Cutting Through The Crap

Wednesday, October 15, 2008

Death With Dignity

Many years ago, a patient on whom I'd previously operated for breast cancer came to see me, with her adult daughter. She'd recently been diagnosed with pancreatic cancer, and she'd decided not to have any sort of treatment. None of her current doctors, she said, were ones with whom she felt comfortable sharing her concerns, her desire. At some level, I was touched that she trusted me with her request: making personal connections, establishing trust with my patients was something I valued. What she asked was that I provide her, over time, with enough narcotics and sedatives that, should she choose to do so, she'd be able to take her own life.

In my state, Washington, there's a ballot measure allowing physicians, under very specific conditions, to provide lethal doses of medicines to certain small subgroups of terminally ill patients. Based on a law in place in Oregon for ten years, studies of which have not revealed abuse (and, in fact, a rather low incidence of use), the proposition has, of course, provoked strong opposition. Officially, the state medical association opposes it, and claims its membership overwhelmingly share that view. The fact is that a little over half of the members, myself included, favor it. I realize it's a very difficult issue. And yet, in virtually every hospital in the country, it happens all the time, in ways not very different from what the bill proposes.

I've written about this, if tangentially, on my other blog, too. There are no easy or universal answers. And that's the point. At the time of approaching death, doctors are often at a loss: death, by definition, is a failure for those whose job it is to heal. And yet the job isn't over; we can't turn away. It's generally accepted that a person ought to have the right to refuse care for themselves. Withdrawal of "active" (for lack of a better word) care is a regular occurrence, both in the situation where an alert and cogent patient requests it, and where family does so, for a patient no longer able to decide for him- or herself. It's the former situation -- a mentally clear patient -- to which the "death with dignity" laws apply.

In hospitals, in addition to withdrawal of care, drugs are given for comfort -- narcotics -- wherein the main goal is relief of pain but with the understanding -- because it's part and parcel of the effect -- that the arrival of death will be accelerated. Sometimes there's a sort of dance around that fact, and most certainly there's a need to be certain everyone -- all care-givers and family -- understand and agree. It happens, and to some extent it's extra-legal. It's not euthanasia, it's comfort care. But it's no secret what's happening.

"Death with Dignity" laws take that concept and make it above board, and out of the hospital. I understand how some recoil from it; the law allows not only for doctors to refuse to participate, but also that hospitals have a right to prevent their staff from doing it as well. As it should. But in my view, people have a right, in one of the most difficult, personal, momentous and fraught times of their lives, to make decisions for themselves. To make their own decisions about their own suffering. Not all doctors, of course, would feel right about being drawn in to providing the means. Nor would they have to.

As I read the bill (linked above), I was struck by the stringency of it, and by the complexity of the requirements upon the doctors involved. In fact, it could be -- not to put too fine a point on it -- a pain in the ass. And yet, the airwaves are filled with disinformation and dire warnings: it can be carried out even if the person is depressed (it can't: when depression is suspected, mental health referrals must be made), it can be foisted upon the most vulnerable (I don't see how it can), the sufferer need not notify anyone of his/her decision (that's true: but the law requires that the caregivers encourage it, and document same.)

The subject is difficult and painful. I could write volumes on it; in a way, not to do so is to treat it too simply (if needed, I can enlarge upon my thoughts in comments.) I fully sympathize with those who oppose it; but I don't sympathize with the idea of preventing others, who disagree, from having the option. Realizing it sounds a little flip: if you don't believe in "death with dignity," don't avail yourself of it; nothing forces it on anyone. And don't judge the suffering of others, and how they choose to deal with it.

[For a thoughtful panel discussion of the Oregon experience, read this. It's worth it if for no other reason than to remember, in this political season, that difficult issues can be discussed respectfully by people who disagree with one another.]

10 comments:

Frank Drackman said...

Wow, and I thought my Blog was creepy. Isn't there some Oath, Hippo-something or other, about not giving deadly drugs...Yeah, I know, it forbids surgery, and abortions, and its not legally binding anyway. How about that thing that guy used in "No Country for Old Men"? alot of people get dysphoric with Narcs. Oh yeah, I'm still waiting for your Electoral Vote prediction :)

Justine Hemmestad said...

Dr. Schwab,
This is a very thoughtful post.

belovedparrot said...

I've always wondered why it's considered humane to kill an animal/pet because its suffering is too great, yet we don't allow the same for humans.

Like abortions, it's a personal decision that should be honored.

Frank Drackman said...

But using the same logic, since Animals don't have abortions, then we shouldn't either? I mean, even a King Cobra won't get an abortion. O.K. I know, plenty of species eat their young, so my argument falls apart there...Just sayin, replace your lethal dose of wateva with a Captive Bolt device like Bessie gets at the stockyards, cause its the same thing.

Devorrah said...

My dear Uncle George died a few days ago of lung cancer, and even with lots of narcotics and sedatives it was still not an easy death. He was 84, and he chose not to treat the cancer (he died a week after diagnosis). Even with the best palliative care available he died in air hunger, and it was a mercy if the drugs accelerated his death. If he had chosen to consciously speed his own death I think that would have been an understandable and reasonable choice.
And Frank, killing a mammal for it's meat isn't the same, as we didn't serve Uncle George up at the memorial service.

Sid Schwab said...

Frank: I have a hard time telling if you're being facetious. When Bessie has cancer and is miserable and asks to be put to death, then it'll be the same thing. And when two of her fellow cows agree, the ones with medical degrees, and they put their hooves on the documents, we'll be on the same side.

Frank Drackman said...

Fa-cet-i What?!?!? Whenever one of y'all Yankees use one of those $5 words I know theres gonna be a dead grandmother somewhere, but Kudos(hows that for a $5 word?) for your Bovine Imagery. Cows with M.D.s putting Humans to death!! I love it, oh yeah I think Chik-Fil-A already did that one. Y'all got Chik-Fil-A's Up There in Canada?

Sid Schwab said...

No, Frank: the analogy (look it up) was to bovine on bovine action.

MargaretWV said...

"And yet, in virtually every hospital in the country, it happens all the time, in ways not very different from what the bill proposes."

That's what we're pinning our hopes on -- me, my husband who was diagnosed with metastatic stomach cancer last year, and our two young children.

Thank you for speaking out on this. Sure wished we lived in Oregon, though.

Anne said...

Very well put. Visit www.yeson1000.org and please vote YES on I-1000.