Is it getting harder to die these days?
No one can predict exactly what direction these shifting conversations will take us. But since our decisions about how we face death are bound to have an impact upon the kinds of persons and communities we are and will become, it seems critical to our society's health that we examine the arguments carefully and proceed with extreme caution.
In the past year The Troubled Dream of Life: Living With Mortality (S & S Trade, 1993) by ethicist Daniel Callahan, Death and Dignity: Making Choices and Taking Charge (Norton, 1993) by physician Timothy Quill, and How We Die: A Reflection on Life's Final Chapter (Knopf, 1994) by physician Sherwin B. Nuland have critically examined our modern experience of death and found it seriously wanting. Though they offer differing prescriptions for the problem, Callahan, Quill, and Nuland seem to agree that in our pursuit of--and sometimes obsession with--the magic bullets and miracle cures of modern medicine, we have lost what earlier ages called the ars moriendi: the art of dying well. In the past, Callahan argues, death was normally a public event in which people had the chance to bring their affairs and life to a close in the prayerful and supportive company of friends and family. Persons and society had familiar and established ways of facing and moving through the pain and grief of death. (Last year's Michael Keaton film, perhaps not so ironically titled My Life, offered an example of the sort of tame and peaceful death Callahan envisions.)
But modern death has become something increasingly wild, a protracted, even interminable, process in which dying patients--and their doctors and families--are unsure whether to prepare for death or rage against it. The dying are progressively isolated from their surroundings, families, and consciousness, moving through a series of diminishing half-lives that end not with a bang but a whimper.
Nuland complains that in the zeal to treat and cure diseases modern medicine too often exposes dying patients to a three-fold abandonment: keeping them ignorant about their prognosis, overtreating them with increasingly futile remedies, and, finally, walking away when a cure is no longer possible.
And indeed many Americans seem increasingly uncomfortable with the wildness of modern death, even willing to embrace some very radical solutions.
In 1991 Derek Humphrey and the Hemlock Society published Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide and this suicide cook-book became a runaway best-seller. The same year physician Timothy Quill reported in the prestigious New England Journal of Medicine that he had assisted in a patient's suicide, and he received a good deal of support from his medical peers and no criminal sanctions from the state.
And, of course, you would've had to have been in a cave to have missed the press coverage of the continuing adventures of retired pathologist Jack Kevorkian, "Dr. Death," who from 1990 to 1993 assisted in 20 suicides, confounding every effort of the Michigan legislature and criminal-justice system to bring his killing spree to a halt.
While prominent ethicists and physicians consistently decried Kevorkian as a rogue and an aberration, reports of his antics found an amazingly voracious and supportive audience, clearly striking a resonant chord among many patients and doctors.
Indeed, polls consistently show dramatic increases in support for euthanasia and physician-assisted suicide among both physicians and the general public, which may explain why recent ballot initiatives in California and Washington in support of these practices failed by narrow margins and why similar initiatives are scheduled for several states in the next two years.
As more than a few ethicists and commentators have suggested, the popularity of Kevorkian and physician-assisted suicide is in no small way an indictment of the way modern medicine is bringing us to death.
Many critics argue that a good or peaceful death has been the casualty of a medical profession overly committed to waging a high-tech war against death and disease and insufficiently skilled at basic patient-care issues, such as communication and pain management. As a result, we end up with too many physicians who, seeing every death as a personal and professional defeat, fail to notice that their patients have slipped beyond curing and that it is time to turn off the machines and help them to die well.
According to this critique, the way to recover an ars moriendi is to restore patient autonomy and to make dying patients and their families full partners in end-of-life treatment decisions. So the past decade has seen a tremendous push for living wills and other advanced directives, while more and more families in hospital waiting rooms find themselves asked if they want "everything done" for their beloved.
Yet overall, these steps have not helped patients die well. Too many patients and families experience these choices as extremely burdensome both because they are unequipped to make good medical judgments and because their fear of not having done enough for a loved, or not-so-loved, one often traumatizes them into asking for overtreatment. Indeed, for every story about a doctor refusing to deescalate treatment, there is a tale of a family requesting, even demanding, futile medical treatments for their dying relative.
So while the recovery of an art of dying well does require a medical profession more committed to patient care and better skilled at communication and pain management, Callahan has suggested that a deeper problem is that all of us, patients and physicians alike, have lost a shared sense of death as a part of life and a good death as a part of good medicine.
With the modern conquest of so many diseases and the development of ever new treatments, we have become so adept at postponing death that it has become a moveable feast.
But we have begun to think that that which can be moved can, and should, be removed. So the goal of medicine has shifted from caring for patients to curing all diseases, and we have moved from trying to end the untimely death of the young or able to the practice of pushing back and delaying every death, often at disproportionate cost.
We have forgotten that every life ends in death and that one of medicine's most important goals is to help us die well. This forgetting has not stopped our dying, it has only stripped us of the chance to prepare for and face our dying well.
As we've seen, one increasingly popular solution to the wildness of modern death has been the option of physician-assisted suicide. Many believe that by picking the time and place of their dying, patients and their families can escape a double threat of suffering and indignity. They believe they can avoid the misery of an intolerable terminal disease, as well as the degradation of a deepening dependence upon evermore aggressive, invasive, and futile medical treatments. Furthermore, and perhaps just as important, physician-assisted suicide, the argument goes, would allow patients (and their families?) to face death with dignity by allowing them to take charge of their dying.
