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Thursday, June 13, 2002I'll throw in an anecdote here, because I found it food for thought. A friend of mine had her medical insurance through one of the largest U.S. HMOs. She unexpectedly became pregnant at the age of 37, and the nurse-advisor recommended insurance-covered amniocentesis because of the higher risk of age-related genetic disorder, Down syndrome in particular. My friend, because she had no intention of having an abortion in case of Down syndrome, declined the procedure as a waste of time and resources. What followed, according to my friend, was a long bullying lecture on the social irresponsibility of taking the risk of having a child with Down syndrome. The secondary implication was that my friend was of course entirely too stupid or naive to understand the difficulties of caring for such a child. Knowing my friend, this incident for me has high comic import. At this point in the story, I know what's coming next. No one who is any judge of human beings would have sized up this woman as the sort who could be profitably bullied. The advisor will be subjected to the verbal equivalent of being grabbed by the collar and smashed up against the wall. The advisor will end up stuttering and back-stepping. The subject will not be raised again. But how often is this sort of thing played out with a less stalwart and less pyrotechnic leading lady? It is in the interest of the HMO, a private company, to promote abortions rather than the birth of children with genetic defects. This sort of thing is played out all too often, and not just in the realm of abortions. I've seen women who were bullied into taking estrogen when the dogma of the day was that it was all benefit and no risk. I've seen elderly people bullied into cardiac catheterizations they didn't want. I've seen more people than I can count bullied into taking cholesterol lowering medications. Most of us bully smokers, drinkers, and those who are overweight. We're taught to do it in medical school and residency. "Still smoking?" the attending would say. "Read them the riot act." Unfortunately, we are too often likely to use the same riot act technique for anyone who balks at our recommendations. I know I've been guilty of it. I've also been on the receiving end of it as a patient. This attitude is rarely beneficial. The smoker knows smoking is harmful. He'll quit when he's ready. The overweight person knows he's fat. It's only cruel to treat him with disdain and disapproval. He'll probably only eat more as a result. Ditto the drinker. Bullying people into treatments they don’t want only fosters a loss of autonomy and a contempt for traditional medicine. Both probably have something to do with the popularity of "alternative medicine." But, when we enter the realm of life and death, this can take on an especially sinister tone. It's the main reason we need to be on guard against the movement for physician assisted suicide, for even when a doctor isn't being an out and out bully, his personal biases can have a significant impact on patient decisions. Moira Breen's friend was lucky. She could defend herself against the bullying of her nurse adviser. Imagine if she had been a frail, elderly woman with no family to support her. Suppose her only social outlet was coming to the doctor. Maybe he reminds her of her deceased husband. Maybe she just finds his company delightful. She needs a reason to come to the doctor, so she complains about her arthritis, or abdominal pain. All the time. The doctor is trained to treat the complaint. He gives her pain medication after pain medication, but she still complains. He sends her to specialists. She still complains. She senses his frustration with the persistence of her symptoms and mistakes it for frustration with her. It makes her feel anxious, and maybe a little sad, because she really likes him. She starts to feel that she's a burden. She suggests one day to the doctor that she would be "better off dead." If physician-assisted suicide were legal and widely accepted, the doctor would be all too likely to seize the option as a good solution. He would likely feel frustrated and anxious about failing to rid her of her pain. If she were silenced, his pain and frustration would be gone. Neither the patient nor the doctor would be overtly aware of their underlying motivations. Once they start down the road to assisted suicide, such a patient would find it difficult to turn back. She wouldn't have the fortitude to risk her doctor's disapproval. This isn't such a far-fetched scenario. (I think it happened recently in Australia, but in that case it was publicity the patient craved, and it was the influence of family and euthanasia activists that led her down the road to suicide.) Many lonely elderly people come to the doctor to just talk. Sometimes the motivation for their visits is obvious, but a lot of times it isn't. A lot of times, they aren't able to fully acknowledge the motivation for their visits even to themselves. These are the people who are difficult to treat, and they are the ones who would end up being "assisted" to death. They are also the people who would be most susceptible to the suggestions and biases of their doctors. "Bullying" in this case would be too strong a word, but subtle physician influence would certainly be a factor. Putting You Out of My Misery: Steven Den Beste calls this woman's actions the ultimate sacrifice. The sacrifice that this 63 year old woman made was to take the lives of her two terminally ill sons who were living in a nursing home. They were both in the advanced stages of Huntington's disease. Relatives described their condition as deplorable: "They were like babies," said Janelle Scott, Carr's sister-in-law. Their only living sibling, 38-year-old James Scott, is in the early stages of the disease. He said his brothers, riddled with painful bed sores, had been in and out of nursing