DON’T KILL THE PATIENT, TRAIN THE DOCTOR

By Robin Bernhoft, M.D.

Euthanasia advocates say that only death can relieve pain and depression, but some doctors are learning better alternatives.

Sooner or later, every one of us are going to die. I know I will, although I hardly ever think about it. I suspect you don’t think much about it, either.

There are people, however, who think a great deal about death-theirs, yours and mine. They have managed to build our fears of dying into a serious cultural and political movement. They seek to legalize euthanasia, also known as “mercy killing,” “aid-in-dying,” “self-deliverance,” “physician-assisted death” or “physician-assisted suicide.” They have had the usual support such ideas get from certain sectors – and by no means all of the mass media, but enough that the public has been persuaded. National opinion polls have shown widespread support for euthanasia among churched and unchurched alike.

Mercy killing has been around for a long time. It had a brief heyday in the 1930s, but faded from sight after Adolf Hitler gave it a bad name. Later it became a debate topic, the kind high school civics teachers dust off whenever they need to generate some excitement.

Now euthanasia is showing up on state ballots, as it did in Washington state in 1991 and in California last year. Both states defeated their measures, but euthanasia proponents vow to press on and try again.

How did this issue escape from the classroom into the public arena?

Certain ideas helped move euthanasia to the front burner:

* Quality of Life has, for many Americans, replaced innate sanctity of life as the measure of human dignity. This means, in effect, that the value of an individual life is not absolute (created in the image of God). Rather, life must be measured in terms of productivity, independence and personal criteria. Such measures produce highly variable judgments about the value of one’s own life, or the lives of others. When the disadvantages are felt to outweigh the benefits, life becomes expendable. Euthanasia is then a “compassionate” act, performed in the “best interests” of the victim.

* Moral relativism produces an extremely flexible ethical code, based more on the facts of a specific situation than on the inherent nature of the act in question. For example, one might say: “It may be killing, but let’s hear the circumstances.” Intentionally ending another person’s life can be seen to be justified if the alibi is compelling enough.

* Radical autonomy is a belief that fundamental rights exist that cannot be impinged upon by society’s desire to protect the innocent from harm. Radical autonomy discards these protections.

Despite our legal tradition of weighing competing interests-society’s versus an individual’s-euthanasia activists claim the absolute right to choose the time of their own death, and the absolute right to deputize someone else to bring it about. They assert that neither “right” should be impinged upon in any way, no matter what harm others might suffer.

Fear of Machines

Whether or not one accepts these values, changes in the circumstances of dying have produced a major backlash against terminal care as it is now practiced. The increasing availability of high-tech medicine and its escalating costs have created a common fear of being kept artificially alive beyond any reasonable hope of benefit and being bankrupted in the process.

Many people fear loss of autonomy, loss of dignity, loss of cleanliness and loss of meaning more than they fear death. Often these fears combine with a glamorization of suicide to form the ultimate bold assertion of control over one’s fate. Death is then preferred to what seems to be in unacceptable quality of life.

We doctors, meanwhile, have lost much of the heart of medicine, and we see the patient not as a fellow human we can help, but as the carrier of a disease we can conquer. Often when we cannot cure the disease, we subconsciously view he patient as a traitor, a dying reproach to our best efforts, a failure. We avoid such patients. We tend to lose interest in controlling their pain and depression. Symptom control costs a lot in time and emotion, and it doesn’t pay us very well. Many health insurance policies cover high-tech, heroic care generously, but do not cover symptom control very well at all. Hence the shocking neglect of measures that provide comfort, which I think is another one of the chief forces behind popular support for euthanasia.

Others look coldbloodedly at cost. No one wants to waste money on futile care. But we must not decide to start killing people with AIDS, cancer or the various problems of aging just to save some money. Euthanasia is always cheaper than any sort of medical care, an equation that will tempt many lawmakers.

There are many sincere, apparently reasonable motives for legalizing euthanasia. But the arguments against it are even better.

Aid-in-Dying: Why Not?

1. Technology. Americans are ambivalent about technology. We are grateful for longer life expectancy, but the sights and sounds of the Intensive Care Unit (ICU) scare us-unless we have been there long enough to get used to them.

Hollywood has given us the impression that most Americans die in the ICU. Is this true?

Last year, two extensive surveys-one done by the National Institute on Aging-showed that most people die peacefully in their sleep. A third of Americans die at home, 45 percent in the hospital; only 31 percent need pain medication prior to death. Dying in the ICU, hooked up to machines, is relatively rare.

2. Pain. Untreated suffering is the chief reason most people support mercy killing. Pain is what makes it seem merciful. Many consider it more compassionate to put people out of their misery than to let them suffer. This would probably be true, were those the only choices. Not that everyone dies in comfort; Russell K. Portenoy, M.D., estimates that between 50 and 75 percent of cancer patients’ pain is undertreated, even by specialists.” The World Health Organization drew a similar conclusion in a 1989 survey.

But it doesn’t have to be that way.

