LIVES IN THE BALANCE TIMES, AND ATTITUDES TOWARD EUTHANASIA, HAVE CHANGED.

Byline: Jonathan Dobrer Local View

THE current hit film ``Million Dollar Baby'' brings up the always hot-button issue of euthanasia and assisted suicide. This is an important topic to discuss with sensitivity and respect.

This is an area of medicine that has changed dramatically during my life. When I was young, there were no hospice programs. Many sick were kept, not living, but dying, because death was the enemy and the battle was fought on the body of the patient. Every death seemed a failure of medicine.

Patients and families were often kept in the dark and information withheld so as not to remove ``hope.'' This is still often the case.

When the doctor told my stepfather that there was nothing more he could do for him, my mother was furious. She wondered how a doctor could take hope away. I asked how she or my stepfather could make intelligent decisions without getting real information. She understood my point, but still had trouble accepting a straight conversation about death.

Later, when she was undergoing a medical crisis, I asked were her heart to stop if she wanted it to be restarted. She said no. She survived that crisis but no longer saw death as the ultimate enemy. She came to believe that pain and suffering were her foes and death, in the words of Walt Whitman, could be a ``Deliveress.''

When she had a massive stroke and her higher brain, the part of her brain that made her my mother, was gone, there was no question between my brother and me; we did not want to prolong her death. We stated this clearly to her doctors, and they raised her morphine level, in theory to ease the struggle of her Chain-Stokes breathing, but also knowing that it would depress her respiration and she would soon expire.

Forty years ago, this would have been a hit-or-miss decision, probably not discussed with family but carried out according to the view of the doctor. Years ago families and patients had to fear the insertion of breathing or feeding tubes because it was almost impossible to get them removed. Some people, who might have lived, died because of a well-founded fear of losing control over their own fate. Such are the unintended consequences of medical and moral rigidity. Today things are generally more open.

We have begun to understand that there is a difference between prolonging life and prolonging death. Sometimes the call seems easy, at least intellectually; but hard calls, those people and conditions in the broad and blurry middle, should always be terribly difficult.

Just as there is no magical quarter inch where short becomes tall, yet we can agree that Shaq is tall and Mickey Rooney is short, there is no sharp border between when we are living and dying.

We cannot think of the people whom we love as things to be cast aside when infirm. Nor should we do our moral calculus as a monetary calculation.

Insurance companies do this. They weigh cost versus benefit. Do they give a new young heart to a 60-year-old who is fit and has a bad heart from an infection but not to the obese smoking couch potato? Do they run actuarial tables and prorate care? They do.

Do we continue to spend 80 percent of a person's total lifetime medical costs in the last year of their lives? Or do we do formally what we have done on an ad hoc basis: withhold care from older people and bad risks? Please do not offer easy answers. These are critical questions about which society needs to have a deep conversation.

One fear that people who oppose all forms of euthanasia legitimately have is that legal decisions and societal attitude will become conditioned by economics. We will accept aggressive end-of-life procedures because we do not want to pay, either through insurance or our own personal funds, for the care of the sick or elderly.

Do not dismiss this fear. Just look at the report that showed 33 percent of personal bankruptcies were based on medical costs - and over half of those families had medical insurance.

Do we, as a society, decide that life is not worth living if you are depressed or paralyzed, if you are in irremediable pain? And if we don't decide, who does? Who decides your fate if you are depressed and want to die, but your doctors and family believe your depression might be transitory? How long do you wait? How long a coma or depression is enough?

If these seem to be easy questions with absolute answers, I suggest you rethink them. These are not easy questions with always obvious answers.

I have always found it helpful to ask what I think I would want for me - and not let love or guilt overly sway me (though sway me they must). I must also know that this is only theoretical, because it is not me on the table or attached to the ventilator. I have to calculate the chances of recovery and the great question: Am I prolonging life or death? I have to temper my conclusions with humility.

I must ask whether I'm motivated by my pain at seeing someone slip away, or the physical and or emotional pain they are undergoing. There is a slippery slope between compassion for the terminal and casting them aside.

I must deal with life and death with a clear sense of the awesome nature of such decisions and the humility to question myself and allow myself to be questioned.

We, as a society, must take these issues seriously. This is a deeply moral concern that deserves a respectful conversation. It is more than a million-dollar question.

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Photo:

A scene from the movie Million Dollar Baby starring Clint Eastwood and Hilary Swank.