite the relative contraindication to surgery.

It is hard to truly know if the cancer has responded to the chemotherapy and whether that will correlate to some degree of improved survival. Furthermore, if surgery could potentially remove all the remaining viable disease, when is the appropriate time to proceed if we aim to maximize the benefit of chemotherapy that may be working? These cases are best discussed in the setting of a multidisciplinary conference among experts in that specific cancer to determine a reasonable option. It’s important to anticipate the expectations of patients and their families preoperatively. Developing such an aggressive malignancy at a younger age increases the likelihood that the cancer will inevitably recur or progress despite our best efforts (patients included).

I have learned not to try to prognosticate a diagnosis prior to understanding more about a patient’s cancer. It is inherent that when patients learn that they have cancer, they immediately want to know how “bad” it is. Not all cancers behave the same, nor will they respond the same to treatment. There are some cases of metastatic cancer that the patient will inevitably succumb to. It is important to discuss the likelihood of that happening if there is a valid argument regarding whether any treatment should be prescribed considering severe comorbidities and decompensation.

At the same time, assessing the appropriate stage of cancer is more accurately done following surgery, and that can allow for additional information to be shared with the patient about their prognosis. It has been shown multiple times in the literature that patients don’t retain much about a conversation regarding their prognosis, and I tend to defer it until the postoperative visit, when the cancer has been pathologically staged.

In certain cases, what I do offer is that most patients are typically unresectable at the time of diagnosis of “X” cancer, and the fact that we’re able to proceed to the operating room is optimistic. Whereas most medical or surgical oncologists will provide prognostic information to the patient as a median variable, most patients will take that as an absolute number. The addition of a best-case, worstcase, and most-likely case scenario is a strategy that addresses the perception of that patient’s survival. A best-case scenario also preserves hope without being overly optimistic, and it has been my observation that patients appreciate knowing that certain difficult life decisions need not be undertaken if they can wait.

The personalization of cancer care is more elaborately expressed in multidisciplinary tumor conferences and clinical trials.

September 2017 | Oncology Fellows

Medical Ethics in Pediatric Oncology

Surgery in Oncology Is Not Always a Simple Decision