Introduction; an article vs. Assisted Suicide by S. Busch

Consultant, Not Counselor

S. N. Busch

During a recent case in which I was a circumstantial caregiver for an elderly patient receiving home-based palliative care, the boundaries of medical authority became starkly apparent. As New York's Medical Aid in Dying Act awaits Governor Hochul’s signature, questions about how physicians define their role in end-of-life care have never been more critical. 

The new physician was called in to evaluate the possibility of introducing IV fluids. After a quick glance at the patient and the data we presented, he asked to speak outside—and immediately adopted a psychological stance, urging acceptance of decline and recounting cautionary tales of families who "forced" care. He dismissed carefully documented observations, referring to them as "an ICU you have going on in there," and implied denial. We clarified that the previous doctor had requested the documentation and asked for it each time he had visited. But the new one stated, "I will determine… Don't try to be doctors. I am the doctor." The program's fixed schedule (a physician every X days, a nurse every Y, a social worker every Z weeks) was presented as immutable. Only after digging in our heels against the rigidity of the schedule ("... So we let the patient dehydrate until the next scheduled visit?") and the prescriptive worldview, did he offer a superficial "We don't give up on anyone…" before leaving.

We sought emergency care after the patient developed a fever within hours. He improved dramatically within 48 hours of arrival in the ER, progressing from unresponsive to communicating discomfort and needs.

Another case involved a patient with endocarditis who was being pushed towards a choice between biological and mechanical valve replacements. A cardiothoracic surgeon was summoned by the internist. He answered all the patient's questions, especially about the ramifications of each decision, neither of which sat well with the patient. The on average once-a-decade repeated biological valve replacement was not an attractive option, and being permanently on anticoagulants frankly frightened him, given both his tendency to clumsiness and having lost someone close to him to an overreaction to the same medication he'd be put on. While he acknowledged that there were no shared genes, the psychological barrier was present. The surgeon said to think about it. He later returned, "I just examined your studies – I hadn't examined your case myself earlier. I believe I can repair your valve." He explained what the repair would involve, and also shared that we should understand that it was him and us against the whole hospital. We gave him the go-ahead. Our joint decision stunned other medical staff, who asked in passing, "So, what did you choose?" when they saw the patient was post-op — and were shocked when he said that it was repaired, not replaced.

The contrast between these two clinical encounters illustrates how the integrity of medical care depends on physicians maintaining professional boundaries, offering clear, expert consultation without shifting into personal counseling, so that patients retain genuine autonomy in complex care decisions.

That cardiothoracic surgeon did a "world-class" job according to the patient's cardiologist and internist. The surgeon was essentially acting as an exceptional medical craftsman. He respected the psychological challenges, and didn't try to counsel his patient out of them. He also went to bat for his patient, resolving bureaucratic issues that had delayed the valve repair by preventing an infected tooth from being treated.

One physician expanded his medical problem-solving to the point of advocacy, while respecting boundaries; the other contracted his medical assessment while overstepping into counseling.

When patients say, in whatever form, "Give it to me straight, Doc," the request may reflect a desire for clarity, or for guidance. But it's often interpreted as a cue to narrow the conversation, or to translate uncertainty into preemptive finality. The line between clinical interpretation and personal framing can shift, especially under cultural, societal, systemic, or political pressures, given the ever-more multicultural makeup of both service provider and service recipient. That shift is rarely acknowledged when it happens, and ay, there's the rub.

Physicians face many pressures: time constraints, systemic demands, institutional expectations, and patient hopes, in addition to their own cultural and religious backgrounds that can subtly influence how they present options or outcomes. Patients sometimes expect or ask physicians to provide guidance on existential or spiritual matters, but even then, physicians should clearly direct them to chaplains, counselors, or social workers who specialize in that support. The goal must remain clear communication grounded in medical expertise, coupled with respectful acknowledgment of the patient's broader life context, and appropriate referrals when needed.

And policymakers should let physicians reclaim what brought them to medicine in the first place: offering not closure, but care: Medical Aid in Living.