“I like to say that I am a therapeutic nihilist,” our attending stated, in the matter-of-factly way he was prone to speaking on rounds. It was admittedly a strange way to describe oneself as a critical care doctor. After all, to call yourself a nihilist is, in a certain way, to suggest that you don’t care. We often characterize nihilists as those who, faced with the conundrum of creating meaning in a vast and uncertain universe, opt out: in our colloquial imagination, they are those whose willful abandon betrays a lack of investment.
Or at least, I would have thought so, prior to working with him.
It was, all things considered, a relatively calm time in the medical intensive care unit. We hadn’t yet had any of our patients pass away. But we did have two patients, more tenuous, who we were worried about.
We were in the throes of “goals of care” conversations with these families. “Goals of care,” a phrase often used in health care settings, is a way that we have come to describe talking with patients and their loved ones about what they would like at the end of life in order to meet their needs as patients. In their best form, these talks involve shared decision-making: we learn about who people were before they were sick, what they liked to do, who they were outside the context of artificial lights and endlessly beeping monitors. In the circumscribed way that you can know someone when you’ve only met them during the worst days of their life, we try to understand our patients and their perspectives.
In critical care, what is often at stake in these conversations often boils down to optimism and pessimism, hope or despair. They are also, fundamentally, about uncertainty.
“At what point,” our attending asked us that day, “do we declare medical futility? How certain would you have to be of a bad outcome?” We spent many afternoons discussing situations of varying levels of hopefulness. There were patients we wanted to do well, hoping against hope despite the odds being very much not in their favor. Uncertainty formed a pit in our stomachs, willing us to face uncertain outcomes. What we did then was focus on the process of exhausting all possible outcomes, as well as the delicate work of navigating the mixture of feasibility and desire that often characterizes choices at the end of life.
Often, I found myself thinking back to our conversations about nihilism. Therapeutic nihilism might be described as one approach to the moral aporia of sitting in the balance between life and death. Rather than describing a lack of care, it represents an investment without guarantees. In other words, it calls for a measure of doing the right thing where we focus not on outcome — whether or when the patient lives or dies — but process: doing right by the deep and painful process of grieving, shepherding people through the liminal terrain of the end of life, nestling into clinical decisions which may not affect the inevitable outcome but matter insofar as they may bring peace.
As I round out this first year of being a physician, I find myself drawing heavily on the concept of therapeutic nihilism — not as a narrow descriptor of my own orientation but rather as one of many poles on the moral spectrum. This last year — as have all my years of medical education — has involved a litany of implicit moral lessons about the role of the physician. Most important among them has been the recognition that what we do is less about being right — though surely, that matters — and more about doing right by others, accompanying them in their journeys, marshaling the resources (cognitive, emotional, material) we have available to us to do so. When what we hope will occur may not always hope to pass, our assurance of having given our best is often all we have.