The Pharmakon

The physician plays a unique role in this very ancient ritual that somehow our culture has shortcircuited. In our Grimm's story the physician is instructed to be very clear to the patient when he is expected to die and he must use the words, "there is no remedy that can save you and no physician in the world can cure you". These words are deliberately very clear. Yet few physicians can say these words to his patient even when it is most obvious the words are correct.

In alchemy the term pharmakon is the mercurial agent that gets the reaction going. It is the change agent. It also has a paradoxical meaning;at once meaning remedy and at the same time poison. In homeopathy often the remedy is through treatment with what at larger dose would be a poison. Arsenic is sometimes used to treat like symptoms that resemble arsenic poisoning. In our story the physician is the pharmakon, both the poison and the remedy. The poison is of course the news that there is no cure; the remedy is the same news. But how is this perceived as a remedy?

We need to look at the process of dying from a particular standpoint. If we look at the heroic structure that is collapsing because the person is ill unto death at what point is the transition from heroic battle to acceptance. What does it look like? When I worked in a hospice inpatient unit a family was with the father who was dying of liver failure. He was brought there to die but the family was in between acceptance of this reality and the heroic pathway. As the father's breathing became labored and it was clear the man was dying the wife panicked and asked if she should send him to the hospital to be treated. This last minute doubt is very common and in this day and age much could be done to drag out the dying process without substantively change the underlying disease. In this situation the medical director was nearby and was asked to speak with the family. I was very aware the physician was assuming an archetypoal role. Perhaps it was as palpable to her. She proceeded to tell the family she could send their loved one to the hospital and they would engage heroic measures to save his life but it would cause more suffering while not likely changing the outcome. He would still die only on machines and involving invasive procedures and more pain. The family chose to keep him in the unit and provide only comfort measures.

I watched carefully the wife's reaction when told by the physician that there was no more that can be done to save her husband. At first she broke down into tears as did the rest of the family and then she gathered her strength and moved close to her husband's side and sat with him. She then called the rest of her family to come to the unit to say their goodbyes. In a short time she abandoned the heroic stance that was no longer serving herself, her husband or her family. So in that sense the physician as pharmakon became the catalyst for the transformation away from the heroic pathway. The physician was the poison (the bitter news) and the remedy (the transformation to acceptance).