Throughout the year, IAHPC board members contribute a range of opinion pieces and other thought-provoking articles to the IAHPC Newsletter. Now it’s the turn of Dr. Eric Krakauer, Assistant Professor of Medicine and of Global Health and Social Medicine at Harvard Medical School, US, and Visiting Assistant Professor of Medicine at the Ho Chi Minh City (Vietnam) University of Medicine and Pharmacy. He has lectured and published on integration of palliative care into public healthcare systems in Vietnam, Nepal, Malawi and Rwand,a and on clinical and ethical issues in implementation of palliative care in low- and middle-income countries.
What is palliative care? This question has provoked extensive debate and diverse opinions. Those with a special interest in the dying argue that palliative care is primarily end-of-life care. Others argue that it is for people with life-limiting illnesses but should be offered ‘early’ in the course of such illnesses along with often noxious disease-modifying treatments. Disagreement continues despite the guidance provided by the World Health Organization (WHO) 2002 Definition of Palliative Care.
Yet the text of this definition suggests another, more essential question: Whence palliative care? Asked another way, where did or does palliative care come from? Why is it necessary? What called it forth into being? And does this call and this necessity persist?
The WHO definition states that palliative care is “the prevention and relief of suffering”. Preventing and relieving suffering is palliative care’s most essential task. Palliative care attends to suffering, to the suffering of sufferers. It is not defined by a bodily organ, such as the heart or lungs or kidneys, nor by an organ system such as the nervous system or endocrine system, nor by a category of diseases such as malignancy or infection or auto-immunity, nor by a specific skill such as surgery or radiology or pathology. Rather, it is a response to suffering. It is not a response simply in that it reacts to a specific form of suffering after it already has occurred. Rather, it is a calling, a vocation. It is a response in that it hearkens to the voices of the suffering and seeks both to prevent and relieve suffering. Thus, it is not just a profession with a set of rules of professionalism. As a vocation, it requires careful and constant attention to the voices of the suffering. Palliative care is a healthcare discipline defined primarily as a calling rather than as a ‘specialty’: a branch of the rational division of healthcare labor.
Thinking of palliative care in this way can resolve many of the aforementioned debates. If there are places in the world where a given type of suffering is well prevented or relieved by healthcare and social supports currently available, then palliative care need not attend to that type of suffering. But where said type of suffering is not well prevented or relieved, how can palliative care ignore this, even if it is a type of suffering not typically part of its purview? Where the wounds of burned children are debrided without any analgesia, can palliative care ignore their suffering because it is acute rather than chronic? Where illness has made a patient and her family destitute with nothing to eat, or no money for transport to the clinic or for her children’s school tuition, can palliative care ignore this social suffering because an effective response may be complex or expensive? Where no care is available for a patient who has no ‘life-threatening illness’ but is quadriplegic after a traumatic cervical spine injury, can palliative care ignore this patient?
It’s your call.