New Jersey may soon vote whether to give doctors the legal authority to prescribe medications for terminal patients to take, if they wish, to commit suicide. Incredibly, the macabre name of this bill is the “Death with Dignity Act.” As an oncologist, as the first hospice certified physician in the state, as a caregiver who has sat at the final bedside of thousands, let me declare emphatically – There is no dignity in death. Death is dead. Death is not an action or process. Life is the process and there can only be dignity while we live. As long as our focus is on getting to death by the quickest route, we risk depriving the living of the opportunity to live with dignity.
The NJ Home News Tribune (Sunday 11/25/2012) presented four excellent views on whether this bill should receive our support. Reduced to each argument’s essence these opinions are:
- Rev. Bill Neeley (Unitarian): Choosing the time of one’s death, especially if one is suffering and terminally ill, is a matter of personal freedom and for intellectually intact patients should be an option.
- Rev. Michael Manning (Catholic): Only God can chose the time of death, the bill threatens the physician-patient relationship and may be a slippery slope.
- Roseann Sellani (RN, JD): Having this choice would improve honest communication about end-of-life between patients and doctors and give a vital freedom.
- Donald Pendley (Hospice): The bill devalues the importance of life and distracts from efforts to provide pain and symptom control.
What is being said, in other words, is that because doctors communicate badly, or at least insufficiently, about end-of-life issues, and because doctors provide erratic and often inadequate comfort care for terminal patients, that patients should be given the freedom, and assistance, to die. In addition, this argument hinges on the concept that for large numbers of patients quality, near the end-of-life, is not possible. Therefore, this bill deems it reasonable to turn to your doctor and say, “listen, I do not believe you can help me live, why don’t you just help me die.”
This logic is flawed and places patients in great danger. The first error is to assume that doctors do not and cannot communicate well about dying. There is no doubt this is an area where the physician-patient relationship often breaks down, but there is also no doubt that it is an increasing focus of education and learning. Medical students now routinely take classes in end-of-life care, physicians are much more focused on the skills necessary and the specialty of Palliative Care, for which communication is a core skill, is exploding. For most patients and families basic information about their situation relieves much suffering and confusion. Doctors can do better. We must demand it.
The idea that most patients experience uncontrollable suffering at the end of their lives is without foundation. With proper palliative care more than 90% of pain can be controlled, we can relieve anxiety (i.e. fear), shortness of breath, depression and most other symptoms. In fact, recent data shows that many terminal cancer patients not only live better, but longer, receiving hospice care rather than active chemotherapy. This bill deprives patients of these highly effective techniques by giving up and says to the physician there is no need to offer quality care, death will do.
Is suicide an individual freedom? That is an ethical question far above my pay grade. However, that is not the freedom proposed. What is proposed is “physician-assisted suicide.” That involves two people and their relationship and I have absolutely no doubt that the relationship will be corrupted. Having been involved in such interactions every day for decades, if the active reach for death is on the table, the physician-patient relationship will never be the same. Physicians and patients already struggle with end-of-life communication; I cannot imagine that trust will improve with the addition of assisted suicide. The motivations of patient, family and physician will be suspect, tainted and goals distorted.
The physician-patient relationship by definition focuses on life, and the end of our lives is still about life, not death, and can be lived with quality. To undermine the foundation of the physician’s role is to deprive the patient and family of that opportunity. If we truly wish suicide to be a realistic alternative then perhaps someone else, like perhaps funeral home directors, should do it. At least that relationship is clear. Why does that sound ridiculous? Because funeral homes are about being dead and doctors are about being alive. Why don’t we just keep it that way?
Outstanding commentary, direct, precise and right on target.!!!
While for cancer care, I am with you on the need to focus on palliative care; not so sure with respect to some other diseases such as ALS and MLS. But you set out the issues and concerns very well.
I was very disappointed by your article. I have read your summary’s before,
and found them to be so accurate. If you feel that you do not want to be party to help someone, who is not being helped. by the so called fabulous meds, and there are those, but why abandon any other dr. from doing so. Have you ever been in intractable pain, and 98 years. why would you deny others. It is not your call to
oppose a bill that can help other’s
.
My deep concern, after having spent a career treating people in terrible pain, is that this bill will result in doctors not giving good pain control but instead just letting suicide substitute for care. It will confuse patients that they cannot have quality life, and instead put pressure on them to end their lives. It also deeply confuses the role of what a doctor should offer, which is life and comfort. If the time comes that most patients that need pain control, get pain control, and there remains only a few patients who cannot be helped, then we can consider such an action.
jcs
Disappointed is the right word Tom Challener. Deeply.
My concern is focused on the massive number of people who at the end of their lives because of the failure of proper medical care receive poor control. I see every day patients who come to me in agony which has not been addressed who are already talking about ending their lives because of their suffering, when all it takes to give them back quality and an element of hope is listening, caring and proper symptom (i.e. pain) management. I have no ethical or moral issue with the natural freedom to end one’s life when that is a rational alternative, but in my experience the primary focus of a compassionate physician should be to offer measures that improve life, not take it. jcs
Hi James On reflection omit the deeply..it’s too polarising. x We need to keep talking about this
I am certain there is a balance; the problem in my mind is the failure, to date, of physicians to adequately address end-of-life quality and I see death as a weak alternative to life lived without suffering. jcs
Surely the question must revolve around our understanding of ‘life and living’. To be rendered into unconsciousness or to a place of great illness from which there is no hope of recovery to wellness does not for me and a lot of people, equate with bringing comfort. If I choose to quit and shuffle off this mortal coil then that’s all I’m asking of my society and my doctors. It should be my choice and no one else’s…with the right to change my mind. Lx
The right to choose one’s future is vital and is a natural right. In my experience if a patient has the opportunity to live (by which I mean a state in which one is aware and can interact, learn, share and laugh) it is a choice most would make. We live for each moment and with proper care we can often provide the chance to live moments in comfort. I agree with you that the goal is not to live with some terrible terminal illness in an unconscious state. That is not “living”, even if it is life. jcs
Final point..putting legislation in place to properly protect whilst allowing a controlled end should not undermine your goal of improving end of life care which is entirely laudable..blocking legislation that allows for choice prevents those who will not end their suffering by taking adequate pain killers from taking control of their own lives.
I really hope that our communities can find a way to embrace both objectives with a compassionate heart.
Compassion. You are so right. That is the key.
jcs
Far as I can tell, the doctors I’ve seen have very little to offer but to extend life or palliate pain. The so called compassion is a self justification that keeps a gigantic industry alive. Doctors are not trained to study health, but only disease.
You are absolutely correct that the “disease” model of health, needs to be replaced by a wellness model. There is so much to be done regarding prevention and health maintenance by getting back to basics such as diet, exercise and handling of stress. On the other hand, I have seen tremendous good and healing done by skilled intelligent compassionate physicians, who make a major difference everyday.
Thanks, jcs
When will this paradigm shift occur such that our nation not go bankrupt? I’ve been aligned with or have surveyed numerous alternative therapies and the practices of industrial medicine and pharmacy has served to disarrange the best efforts at reform.
Alternative medicine is in such disarray that it is threatened with dissolution. The paltry sums given to NIH for complementary medicine are ridiculous. While there may be many things to applaud in advanced studies, the fact is that medicine could be much simpler and cheaper.
Absolutely no doubt that a more focused, health oriented medical system could be much cheaper.
jcs
I see that I am perhaps off topic. And my own experience in being honest with myself is that many days the value of life escapes me. Other days, not so bad.
History shows medicine has been a lot worse in the past. The ethical issues are more complex today for sure.
The ethics are indeed staggering.
jcs