My experience, and that of many cancer specialists, is embodied in the case of Bill. In 1988, at age 80, Bill showed up at an emergency room with severe chest pain, cough and a 40-pound weight loss. A chest X-ray showed lung cancer, and the two doctors taking care of him told him nothing could be done and that no pain medicine stronger than Demerol and codeine could be given. They weren’t strong enough. He went home in extreme pain planning to kill himself.

Fortunately, his daughter got a third opinion. A cancer specialist put him on oral morphine. Within a couple of days his pain was completely gone. He then tried some mild chemotherapy. Today, five years later, Bill is looking forward to yet another year of active, enjoyable life.

If aid-in-dying had been legal, Bill would have died back in 1988. But he’s glad he didn’t, and he worked actively against Washington’s euthanasia initiative two years ago.

There are a lot of people out there like Bill. Some of them are old, some are young. Betty Rollin wrote in Last Wish that her mother was also on Demerol and codeine, and like Bill, she wanted to die because of her pain. Demerol combined with codeine is commonly ineffective, but frequently prescribed. Dr. Kathleen Foley at Memorial/Sloan-Kettering in New York, reported a series of patients who wanted to die because of untreated pain. Virtually all regained their desire to live when converted to an effective treatment such as oral morphine.

The World Health Organization reported that over half of American physicians in 1989 did not know that oral morphine existed. In some parts of the country, pharmacists do not carry it for fear of robbers, or refuse to fill prescriptions large enough to do the job.

It does not have to be that way. In Britain, the Hospice movement, which pioneered effective pain and symptom control, is said to have made euthanasia irrelevant. In my experience at a London hospital in 1983-84, I saw British doctors as a good more sophisticated in pain control than Americans. Even Dr. Pieter Admiraal, an anesthesiologist and clinical pharmacologist who pioneered Dutch euthanasia, has stated repeatedly that essentially all pain can be controlled, and that euthanasia for pain is unethical. (Admiraal considers paralysis and similar quality-of-life considerations valid justifications for euthanasia.)

There is no reason for anyone to die in pain, let alone 70 percent of cancer patients. What should we do to help them? Legalize euthanasia, so they can die unnecessary deaths to escape unnecessary pain? Or teach their doctors modern pain control techniques so they can enjoy the time they have left? The latter is well within our power. Nurses can also be brought up to standard.

Using Pieter Admiraal’s standard euthanasia for pain would be medical and social malpractice.

3. Depression. Psychiatric care of terminal patients is also inadequate. According to Conwell and Caine, 90 to 100 percent of people who commit suicide are mentally ill, a large number of whom have treatable depression. Unfortunately, 75 percent of elderly people who commit suicide do so after their family doctor fails to detect curable depression. This leads Conwell and Caine to claim that many doctors on the front lines, who would be responsible for implementing any policy that allowed assisted suicide, are ill-equipped to assess the presence and effect of depressive illness in older patients.

Legalization of euthanasia could very likely lead to euthanasia for treatable depression. Again, using Pieter Admiraal’s standard, euthanasia for treatable depression would be medical and social malpractice.

4. Hard Cases. Tragedies of suffering grip the public imagination and fuel the fires of the euthanasia movement. The most common, and most sympathy-evoking, are tales of excruciating, untreated pain. Hemlock Society often cites bone cancer as the sort of pain that cannot be treated.

My brother Larry died at age 41 from multiple myeloma, a cancer that spread through the marrow of his ribs and spine. He shrank from 6’2″ to about 5’7″ over three or four months. His back developed a right angle where the bones broke behind his heart. His ribs had multiple fractures and moved when he breathed. Rather than running side-to-side, they ran front-to-back.

Although his case sounds somewhat horrifying, my brother died in comfort, with a clear mind. His doctors knew how to treat pain. They weren’t afraid to give as much morphine as he needed. They knew they wouldn’t kill him, drug him or make an addict of him (as if that mattered anyway). They remembered from freshman pharmacology that there is a wide range of safety between a dose of morphine that makes the pain go away, a dose that makes you groggy, a dose that slows your breathing, and a dose that kills you. For most American doctors, freshman pharmacology is a vague, long-ago memory.

Larry was the sort of person Pieter Admiraal probably had in mind when he said pain can almost always be controlled.

AIDS is often viewed as a justification for legalizing euthanasia. AIDS sufferers commonly fear untreated pain. While the various pains of AIDS are no harder to treat than cancer pain, the skill is not widely held. As with cancer, if the issue is pain, one does better to train the doctor than kill the patient.

AIDS sufferers also have social fears: desertion by friends and family; homelessness and inadequate health insurance coverage. While these fears are often well-grounded, there are better ways to allay them than killing the victims.

Positive Alternatives

You need good ideas to drive out bad:

* Private and public investment in hospice care centers should be encouraged, so that a greater number of Americans need not experience pain.

* Private insurance companies should be encouraged, or required, to offer policies covering both inpatient and outpatient hospice care.

Either we muster the will to provide good quality terminal care to everyone, or we get used to the idea that the poor and uninsured people will choose death a lot more often than the middle class or the rich. Not every welfare patient will get the quality of care my brother received. And they will ask, “I can’t get my needs met, I’m miserable enough, why shouldn’t I die?”

(The above material was published by FOCUS ON THE FAMILY CITIZEN, September, 1993)

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