JOURNAL OF PALLIATIVE MEDICINEVolume 4, Number 2, 2001Mary Ann Liebert, Inc.

“But I Have Promises to Keep”

ROBERT LYMAN POTTER, M.D., Ph.D.

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IN KANSAS CITY a group of 75 physicians havemet intermittently over the past 3 years to pro-

vide leadership for Midwest Bioethics Center’sPathways Project to improve care at the end-of-life. We asked what we ought to expect of our-selves as excellent end-of-life care providers fordying patients. We wanted to say something thatwould move us beyond being technological wiz-ards and toward being compassionate guides.Our plan was to create a picture of good pallia-tive care to share with the medical community asa model of best practice.

Approximately 20 physicians committed to theproject. After working in small groups and thengathering the results into one document, we dis-covered that we had created 16 pages of idealizedexpectations that none of us could completelymeet. The most zealous moral saint would strainin vain to meet all of our standards of excellence.We knew that our colleagues in practice wouldreject these ideals as a set of burdensome de-mands rather than welcome them as ethicalguides to action.

Two of our more pragmatic members sug-gested that we make a short list of the bare min-imum expectations: a core of commitment that wemight actually be able to achieve and, thus, keepour promises to our patients. None of us approveof minimalist morality, but since we were tryingto show how ethics can be practical we agreed toredesign our expectations as the “essence of ex-cellence.”

We created the initial 16-page document in amere 2 weeks, but we slaved over the concen-trated statement for months. We labored overevery sentence, phrase, metaphor, word, and syl-lable. We argued until our mutual pledge to civilexchange was frayed. Patience wore thin, and col-

legial openness threatened to regress to compet-itive partisanship. This is no laughing matter. Ina pluralistic society where multiple moral com-munities interact, reaching agreement on moralvalues is a severe test for the democratic process.As respectable doctors we were not accustomedto being challenged on every word, especially notby our professional colleagues. We learned thatthe hard work of moral discourse is the only wayto achieve an ethical consensus.

Our plan was to display these promises in anattractive picture frame that could stand on atable or hang on a wall in the waiting room or ex-amination rooms of our offices. These were dis-tributed to the 20 physicians who worked on theproject. When surveyed 6 weeks later, only 5 ofthe 20 physicians had displayed the promises.Some admitted their own reluctance to deal withthe subject openly with patients. Others reportedthat their colleagues or staff would not allow thepromises to be displayed. It is hard to be held toany promise.

These words are not copyrighted. Use them asyou are able. If you do not like this model, thenbuild your own. The moral discourse process ofreaching consensus is worth the trouble. We sin-cerely recommend that you work over these lineswith the same intensity as we did, as a commit-tee of word artists painting a poem. If you wantto use a different color word, brush it in so thatyou may claim these promises as your own. Ourfinal and strongest recommendation is that youavoid medical jargon.

The final product still contains disputed words.For example, is “dying” the right word to use tograb the attention of the terminal patient, or doesit wrongly suggest to every person who reads itthat they may be on the way out? Ought the word

Special Article

Midwest Bioethics Center, Kansas City, Missouri.

“pain” appear somewhere because surveysdemonstrate that patients are very interested inhaving their terminal pain well relieved? Is “keepyou comfortable” a strong enough assurance tothe fearful patient? “Hospice” is the one exampleof medical jargon in our statement. Should theword remain or should “palliative care” or “com-fort care” be substituted?

This is our unfinished final product:

My Promise as Your DoctorWhen you are approaching the end of your

life, I promise that I will: � tell you when I think you are dying� respectfully listen to your concerns� help you make choices about your care

� do my best to keep you comfortable� talk with you about hospice care

When health care professionals commit topromises such as these, palliative care will bemeasurably advanced, and we will be able to hearthe voice of the dying patient say, “Thank you.”

Address reprint requests to:Robert Lyman Potter, M.D., Ph.D.

Program AssociateMidwest Bioethics Center1021-1025 Jefferson StreetKansas City, MO 64105

E-mail: rlpotter@midbio.org

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