A Moral Compass in Cancer Care: Stories from the Oncologist's Perspective

BY Prof (Dr) Sanaullah Kuchay

In recent years, significant strides have been made in the field of cancer treatment. We've transitioned from traditional drug-based therapies to more advanced approaches like molecular targeted therapies and immunotherapy. While these innovative treatments offer hope to patients, it's crucial to consider the ethical implications, especially in our context where over 60% of patients are diagnosed at late cancer stages, often with limited survival prospects. It's a well-known fact that many individuals from lower-middle-class backgrounds cannot afford the high costs associated with these cutting-edge treatments.

To shed light on this issue and provide a realistic perspective to both patients and physicians, I want to share some of my experiences as an oncologist. My intention is not to dictate specific guidelines for the use of these expensive therapies but rather to encourage ethical decision-making in the initial stages of treatment planning.
My journey began in 1990 when a distressed young man, about 34 years old, approached me seeking help for his ailing mother. He passionately implored, "Please give my mother a lethal injection." My immediate response was, "Are you out of your mind?" He explained how, a decade earlier, another ‘renowned doctor’ had proposed such a measure, which he vehemently rejected at the time due to his emotional attachment. Now, a decade later, his mother lay bedridden with bedsores, and their family was struggling to make ends meet due to her prolonged ailment. This incident deeply shook me and raised questions about the ethical dilemmas faced by oncologists.

Throughout my career, I encountered numerous patients suffering from incurable diseases, enduring terminal phases that sometimes spanned years or even decades. While I witnessed a few miraculous recoveries, I was haunted by the ethical implications of the decisions we make as physicians, particularly when expensive treatments are involved.
Upon joining the cancer care services at SKIMS in 1992 and later heading the department at SMHS Hospital, I felt the emotional pain of families desperately seeking financial assistance. We initiated a cancer fund, but it was eventually discontinued when the state government introduced a grant-in-aid scheme under the Cancer Treatment and Management Fund for the Poor, offering a maximum grant of INR 50,000 to eligible patients. This helped many underprivileged patients access necessary treatments.

However, this grant was insufficient to cover the costs of treatments like immunotherapy and targeted therapies. For more financially privileged individuals, the cost of these treatments may not be a significant concern. But for economically disadvantaged families, it becomes a double-edged sword. It's well-established that the chances of curing stage 4 cancer are almost negligible, and these costly treatments only offer a few additional months of survival compared to free treatments provided under Ayushman Bharat, a government healthcare scheme.
As an oncologist, we face a dilemma when deciding whether to recommend these expensive treatments for poor patients. We must consider the grim reality that there is no cure for stage 4 cancer, and the family will bear both the financial and emotional burdens. That renowned doctor's once-unthinkable decision of administering a "lethal injection" began to seem justifiable in this context.

To illustrate this issue further, let's examine some cases I encountered recently. I met a 32-year-old woman with stage 4 breast cancer, diagnosed with bone metastasis. Her husband's monthly income was just INR 25,000, and they had young children, elderly parents, and a younger sister to care for. Her prescribed immunotherapy cost around INR 2.5 lakhs per month, in line with international guidelines. However, the financial burden was immense. This led me to question the purpose of treatment. Should we opt for free treatment under Ayushman Bharat, which would extend her life without the possibility of a cure, or pursue the expensive treatment, which might offer an additional 15 months of survival but at a great cost to the family?

In a moral crisis, I concluded that favouring the education of two young children and supporting the family's future was the better choice. The marriage of the sister could be postponed, but the education of the younger ones was crucial. The family's ability to maintain their living and healthcare for their elderly parents was paramount. In choosing to continue the costly treatment, the patient would still face an inevitable outcome, but the family would be better equipped to cope if she received free treatment under Ayushman Bharat.
Another case involved a 56-year-old man with lung cancer who received immunotherapy for 27 months. After his passing, I met his widow, who had lost her husband and their family's livelihood. The family had to sell their home to finance the treatment, resulting in the abandonment of their children's education and a bleak financial situation. The suffering of this family, which was once content, was a direct result of the treatment decision made without proper counseling and guidance.

In another distressing case, a man spent approximately 40 lakhs on his father's lung cancer treatment, exhausting all resources and even contemplating selling a kidney to clear the debts. These heart-wrenching stories emphasize the need for more responsible decision-making by physicians.
In conclusion, the cost of treatment must be justified by considering not only the outcome for the patient but also the impact on the patient's family. While it is our duty to provide care, we must carefully weigh the implications of costly treatments, especially in the context of lower socioeconomic status.

In our pursuit of clinical excellence, we should revisit the fundamental principles of ethical decision-making. We should not rush to prescribe expensive treatments, especially when patients lack medical insurance. Instead, we must prioritize the patient's well-being and the financial stability of their family. Understanding the economic status of the family is essential when making treatment decisions.
In our region, where most patients are uneducated and have limited knowledge about diseases, the responsibility falls squarely on the treating physician to make rational and ethical decisions, especially for patients with incurable cancer. We must not only follow international guidelines but also adapt our recommendations to the financial realities of our patients.

In light of the conflicts of interest in the medical field, it is essential that patients or their attendants seek a second opinion from another oncologist when facing expensive treatment options. This step can help clarify any doubts and ensure that the best interests of the patient and their family are at the forefront of the decision-making process.

As professionals, it is our responsibility to make informed, ethical, and compassionate decisions that prioritize the welfare of our patients and their families. It's time to reevaluate the way we approach cancer treatment and ensure that our decisions align with the principles of medical ethics and human compassion.

Prof (Dr) Sanaullah Kuchay is Ex HoD, Radiation Oncology, GMC Srinagar