“So, I told the doctor at the nursing home that I loved my father more than anything. Dad was my friend and the most wonderful man I had ever known. I wanted everything for him. But, I said, Dad was sick, weak, confused, and he never wanted to live like that. The next morning he was dead. That was OK by me.”
I once participated in a panel discussion about hospice, palliative care, living wills, end-of-life quality and, especially, pending legislation to legalize physician-assisted suicide in New Jersey. There were many arguments, for and against physician aid in dying. There should be a right to die. We do not have a right to die; life is too precious. We must have a choice. We have too much choice. Suicide is needed to relieve suffering. Suicide will increase suffering by ignoring comfort and wasting life. It will destroy the physician-patient relationship. It will make the physician-patient relationship more honest, stronger.
I had heard these thoughts before. Then, a new idea entered the debate. In the words of a woman perched in the second row, “Well, it should be legal because doctors do it all the time.”
“Do you mean that patients’ are deliberately killed by their physicians?”
“Absolutely,” was the answer, confirmed by the nods of a nearly unanimous audience.
An older gentleman clarified: “It’s like wink-wink and then it’s done.”
I was flabbergasted. Giving a treatment or medication in order to deliberately cause death is not only unethical, a calamitous violation of the Hippocratic Oath, it is 100 percent illegal in all 50 states and the District of Columbia. Whether, it is a relative, a pharmacist, a nurse or a doctor who carries out such an act, whatever the reason, we have a special term for that act. We call it first-degree murder.
Nonetheless, for many mercy killing is part of urban legend and is, wink-wink, acceptable. Almost all the attendees the other night, and one of the speakers, who notably holds a PhD in Sociology, believe that it happens all the time and at some level is necessary. Are they correct? Are back room medical murders really a ubiquitous dark secret? Perhaps, we fail to understand the difference between intent and result.
Professional caregivers, especially at the end-of-life, often take advantage of the centuries old concept of double-effect. This canon says that if I give a terminal patient a drug, such as morphine, with the specific goal of providing comfort and if while I am making that patient comfortable it has the side-effect of causing sedation, slowing of breathing and even hastening death, that is ethically acceptable. It is about intent. My intent is to relieve suffering and preserve the quality of life. My goal is not to end life.
Physicians, palliative care experts and hospice workers know that when life is frail and there is great pain, shortness of breath or suffering, it can be very difficult to give just the “perfect” amount of medicine so as to provide comfort, but not accelerate the patient’s demise. If we want to be absolutely safe, that is, not risk life-ending side effects, we will have to let patients suffer. This would be reprehensible. There is a risk to provide comfort and compassionate people put quality first.
I suspect that most of the time what is seen as intentionally causing death is, rather, intentionally providing comfort with the possibility of death. The complex situation at the end-of-life caused by fear, anger, fatigue, deforming disease, treatment, other illness, complication and aggressive comfort measures, makes it very difficult for the lay person to sort out what is cause and what is result. A caregiver’s inadequate explanation such as, “The time has come to make her comfortable,” or, “We cannot let his suffering continue so I will hang the morphine drip,” may be very confusing.
Euthanasia has been debated since Socrates, but continues to be illegal in most of the world. In 30 years experience at death’s bedside, I have only seen one event that approached intentional comfort killing and that physician faced disciplinary action. However, as was clear from our conversation the other night, many people believe bedroom murders are a common event. I hope not, but beyond whispered stories, it is hard to be sure.
While there are many sound arguments for physician-assisted suicide, the legion of medical murder does not belong in that discussion. Any “doctor” who would carry out such an act is not a humanitarian to be respected, protected and followed. Their evil is not the start of a slippery slope; they have fallen off the mountain. The possibility of such deeds poisons the medical profession and all of us.
James C. Salwitz is an oncologist who blogs at Sunrise Rounds.