DUMMERSTON — Rachel Cohen-Rottenberg's March 23 Viewpoint, “Death with Dignity bill promises only indignity,” is right on in many respects, but less so in others.
She states that “most kinds of physical distress” that a person in a terminal condition experiences “can now be managed by medication... and if such is the case, why should (he or she) want to end his or her life prematurely?”
It's certainly true now, from what I've learned and observed, that most kinds of physical pain can be relieved, but the caveat is in in the word “most.”
There are some forms of physical pain that are beyond control, such as pain experienced by those with bone cancer.
Further, there is often associated mental, emotional, social, or even spiritual distress, and - for some - other considerations that deny quality of life and provide incentive to not unduly prolong one's physical death when one knows one has an incurable and irreversible disease and a limited time to live.
There is truth in the saying that for some terminally ill people, a prolonged medical fate is worse than death in the kind and quality of life they're made to experience.
The focus on indignity and the equation of indignity with disability for me misses the point in the end-of-life patient choice bill under consideration in the Legislature.
Indeed, the words “death with dignity” miss the point. The point for me is to provide an end-of-life choice for the terminally ill, mentally competent person who makes what the bill calls an “informed decision” to end his or her life.
This person's decision is based on knowledge of one's medical diagnosis and prognosis, awareness of all feasible end-of-life services that are available (including pain control, Hospice care, and comfort care), and the understanding and acceptance of one's family or next of kin.
Dr. Sherwin Nuland, a retired physician who wrote the book How We Die (Alfred A. Knopf, 1993), has in mind the “very small number of people [who[ will remain unresponsive to every measure - pharmacological, psychological, sociological, spiritual - directed by the most expert of palliative physicians toward the relief of their anguish.”
Difficult and morally challenging as the situation may be, the pleas of these people for help in dying need to be honored. For them the prayer of the poet Rainer Maria Rilke rings out: “Oh Lord, give each of us his own death.”
Dr. Nuland, interestingly, is basically opposed to assisted suicide as an end-of-life option, with the exception noted above. In an article he wrote for The New Republic in 2002,“The Principle of Hope,” he sets forth essential points that should be taken into account if people are to be granted the right to be given help in dying.
In summary, the terminal person's choice to die must, first of all, be defensible to the people to whom the dying person is closest.
Second, the dying person's request - or repeated requests - must be made to a physician with whom he or she has a longstanding relationship.
Third, to ensure that all therapeutic options have been considered and exhausted, the consultant chosen by this physician must be one whose specialty is in the area of the dying person's disease.
Fourth, consultation with a palliative care expert and a psychiatrist experienced with patients at the end of life should be mandatory.
Last of all, he offers the suggestion - and it is only that - that the ideal would be to have “the final consent [put] in the hands of a council of elders, people in a community or institution known for their probity, wisdom, and sense of civic responsibility.” Perhaps a hospital's bioethics committee could fulfill this role.
This approach, with the exception of the last suggestion, is essentially contained in H.274, the “Death with Dignity” bill in the Legislature. Some of the elements in the bill for me need review and tightening, but in the main, the bill is well conceived, based on more than 12 years of experience with the law in Oregon.
Pain Management at the End of Life, a book published by the Hospice Foundation of America, concludes with a chapter on the ethical dimensions of pain and suffering. The author of this chapter, Dr. Ben Rich, has in mind the dying person for whom “the process of dying entails rigors that render consciousness unbearable.”
He quotes Joseph Conrad in his classic novel Lord Jim: “He might have resigned to die, but I suspect he wanted to die without added terrors, quietly, in a sort of peaceful trance. A certain readiness to perish is not so very rare, but it is seldom that you meet men whose souls, steeled in the impenetrable armor of resolution are ready to fight a losing battle to the last.
“The desire for peace waxes stronger as hope declines, until at last it conquers the very desire of life. Who of us has not observed this, or perhaps experienced something of that feeling in his own person - this extreme weariness of emotions, the vanity of effort, the yearning for rest.”