Your Patient Is Dying

Your patient is dying. He has only a few months to live, perhaps weeks. Treatment is useless, except palliative care. He is of sound mind, however, and does not wish to endure the road that lies ahead. It will be painful, especially at the end. This much is clear. As a resident of the state of Oregon, he requests a lethal dose of medication that will end his life on his own terms; ending it when he is ready. Not now, but when he is ready. Maybe he won’t even need it, but just in case, he would like the option to die with some dignity. His petition passes the medical review board, and he asks you for the prescription. Do you write that script?

Your patient is dying. She’s been dying for years actually. Cancer. The only difference now is that there is no more treatment. Treatment would only cause more pain and suffering, with no chance of fixing what is already broken. But she’s already in pain, and a significant amount of it at that. Morphine has become the only means of controlling it, but the pain is too much. She needs more. More morphine may kill her though; an overdose can cause severe respiratory depression, followed by death. She begs for more from the hospital bed, writhing in agony. She only has a week or two left. Do you give her more? More will kill her. Do you write that script?

Your patient is dying. Again, she has only weeks to live. She is of sound mind, but her body is deteriorating. She has Amyotrophic Lateral Sclerosis (ALS). This is a disease where the neurons that control voluntary muscle movement degenerate. She can no longer move. Control over the bladder and bowels has ceased. Soon her respiratory muscles will cease functioning as well, and she will die of asphyxiation. It is truly a terrible way for one’s life to end, entombed in one’s own body. Your patient wishes to die now, leaving this world on her own terms, but she can no longer move, and thus cannot take any medication herself. You, her physician, must do it for her. Could you administer life-ending medication? Do you write that script?

Your patient is dying, although he’s not eligible for hospice. It could be six months; it could be six years. We just don’t know. But your patient knows that his family can no longer afford his medical bills. He cannot work, and his chronic conditions have already broken the family bank. He knows that everyone is better off without him; heck, his son has already said so underneath his breath. But he heard. Instead of years of medical bills, hospitalizations, emergency surgeries, and pain, none of which he can afford, why not leave this world now? That’s what he’s asking. It’s rational; he’s rational. He just wants something that will make everything easier for his family. If you don’t help him, he’ll do it himself he says, but it would be messy and he’s not sure he can do it. Help me, he pleads. Do you write that script?

Your patient is dying, although not in the usual sense of the word. She is nineteen, but everyone begins dying from birth. The ratio of person to death is 1 to 1. It is indeed inevitable. Your patient simply does not like her life and believes that no one loves her. Her family is gone, and doesn’t think she can go on. She wants to kill herself. Do you give your patient what she wants? Do you write that script?

These five scenarios represent a continuum, a spectrum of patients that face their potential and inevitable death. On the one hand, we have a vignette that is perfectly legal in Oregon. Terminally ill patients with less than six months to live may request a prescription to end their life on their own terms in that state. Only about half these patients will even fill this prescription after requesting it, and an even smaller percentage will ever take it. But legally, as a physician, you have every right to write that script. You will not be sued, and you will not lose your license. You are providing a service to your patient under the Death with Dignity Act; final request to help them die in a way they feel is best for them.

On the other hand, I’ve provided a scenario where you will lose your license, and another which is illegal. There are always people who wish to end their own lives. I remember when I was working as an EMT, I saw a patient who had inflicted many wounds upon herself and begged us to let her die. The patient’s mental status was altered, and it was our duty to provide lifesaving care. We would have been sued if we did not. In this country, suicide is not a right.

Physician assisted suicide and euthanasia were the topics for this week’s Medicine and Society class. These are contentious issues that evoke soliloquies concerning dignity, economics, and the American fear of death. The vast majority of the class decided in the first scenario that not only would one write the prescription, but the patient has every right to request life-ending medication. Two-thirds of all Medicare medical expenses come in the last 6 months of life. Stop being afraid of death and let a person die with an ounce of dignity. In discussion after class, many of us moved through the next scenario without hesitation. The consensus was that our patient needed more morphine even if it would kill her. That was compassion.

But as we went down the list, the moral grounds became foggier (as if they already weren’t foggy enough). Now instead of the patient taking the medication, you are actively ending someone’s life (versus passively writing a prescription or increasing a much needed dose). But aren’t we in the same predicament as Scenario #1? Really the only difference is the patient cannot physically take the meds. You have to pour it down her throat. It’s subtle change perhaps, but it just feels so different. By the end of the session, there was some debate as to whether suicide is a personal decision: whether you have the right to do what you wish with your own body, as long as it affects only you.

This class always leaves me thinking hours after. This time it was days. While I find suicide morally reprehensible, I can completely justify providing a prescription in the first two scenarios. It is the third where I start to draw the line. But physicians, ethicists, and the general public draw this line differently all the time. How am I supposed to know what’s right? And sure, it’s easy for me to sit here and say that I would give a dying man meds to end his life in Oregon, but would I actually do it? Would I actually sit down, put pen to paper, and write the physician’s order for that man’s death. Would that not rest on my conscience and fester. I consider myself pro-choice and I believe that a woman owns her body and has a right to do with it what she wishes up to a certain point. I think in cases like rape and incest I would even be more than willing to perform the procedure. But what if it was some affluent woman who just didn’t want a child and just didn’t want to bother using birth control? Would I be so willing? I don’t think so. I hesitate, even now.

It is easy to argue about death when we don’t know how it feels to die. It’s easy to contemplate writing a prescription when we don’t yet have that responsibility. It’s easy to make decisions sitting in a classroom when nobody’s life is on the line.

It’s hard to know what is right. So when the decisions get tough, and the moral grounds become foggy, will I be ready? Will I know what’s right?

I don’t know. Honestly.