Finally it is argued that there is really not much difference between allowing a terminal patient to die by withdrawing treatment or stepping in to hasten that death to relieve useless suffering. In one stroke intolerable suffering and the indignity of dependence would be replaced by an autonomous act of conscious persons facing their own death while no real harm would be done. In a society that abhors suffering so deeply and values self-determination so highly, it is easy to understand the growing appeal of this option.
And yet, as much as we need to recover an art of dying well and as much as supporters of physician-assisted suicide promise it will do this while protecting fundamental American cultural values, such as liberty and the pursuit of happiness, there are a couple of reasons to suggest that this is not the path we should follow.
To begin with, sanctioning physician-assisted suicide is fraught with grave moral dangers and could well offer us a cure far worse than the disease. Second, at least for Christians, this approach reflects a seriously inadequate grasp of the meaning of human suffering and dignity.
The first ethical problem with implementing physician-assisted suicide is that it puts the cart before the horse by failing to address the fundamental problems of patient care, communication, and pain management and attempting once again to solve a human problem with a technical fix.
There is no reason to believe that allowing physicians to end their patients' lives will improve their commitment to or skills in caring for the dying. If anything, this option offers physicians who find death hard to face a new and fourth way to abandon their dying patients.
Second, this approach would in one blow trample underfoot age-old bans against rendering harm--primum, non nocere--and the killing of the innocent while introducing the killing of patients as a part of the practice of good medicine. Certainly this sort of radical tampering with the cornerstones of Western ethics and medicine is something that ought to be done, if at all, only for the most serious reason and as the last possible resort.
We should at least try to address patient-care issues before taking this leap. And there are bound to be abuses. The vast majority of persons contemplating suicide are suffering not from a terminal or incurable disease but from clinical depression, which is medically treatable. Second, in Holland, where physician-assisted suicide has been in place for a decade, there is very little supervision of this practice, and it has become clear that many nonconsenting patients--minors and those incompetent to decide--are now being killed by their doctors. And third, as we Americans continue to feel the increasing crunch of our national health-care budget, isn't it likely that our "useless" and costly elderly will feel even more pressure to request suicide while many physicians will feel obliged to apply bedside rationing by "assisting" incompetent patients in their dying?
But even if there were no ethical problems with this option, physicianassisted suicide raises some deeper questions about suffering and dignity. As Christians, we feel a strong moral obligation to relieve human suffering, and we certainly support medicine's commitment to do so. There is altogether too much senseless suffering in our world, and we see indifference to the suffering of others as a grievous sin. And yet Christians do not believe that all human suffering is meaning-less or even avoidable. Suffering is a part of our humanity, a humanity that God created and embraced in all its fullness and frailties.
As Christians, we believe both that the suffering and death of Christ is redemptive and that we may find meaning in our own authentic suffering--whether facing the limits and frailties of our humanity or standing in loving solidarity with our suffering sisters and brothers--by joining it to Christ's. Thus a Christian would have good reasons to be uneasy with any proposal that tries to relieve suffering by attempting either to escape the limits of being human or by banishing our suffering neighbor from our presence, and physician-assisted suicide seems to do both.
Sometimes the hardest human suffering is found in helplessly accompanying our suffering neighbors through this vale of tears, but for the Christian it is hardly the most useless.
And what about dignity? Supporters of physician-assisted suicide argue that we can restore dignity to the dying by giving them control over their deaths, for it is autonomy and self-determination that gives us dignity and makes us persons.
And yet, as critical as autonomy is, it is not true that we lose our dignity by being dependent on others or even by being plugged into machines. For large parts of our lives we depend upon the kindness of others, and we are not diminished by that dependence. We are born weaker than kittens and grow old blinder than bats, and we are all the while the children of God. It is a dangerous thing to say that it is only in our autonomy that we find dignity and only in controlling the time and place of our death that we die well. As patients, we will find our dignity not only in the way we change our world but also in the way we face the things we cannot or should not change. And as caregivers, we will find our dignity in the ways we treat the dying with honor and compassion. We cannot restore dignity to the dying simply by unplugging a machine or allowing them to pick the moment of their exit. Dignity is found in the way we face our dying as persons and neighbors.
In the end recovering an ars moriendi for the modern ear means recognizing that death is a part of life and that preparing for a peaceful death is a part of good medicine. That could be hard in a culture as deathdenying as ours, but as Christians, we do have some helpful resources.
We know from the New Testament that in Christ's incarnation God embraced all our humanity, including our death, and Saint Paul assures us that death is not an end or a failure but a change. So while Christians feel the full weight and anguish of death's loss, it does not represent an annihilation to be avoided at any cost.
We will indeed hope and pray with the best for a recovery or cure while still wishing for a good death, a death affording us the chance for forgiveness and farewells in the company and care of loved ones. Achieving this sort of peaceful death more often in our society will require a recovery of care as the primary mission of medicine, a care that goes on long after the cure has run out.
Improving our personal chances of a peaceful death will depend in part on how we prepare for death. But while this preparation may certainly include conversations with our loved ones and doctors or the filling out of advanced directives or living wills, it will more likely depend upon how we live in the present, as well as how we live up against our dying--for as Nuland says at the close of How We Die, the real ars moriendi is found in the ars vivendi: the art of living.
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|Date:||Oct 1, 1994|
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