The Judgment of Solomon

As a cancer doctor, I’m no stranger to asking patients with a life-threatening malignancy about their wishes. My question generally goes something like this: “Going forward, do you want to pursue intensive treatment, or forgo it in favor of enjoying the time that remains to you, with relief for your symptoms as needed?”

Asking this question is an intrinsic part of my job. But when I found myself having to ask it of a family member, I felt shaken. This was different.

My family’s patriarch, Solomon, was a decorated World War II veteran and a successful self-made small businessman. His affability lit up the room; I never heard him say an unkind word about anyone. As a youth, Sol immigrated from Poland, thankfully escaping the Holocaust. He loved his family unconditionally, and it was mutual.

I was lucky enough to marry into his close-knit family, who enjoyed multigenerational vacations together. Sol saw me as one of his clan.

Even in his late eighties, Sol had the vigor of a much younger man, as his brisk walks attested. But as a child, he’d had an infection that led to rheumatic fever. Unfortunately, antibiotics didn’t yet exist, and the contagion harmed two of his heart valves. Over time, these valves grew so faulty that his life was in peril.

Sol’s trusted cardiologist advised immediate surgical repair. He recommended that the procedure be done at the local community hospital.

Sol found it hard to fathom that a long-ago infection now required this life-saving operation.

He reached out to me to ask, “Is surgery my only option?”

I felt honored by his faith in me, even as I struggled with my fear that we might lose him and hesitated over whether, as a family member, I should involve myself in his care.

My wife, encouraged me to help, saying simply, “Please find out what’s best for Sol.”

I spoke to Sol’s doctor and read his chart. His cardiologist viewed his valve disease as a straightforward plumbing problem—one that must be fixed. He didn’t consider any other alternatives, nor the risks of surgery for a man of Sol’s age and condition.

Knowing that Sol’s life was at stake, I believed that a repair this complex should be done at a hospital particularly skilled in this surgery. I referred Sol to a talented colleague—a cardiac surgeon who had the expertise that Sol needed.

His consultation revealed that the repair was more complicated than suspected, with upwards of a 20 percent mortality risk.

Both Sol and I found this prospect unnerving.

“What’s next?” he asked me.

I in turn asked my colleague, “What would you do if it were your family member?”

“I’d refer them to a surgeon’s surgeon—someone who has the best reported outcomes,” he said immediately.

Only two surgeons fit the bill, and by chance, one of them practiced at a nearby tertiary-care hospital. I asked Sol if he were open to another consult.

Before answering, he asked his children and his wife, Rachel, herself chronically ill and frail. Like the rest of the family, she wanted what was best for Sol. So he set out for the hospital with Rachel, my wife and I, and two other family members in tow.

We all were counting on the hospital’s prowess with this procedure to make surgery the sound, obvious choice. But that did not happen.

The surgeon, whose unassuming manner belied his glittering reputation, carefully examined Sol and studied his records before sharing the good news—and the bad.

The good news: Surgery could correct Sol’s problem. The bad news: It came at a sizable risk of death—even at this hospital. Also, if Sol were to spend a long time on the heart-lung machine, that could compromise his cognition and lead to extensive nursing and rehabilitative care.

Before we headed home, I privately asked the heart surgeon about Sol’s prognosis.

“Although he doesn’t have symptoms yet, they’ll probably appear within several months,” he said quietly. “At that point, he likely won’t have more than a few months to live.”

Feeling drained, we made the short drive to my home, where we held a family meeting—Sol, Rachel, my wife and I, and the rest of the family.

The room was quiet. I’d held many meetings like this before, but never one with my own family. I felt discouraged.

“Sol, do you have any questions?” I asked. “Do you understand the risks and the benefits of the surgery?”

“I don’t have any questions,” he replied. “I know what my choices are.”

“Can you tell us what your choice is?” I asked, hoping that he would pick surgery.

“I do not want surgery,” he said.

Looking back, what struck me, then and now, was the meeting’s brevity. Once Sol had spoken, the die was cast, without much discussion or debate.

His was not a reckless decision but one grounded in his perception of his own best interests. Sol worried that his choosing surgery would prevent his caring for his wife of six decades. The resolute look on his face conveyed both his decision and his devotion to her.

I turned to my wife for her opinion.

“Listen to Sol,” she said firmly, “and let’s do what he wants.”

In that moment, it seemed clear that Sol was choosing quality of life over quantity.

I never shared my disappointment over his decision with anyone else. Together, the family prepared for the worst, putting in place all the support and care that he might need. We couldn’t imagine life without him.

But you never know how things will turn out.

The predicted heart symptoms slowly emerged, but month after month they were managed with medicines. And echocardiograms showed that Sol’s heart disease was not worsening. He dodged the problems that his surgeon had most feared.

With each passing month, our spirits rose, and our dread faded away. Perhaps serendipity, prayer, Providence or slow progression were at play. But Sol also had a compelling reason to carry on: To be there for his wife.

He lived another five and a half years—one year longer than Rachel. So Sol got his wish.

He lived independently at home until just days before his death, and throughout that time he enjoyed travels and visits with family, especially his grandchildren. He stayed engaged with news, gossip and community affairs. He read his local paper daily, never tiring of weighing in on town politics.

I will never forget the lessons that Sol taught me.

First, that even in complex medical cases, an individual’s intuitive sense of what’s best for them may be the best guide to treatment.

Second, that when I ask patients their wishes about quantity of life versus quality, it’s not necessarily either/or: As I believe happened with Sol, quality of life may well add to a person’s quantity of life.

Third, that the best-laid treatment plan, whatever it may be, is more powerful when your patient has an overriding reason to live.