The Ultimate Kindness

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In medical
school in the late 50s, early 60s, consideration of management of
terminal patients, their suffering, their imminence of demise, wasn't
formally presented but was a frequent focus of discussion among
students. It was an expression of genuine concern, of how we would
handle that unwelcome aspect of medical practice. I'm sure that's
been the case in every class of every medical school down through
history.

It got down
to the nitty-gritty of mechanisms, medications that might be used
to ease the passage, of settings in which it would be appropriate.

It got down
to the morality of even considering such things.

There was agreement
that the doctor had a role in such a matter, but the detailed definition
of that role was never reached, despite heroic efforts…, in bull
sessions, sober and otherwise.

Every class
had its component of idealists; matters of this sort loomed large.

Now the Supreme
Court, with its exalted new Chief Justice, is considering the problem.
The premise of this comment is that it is a real transgression of
true justice, of genuine morality, of natural law…! I'm not referring
to the potential outcomes, the potential findings of the SCOTUS.
I mean that it is a transgression of reasonable human interrelationships
for this concern to be under the surveillance of the American justice
system. This is not a subject to be defined and regulated by a central
authority, not even by Oregon. That's still too damn central.

There is one
little glimmer of hope in the present development across the street
from the Capitol Building:

It's a mixed
bag. It is not appropriate for the feds (SCOTUS or any other federal
court or regulating or legislating body) to be active in matters
of local concern. Not just inappropriate, but downright unconstitutional.
There's nothing in the constitution that gives the federal
government any interest in who "pulls the plug" or dispenses
a slight overdose.

But then, it's
reported that Chief Justice Roberts was somewhat disapproving of
the Oregon law which codifies the circumstances in which doctors
may dispense an easy passage. That's a commendable attitude in terms
of the appropriateness of such a law in the big picture, in terms
of the morality of it. But, it is inappropriate in terms of the
confederate relationship between the central government of
the unified states and (any) one of the States. It's not up to the
U.S. Supreme Court to dictate to a State whether or how the State
should address the subject of mercy killing.

But federalism
is not the point of this article. Codification of the management
of the last minutes of the dying and the attendant suffering is
the point. Codification should not exist, shouldn't even be considered.

The parties
legitimately concerned with the goings-on at the end of a terminal
illness are the patient, the family, the doctor and, if in hospital,
the nursing staff. There is no place for the district attorney,
the sheriff, the marshal or the judge.

The state should
stay out of it: federal; state; county; city. It also excludes hospital
administration, medical staff, ethics committee.

There is a
myriad of ways in which one may die. Most of them aren't pertinent
to this discussion, the DOAs, the codes, the easy, smooth progressive
comatose patient who just fades away. But a lot of people suffer
greatly in the count-down.

In the debilitating,
painful deaths of most cancers and of chronic pulmonary obstructive
disease, emphysema, and a few others, the enfeebling progresses
to such a point that the vital energies are sapped and the drive
to breath weakens until the lack of oxygen won't support life…,
and the heart, starved of oxygen, stops. Usually coma intervenes
to give some relief from the conscious suffering, but it may only
be in the final few minutes.

Throughout
the painful weeks or months, while treatment medications and procedures
are provided, analgesics are prescribed. As the disease progresses
the pain increases, tolerance of it, in many cases, decreases and
the attending doctor increases the potency of the analgesics available
to the patient. During this time the patient generally is able to
communicate with friends and relatives, to appreciate some diversionary
activities; not a "normal" life but one from which some
satisfaction…, quality, can be derived.

Then, as the
patient weakens and finality is imminent, but unpredictable in duration
and form, the pain often seems to increase, the distress of the
weakness increases, the only communication may be in the form of
a hand squeeze, occasional eye-to-eye contact with a loved one,
or with an attendant, the occasional wan smile.

Narcotic analgesics,
with morphine as the prototype, are the most potent pain killers.
Along with their analgesic effects they provide a great euphoria,
the basis for their street abuse. A usually adverse side effect
is their tendency to depress respiratory effort, often the cause
of the abuse deaths. None of these effects is precisely predictable
in its manifestation in any given case.

The patient
has been receiving increasing doses of narcotics to maintain some
quality of life. Tolerance of the effects and side effects develops
requiring larger doses. As the disease progresses there comes a
time when death becomes inevitable and then imminent.

As death approaches,
but unpredictably so, often a corner is turned. Nothing is said,
but there may be a silent pleading in the eyes of the patient when
the nurse or doctor visits. Or the professional, having seen so
many of these previously, just knows. The next dose of morphine
will be "a little" larger, may be given intra-venously
where it will have more of an impact, rather than intra-muscularly.
There may be a fleeting euphoria and pain relief, but breathing
slows, coma, however brief, occurs and then death.

Codify that
if you can!

In a healthy
person who has developed some tolerance of the dosage used, whether
through long-term pain management or through abuse, the dose used
in the example above wouldn't faze the subject. In our weakened
patient it is enough to depress breathing below a life-sustaining
level. The precise dosage selected can't be known, only estimated.
Now, is that mercy killing or over-zealous or over-compassionate
pain management…?

There certainly
is room to question the morality and appropriateness of the action
described and I won't get into that herein. I'm just describing,
as best I can, a phenomenon that exists. A wide temporal separation
of implementing expeditious death from the imminence described in
my opinion surely is immoral.

This, in one
form or another has been going on for millennia. It is an unspoken,
even unwitting, contract between patient and doctor, between family
and doctor, between doctors (medical students can debate it, practicing
doctors don't). It needs to remain unspoken. Even this article may
say too much, but it seems appropriate in light of the legislation
and litigation surrounding physician-assisted suicide and when the
antics of such as Kevorkian are observed.

This practice
shouldn't be called physician-assisted suicide. It is best not called
anything. Euphemistically it can be thought of as terminal (extreme)
pain relief or terminal compassion measures or easing the exit;
as the coup de grce or mercy killing or simply as relieving
suffering. I think of it as the ultimate kindness in the art of
practicing medicine. It shouldn't be called murder.

There is concern
for abuse, and it most probably has been abused in an unknown, finite
percentage of cases. It is certainly even more abused in omission,
when the suffering is inadequately treated.

On the other
hand, we've all heard of the "angels of mercy," the sickos
who go around on the graveyard [sic] shift injecting old gomers
without really knowing anything about the individual or the case.
They are murderers; that is absolutely not the same. Abuse will
out; there are plenty of whistleblowers around who will pick up
on indiscriminant practice.

But, if the
silent practice is somewhat abused it is as nothing compared with
the potential for abuse in the codified physician-assisted death
scenario. Once the state has its fingers intertwined into that aspect
of medical practice it will progress in all sorts of bizarre ways.
There would be inevitable incremental creep such as committee selection
of candidates to the expansion of criteria — how about cost analysis
of various illnesses plotted against age?

If your illness
is going to cost the state health plan too much (how much?) and
the odds of survival (what odds?) are too low, then let the state
assert that ultimate kindness in the art of practicing medicine
before the first painful, hopeful…, expensive… surgery. That's ultra-ultimate
kindness: the patient is saved the pain and false hopes (except,
the odds, however poor, might have rewarded that hope!), the family
the lost time and drawn out grief, the medical personnel the preoccupation
with the poor-odds case, and the state, a bunch of money!!

Nobody loses.
The committee retires to the lounge for a round of cocktails. The
doctor downs two or three stiff ones in the locker room. It's a
brave new world.

November
14, 2005

Chuck
George [send him mail]
is a retired orthopedic surgeon in Alabama.

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