Inevitably, death comes to be seen as the enemy in medical care. A resuscitation effort ends with success, or death. Death is the antithesis of triumph in medicine. It is where options run out, where treatments end, where the final desperations of hope surrender. It is failure.
But of course, death cannot truly be the enemy. It is the common end to every story. We do not own life, we wear it for a while. It does not belong to us permanently; it flows through us. Death is no more enemy to us than autumn is to summer; it is what happens next.
Indignity is the enemy. Pain is the enemy. Suffering, in all its vast vocabulary, is the enemy. Death figures in this, of course, for untimely death is the greatest indignity. Our losses to death as we linger here are the most excruciating pain. Death is the remedy for dying, but the root of ineffable sorrow and suffering for those of us it leaves behind.
Death is the enemy, and it is not. Death is simple and inevitable, and inexplicably complicated.
So it is that when a notice from the American College of Physicians, in which I am a fellow, turned up in my inbox this week telling me that "we" were advising the Governor of California to veto the "End of Life Option Act" just passed by the California State Assembly, I was a little upset. The bill in question would allow physicians in California to help patients end their lives willfully. This right is already established as law in Oregon, as it is in other countries.
I favor such legislation for the most visceral of reasons. I can imagine, and have, scenarios in which the surcease of my own life would confer more comfort and preserve more dignity than any manner of preserving it. I have been goaded into just such morbid imaginings by the real-world miseries I have witnessed over the course of my medical career. I have long felt that if I could envision a scenario in which bringing my own life to a close would be the preferred option, then denying that option to others was hypocritical at best.
So, my immediate response to my organization's letter was a bristling resistance. But I stifled that impulse long enough to read the letter in its entirety, and I have to say- I was impressed. The ACP has a long track record of devotion to the best interests of patients that has made me proud to belong. This is distinct from the AMA, for instance, which largely prioritizes the interests of its physician members. One might like to think these are invariably confluent, but of course it is not so- or the whole patient-centered-care movement would be moot. It is not moot; it is much needed.
I respect the ACP, and read their letter accordingly. It persuasively situates their objections to the bill in California in the context of their established code of ethics. It argues that the willful pursuit of death is at odds with the imperatives of medicine, but that extreme devotion to comfort and relief of all varieties of pain is not.
The ACP acknowledges that at times, the relief of pain may, ineluctably, accelerate death- and this is ethical. Death as a by-product of pursuing comfort is permissible; the pursuit of death is not. The case is passionate, thoughtful, internally consistent, and poignantly -- human. The ACP argument relieved my initial resistance, and replaced it with ambivalence.
As a physician, it is not my place to tell my patient what to do; it is my job to tell my patient what's what. The patient decides; the patient is the boss. It is my job to be an adviser, a teacher, a coach. In that role, I have always paused before offering any important guidance, based on training and knowledge, and run it through a filter of raw emotion: what would I do if it were about me? What would I recommend if this were about the person I love most in the world? I have applied that measure consistently across 25 years of patient care. I have always felt that the trappings of medical expertise that make doctor and patient a bit different were most securely situated on the bedrock of the humanity that makes us profoundly the same.
If it were me, I could well imagine those situations where life is no longer liveably intact. I could well imagine scenarios where the best recourse for the relief of pain in its maddening chorus of many voices -- is to relinquish the tattered remains of life, to silence the din, to let go. I could well imagine a final, evanescent gratitude for those helping to gentle me into that night, good or otherwise.
For having imagined my own way into that dark corner, while fully sound of mind and body, I have long felt that others could do the same. I have thus long felt that all should have recourse to the way out I would want for myself.
The difference, then, between the ACP's well-argued position and the personal conviction I have long held reduces to something much like, though a bit distinct from, semantics: the semantics of suicide. Approaching from one side, there is the overt allowance for scissors in the hands of the clinician who willfully applies them to sever the exhausted tether. Approaching from the other, the ministrations of that hand in the service of final comfort may cause that tether to fray a bit faster, and without regret, but also without that specific intention.
Facilitating death to provide comfort, or fostering comfort that facilitates death are alike enough to evoke musings on semantics, yet, apparently, different enough to argue for an executive veto affecting the rights of the 30 million souls who call California home. The difference is, paradoxically, reducible to nearly triviality, yet redolent with terrible portents.
I am ambivalent about the proposed veto. Such are the semantics of suicide. However we define the intention, much depends on its execution. Much depends on the applications of that hand, reaching through the shadows, to find us in that final corner.
Perhaps, then, the approach to this most ultimate of human need is a distraction from what matters most. Perhaps it matters less whether a hand devoted to comfort causes a life line to fray, or a hand inadvertently parts the haggard, final strands of that line in the service of elusive comfort. Maybe all that matters is the comfort, and the fidelity and fervor with which it is rendered, the ethical imperatives it unfailingly serves. In this, the ACP and I seemingly agree.
There is comfort in that. Veto, or no veto, should we find ourselves in that darkest of corners, a hand should reach out to us -- and provide the solace we need.
Director, Yale University Prevention Research Center; Griffin Hospital
President, American College of Lifestyle Medicine
Founder, The True Health Coalition
Author: Disease Proof