The Ethical Dilemma of Dying

Physician-Assisted Suicide has always been a grey area of medicine, because, truth be told, there is no fine line between what is and is not acceptable for a physician to do. Because every patient’s case is different and should be individually assessed and discussed, there cannot be a hard and fast divide between the do’s and don’ts of end-of-life care. Decisions which seem immediately to be counter-intuitive to health sometimes end up being beneficial for the patient, and decisions which alleviate symptoms immediately can, in the long run, reduce a patient’s quality of life to such a point that, because of the treatment, he has had less useful life than he would had the physician withheld treatment and allowed a disease or condition to run its natural course.

A decision that every physician will have to make at some point is whether and when to give up on saving a patient’s life. Centrally, debate abounds as to whether the doctor’s goal should be to preserve useful life, or simply to keep the patient alive in whatever state he may be. If the patient would live in pain with no hope to regain health, his useful life is over, and the doctor’s decision to let the patient die is typically considered justified. Such a case is detailed by Dr. J. Kenyon Rainer in his memoir, First Do no Harm: Reflections on Becoming a Neurosurgeon. The case discussed is of a patient with a terminal tumor, which had spread throughout the brain. The excerpt mentions Bill Walker, a physician under whom the narrator studied; and Jill Lawrence, the head nurse of the hospital:

Jill didn’t move to help me and I looked up at Bill for help.

“Let him go,” Bill said quietly.

“I can get him back,” I said. “Help me!”

“No,” Bill answered. “Let him die.”

“Our job is to help people live, not help them die,” I pleaded. Now Mr. Turnham                                was cold and blue all over. The carotid arteries in his neck were no longer                                    pulsating, and his chest had stopped moving.

“Our job is to prolong useful life,” Bill said. “His life ended two months ago when he became comatose.”

“Maybe his family doesn’t agree,” I argued.

“Why don’t you ask them?” Bill suggested.

“I will.”

Jill turned off the oxygen, unplugged the EKG wires, and turned off the cardiac monitor. While Bill wrote on the chart, she put fresh sheets on the stretcher. She removed the tube from Mr. Turnham’s bladder, washed his face, cleaned his mouth, and combed his hair, then pulled the sheet up to his neck.

“Ask the family to come back to Room ten,” Jill said into the intercom.

Bill met Mr. Turnham’s wife and daughter in the hallway, greeted them warmly, and said, “We gave him nine good months, but I know the last two months were hard on you. I got to the room as his breathing and heart were giving out. I decided not to resuscitate him, and he passed away a few moments ago.”

“I’m so thankful for the nine months you gave him,” Mrs. Turnham said. “But when he went into a coma, and we couldn’t feed him or keep him clean… he wouldn’t have wanted to live like that”.

 

The confusion expressed by the narrator of this excerpt is representative of that which most physicians encounter early in their careers and illustrates how vast the proverbial “gray area” between helping and harming a patient can be.

 

The Hippocratic Oath, which doctors swear as they graduate medical school, specifies that a physician “[W]ill neither give a deadly drug to anybody who asked for it, nor… make a suggestion to this effect”. The oath states not only that by helping a patient end life, a physician stands in contempt of his duty, but that he also does so by merely considering the option of ending the patient’s life, or “[M]ak(ing) a suggestion to this effect.”

A common alternative to doctor-assisted death is improved palliative, or end-of-life, care. This “comfort in death” practice provides all the same benefits to terminally ill patients and is within the ethical bounds of a doctor.  Under palliative care, when the patient enters the final stages of terminal illness, pain and discomfort are treated with various antidepressant and pain-relieving drugs instead of being ended by euthanasia. The American Medical Association issued a policy defending palliative care over euthanasia, stating:

“Instead of engaging in euthanasia, physicians must aggressively respond to the needs of patients at the end of life. Patients should not be abandoned once it is determined that cure is impossible. Patients near the end of life must continue to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.”

Furthermore, the same association issued a set of guidelines and definitions regarding the subject of a patient’s right to die:

“More rigorous efforts in advance care planning are required in order to tailor end-of-life care to the preferences of patients so that they can experience a satisfactory last chapter in their lives.”

Together, these guidelines bind physicians in the American Medical Association to a policy of preservation of life, but basing decisions on a patient’s will, so as to provide a “satisfying last chapter” to the patient’s life. This reliance on patient preference, however, can be used in some cases to defend the practice of doctor-assisted death. An NBC News article over doctor-assisted death reports that, “More than 97 percent of patients cited loss of autonomy as reason for participating in the Seattle hospital’s program, while nearly 89 percent pointed to the inability to engage in enjoyable activities and 75 percent were concerned about losing dignity”. One case of this preference is the story of Ethan Remmel, a husband and father who chose, at 41, to die by lethal doses of sedatives while he retained his dignity and mental faculties rather than allow his cancer to progress to the point that he could not interact with his two young sons. According to the same NBC News article, Mr. Remmel achieved, by retaining control of when and how he died, the satisfying last chapter of his life that palliative care is intended to provide. In his journal, Remmel wrote “I have the medication now. It is safely locked up. I have not decided if or when I will use it, but it gives me great relief to know that I have some control over my dying process”.

The future surely holds fewer limitations on how the physician acts during the terminal stages of a patient’s illness, but we must proceed with extreme caution. The ethical duty of the doctor remains:

First, do no harm.

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