This very modern treatise on dying was reviewed in the March 20th issue of The Economist. As a physician who has seen too many people die, I was anxious to read what modern experts had to say about the process. The young British/American journalist travelled the globe over several years to interview dying adults of all ages, their caregivers, and both proponents and opponents of laws governing medical assistance in dying. Divided into chapters titled Modern Medicine, Age, Body, Mind, Freedom, and The End, she provides multiple interesting philosophical, ethical and societal perspectives on the ultimate fate of all human beings.
The mishmash of laws concerning medical aid in dying around the world are all far too liberal for many religiously-oriented people, but far to restrictive for many frontline healthcare workers and many of the enlightened public, some philosophers and even a few liberal religious leaders. The most liberal laws are in Holland, Belgium and Switzerland and those few enacted in some of the states are vague and very restrictive. In the U.S., the decisions of the terminally ill are very frequently determined by financial considerations because of their ridiculously dysfunctional restrictive health care system. The limitations in the treatment of the mentally ill are discussed with great sensitivity.
The concept of a completed life, originating in Holland, can lead to the belief that it is perfectly reasonable for an elderly but not terminally ill individual to request medical assistance to die. But widespread acceptance of suicide as a rational end to a completed life is also problematic as most suicides are impulsive acts that should be discouraged in the interests of individuals and society at large. The concept of rational suicide is rejected by most self-serving psychiatrists who insist that anyone committing suicide must be mentally ill. But psychiatrists in the Covid era are now hardly underemployed.
Medical assistance in dying has been practiced for centuries, although usually covertly. In the 1980s, Dutch prosecutors quietly stopped pursuing charges against doctors who openly obeyed terminally ill patient’s requests for assistance in shortening their miserable lives. Such practices were always widespread, with the charade of treating pain with prescriptions of enough narcotics to be fatal if taken as one dose. But there was always lingering concern about possible prosecution for murder. In my Exits chapter in Medicine Outside The Box, (2011), I acknowledged having hastened patient’s demise in the process of relieving their pain, as have many other honest physicians treating the terminally ill. But the charade did feel dishonest and at times was shattered as both I and the patient knew what was really happening.
“If I give you enough pain-killers to relieve your pain, you will die.”
“I know that.That is what I want.”
This was always in hospitalized patients with at most few days to live, unlike those poor souls who potentially face months or years of torture if not provided with help to exit. Nevertheless I was chastised in print by a freelance journalist who questioned my motives. Can anyone fully determine their own motives for such actions, let alone those of others?
In Being Mortal, Atul Gawande expresses concerns about relying on laws as an alternative to improving palliative and hospice care and this seems quite a legitimate concern to me. “Death with dignity laws codify the ‘better dead than disabled’ mindset and may make the disabled feel guilty about hanging around.”
In discussion of dementia, Englehart writes – “ …why should we privilege the critical judgements of a being who effectively no longer exists over the expressed desires of a person who is with us here, now? Why not instead think of the person with dementia as a new person, unconstrained by the choices of a past self?” At first glance this seems like a profound insight but it is problematic. With the insidious, unpredictable progression of dementia, when does the old me cease to exist and the new befuddled me become the one to express valid wishes? And who should determine the time of the switch? Certainly not politicians, lawyers, philosophers, ethicists or doctors. And family members may well have a financial conflict of interest. I personally think that dying with a loved one holding one’s hand is overrated. Given a choice, I would prefer to take my last breath all alone or in the care of a dispassionate capable caregiver.
Organ donation is barely mentioned and the accepted practice of organ donation after cardiac death, in which a patient who does not fulfill criteria for brain death becomes a donor immediately after the heart stops beating when life-support is withdrawn, is not mentioned at all.
This is a well-written (with a few grammatical errors) balanced discussion of profound enigmas. But be forewarned, the personal stories related are generally tragic, and there are no easy answers.
The Passionate Reader 