Monday, September 19, 2011

Thou Shalt Do No Harm

The morning email from Obit-Mag.com drew me into “A Faster Darkness,” the story of an elderly parent’s sudden onset of dementia and long, wrenching death. It was a time of irrational conspiracy theories, heavy sedation and the disappearance of all but the physical being the father once was.

The author is Robert Roper, a Johns Hopkins writing instructor, and I found myself thinking of Roper as a survivor before his father actually died, because in many ways he already was gone. But he wasn’t dead, and wanted to be, his son believes. His father would have wanted Roper to get a gun and end his misery. Roper could almost hear his father asking for that very thing, or so he writes. (http://bit.ly/oAJhw3)

Roper’s piece is yet another compelling look into a subject -- life, and how it ends -- around which our culture struggles to find common ground or meaningful vocabulary. Meanwhile those to whom we turn to care for the dying are viewed with distrust by families who find themselves, often quite suddenly, in the impossible position of speaking for someone who no longer can speak for himself.

We like to think of ourselves as quite highly evolved, and yet we can be abysmal communicators, especially in matters of mortality, faith and reason.

The lead story in the Metro section of Monday’s Boston Globe concerned the Boston Cardinal’s sermon imploring Catholic lawyers to put their weight behind opposition to a movement to legalize physician-assisted suicide in Massachusetts.

“We are called upon to defend the gospel of life with courage and resolve,” Cardinal Sean P. O’Malley said. Agree or not, there is rare and welcome clarity in the statement.

Before Death With Dignity can become a question on the 2012 ballot in Massachusetts, proponents need nearly 70,000 signatures of valid registered voters. Proponents want to make it legal for physicians to prescribe a lethal dose of prescription drugs to the terminally ill.

One fear of legally empowering physicians to assist in a suicide is that it “would be difficult or impossible to control, and would pose serious societal risks.” It might surprise you that this slippery slope argument comes not from a religious denomination, but from the American Medical Association. The AMA calls physician-assisted suicide “fundamentally incompatible with the physician’s role as healer.”

There is helpful clarity in that statement, too. Can a physician kill as well as heal? Is doing both too much to ask?

Dr. Marcia Angell, former editor of New England Journal of Medicine, is a longtime proponent of physician-assisted suicide. She told CommonHealth at WBUR.org: “For the patient, this is not a choice between life and death; it’s a choice of how to die -- slowly, or sooner but more peacefully.” (http://bit.ly/p1FYOg)

To disagree with that seems heartless. And yet to agree that this is not about choosing between life and death seems a victory of compassion over reason, because the practice clearly expedites death. For the best of reasons, perhaps, but the practice still expedites death.

The Community Ethics Committee, of which I’m a member, is studying disputes over futile treatment of the terminally ill, a particularly harsh example of society’s difficulty accepting mortality as it plays out most often in hospital intensive care units. Typically in cases of medical futility, a patient is determined by the care team to be in the process of dying, but the family wishes aggressive treatment to continue.

Distrust and bad communication are hallmarks of such disputes. Families are seen as irrational, doctors as heartless. In the middle are nurses, delivering treatments they deem harmful upon defenseless, dying patients.

Last spring, the CEC completed a serious attempt to clarify the line between caring and killing. The CEC’s report, “Palliative Sedation – Continuous Deep Sedation until Death as Comfort Care,” was submitted to the Harvard Ethics Leadership Group.

“Both euthanasia, where the physician is the agent administering a lethal substance, and physician-assisted suicide, where the patient is the agent administering a lethal substance, have as their chief end the death of the patient,” the CEC said in its report. “The primary goal in either circumstance is not to relieve intractable pain but, rather, it is to end life. The CEC felt strongly that the primary goal of Palliative Sedation is to relieve intractable pain and, as a result, it falls into an ethically supportable and potentially advisable treatment option.”

Physician-assisted suicide, even for the most compassionate of reasons, involves the healer in expediting death. It was important to the CEC, in finding ethical justification for palliative sedation, to ensure to the degree possible that patients died from the progression of their disease and not from the sedation.

The CEC supported the use of palliative sedation while deliberately distancing ourselves from endorsing physician-assisted suicide. The terminally ill in intractable pain should have access to relief - a medical treatment option to relieve their pain but not cause their death. To us, it was the difference between caring and killing.

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