homes, were miserable and could only mumble to each other. The news reports don't say whether or not the brother's mumblings were understandable to those around them. No one records how they felt about their condition. We do know, however, how their mother and their executioner felt: Arrested by the officer responding to the call, the mother said she shot her sons because she didn't want them to suffer anymore, police said. The key words there are she didn't want. She didn't want to see them suffer anymore, not they didn't want to suffer anymore. It was her pain, not theirs that she was ending. Den Beste sees this as a noble thing, and a justification for assisted suicide. However, even his arguments are more about relieving someone else's pain, than relieving the patient's pain: This happens a lot more than most people realize. Murder-suicides among old people are common. One old person is caring for another (usually a spouse or sibling) who is severely crippled (quite commonly with Alzheimer's) and eventually reaches the point where the person they knew and loved is gone, leaving an empty-but-breathing body behind. It hurts too much to see what had become of a once-vital person, and so the one who is still competent will murder the other, and then commit suicide afterwards to avoid inevitable prison, and because they can't bear to live without their life-partner. (emphasis mine) There is no reason to believe that these are malicious murders, or that these people would repeat these crimes. On the contrary, there's every reason to believe that they are acts of love, reactions to specific circumstances. While you may not believe anyone could ever want to kill someone they loved as a loving act, that's an abstract judgment. I think you'd have to actually see, and spend time with, someone you loved who was going through that in order to understand that at a certain point the only thing you want is for them to actually die so that they stop suffering. (I've been through it.) Death is not the worst of all alternatives. It really isn't. But some people think it is. Such people have been sheltered; they haven't seen the worst that life has to offer. Can you imagine what it must be like to be totally paralyzed, to the point where you can't control any voluntary muscles at all, and to live like that for weeks, months, years? Completely imprisoned inside your body, unable to communicate, living with unrelieved tedium, and slowly going mad? I'd rather be dead. I would do almost anything to avoid that fate. Mr. Den Beste may rather be dead, but how does he know the other person would? The problem is that we can only imagine what it's like to be in that state, paralyzed, and unable to communicate. We can only project our own feelings and fears on the one who is supposedly suffering. It isn't their suffering we are so keenly aware of, it's our suffering. And he's right, death is not the worst of all alternatives. Hastening death is the worst of all alternatives. A living will that directed family members to kill you if you were in such a state would seem to be an expression of your own wishes, but would it really? After all, what if you changed your mind while you were lying there helpless? What if a whole new aspect of being opened up to you but you couldn’t express it to your family? There you would be, your family projecting their own suffering onto you, and you helpless to stop them from killing you. True, we honor living wills now that direct us not to take extraordinary measures to prolong life, but that is very different than actively snuffing out a life. The measures we take to prolong a life are often in and of themselves quite painful. In the case of terminal patients, they are ultimately futile, so witholding those in such circumstances is justifiable. But to actively end a life, is to assume more than we have the right to assume. And Another Thing: It must have been especially traumatic for the other nursing home residents when the two brothers were murdered: Grief counselors will be on hand Sunday to work with patients, their families and employees, nursing home administrator Chuck Brown said. "Right now we're just concerned with helping our residents get over this and working with our employees," Brown said. Imagine yourself helpless and completely dependent on other people. Imagine if someone just like you were killed for being just as helpless as you are. And that killing occurred in what you thought was your safe haven. God, what that must have done to them. I wonder if they'll ever again be able to trust their caretakers to protect them? This is the other argument against physician assisted suicide. It places the doctor in a dual role of healer and killer, and erodes the trust that is the cornerstone of the doctor-patient relationship. When Hippocrates wrote his oath, he included the injunction that physicians would "not give a fatal draught to anyone if asked, nor suggest such a thing." This was a revolutionary concept back then. Before Hippocrates and his followers, medical care was provided largely by shamans or magicians. They used spells and magic to work their cures. The problem was, they could use good magic to make you better, or bad magic to make you worse. They weren't necessarily committed to your best interests. They could be bribed to give you some bad medicine if someone wanted to be rid of you. That's why Hippocrates put that bit in his oath, to emphasize the committment of his followers to the good of the patient and to the patient's good only. It marked a turning point in medicine and sent us on the road that we've been traveling for over 2,000 years now. Physician assisted suicide would only turn us back to the time of the shaman when a patient had no idea whose interest was being served. It's a road I don't want to go down. posted by Sydney on 6/13/2002 06:23:00 AM 0 comments 0 Comments: |
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