The Ultimate Kindness

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