The term, “euthanasia” is derived from the Greek and means, literally, good death, and my intention in writing this essay is to focus on what a good death might be using my favourite book about the subject, Sherwin Nuland’s How We Die: Reflections on Life’s Final Chapter, as my touchstone. (Vintage Books, 2010 edition page numbers are used as references.)
End-of-life, Palliative care, physician-assisted death, physician-assisted suicide, euthanasia, “dying with dignity”: however you want to identify the issue, it’s in the news. The terminology is a quagmire and the topic itself is so polarizing that it is impossible to read anything that captures the issue completely. I am not trying to do this, let me qualify this from the outset. I am trying only to set out a few questions about this subject that trouble me in the context of this one book that helps me make sense of many of the confusing elements.
To position how topical the issue of a good death is at present, the Ontario Medical Association President, Dr. Scott Wooder, has made a discussion of the End-of-Life, especially as it relates to best practices in Palliative Care, a focus of his Presidency. He has very ably led in a direction that Palliative Care physicians have embraced, at least in my city. When he was part of a panel last week in Ottawa, many of the physicians in the audience were Palliative Care physicians. By contrast, in Quebec, Bill 52, An act respecting end-of-life care is being debated. Social Services Minister Hivon says the bill is “intended for people at the end of their life to die with dignity.” http://www.cbc.ca/news/canada/montreal/quebec-tables-bill-on-medically-assisted-death-1.1263943 These two examples demonstrate two of the most important aspects of the topic for Canadians and their physicians on this important topic.
As a Child and Adolescent Psychiatrist, death is not a usual part of my practice and so, in the debates of medical associations, I listen to my colleagues’ discussions and think of what my own death will be. A line from the introduction of Nuland’s book pushes through all the discussions: “The quest to achieve true dignity fails when our bodies fail.” As a physician, I am personally determined not to be influenced by myths or ideology about the process of dying.” Nuland stresses that his goal with this book is to “demythologize the process of dying”.
Nuland uses six disease categories, common ones that are responsible for most deaths, to illustrate how we die. These, he tells the reader, “have characteristics that are representative of certain universal processes that we will all experience as we are dying.” His goal is to remind us that the successes of modern medicine have contributed to the fact that many of us delay contemplating death, putting off the task of living wills and advance directives. We have more faith in medicine than we do in the most basic scientific fact that we will all die.
As an example, Nuland discusses cardiac disease and the history of the scientific and medical discoveries that have led to our expertise in the treatment of ischemic heart disease, which is the leading cause of death for most of us in the developed world. He also reminds us, however, that, as we developed greater expertise in treating this disease, “modern biomedicine has also contributed to the misguided fancy by which each of us denies the certain advent of our own individual mortality.”
Another piece of evidence that death is not natural part of life, according to Nuland, is the fact that old age is not acceptable on death certificates as a cause of death. In case regulations have changed, I will just note that this text was completed in 1994. In the 2010 reprint that I have used for this review, Nuland updates many facts but not this one. If one can now write “old age” on a death certificate, please tell me. Even so, Nuland’s rant from 1994 is still worth reading in its entirety, for who does not get fed up with bureaucracy occasionally?
“No one dies of old age, or so it would be legislated if actuaries ruled the world. Every January, just when the harsh autocracy of winter has tightened its hoary hold, the U.S. government releases its yearly “Advance Report of Final Mortality Statistics.” Neither among the top fifteen causes of death nor anywhere else in that soulless summary is there to be found a listing for those among us who just fade away. In its obsessive tidiness, the Report assigns the specific clinical category of some fatal pathology to every octo- and nonagenarian in its neat columns…In thirty-five years as a licensed physician, I have never had the temerity to write “Old Age” on a death certificate, knowing that the form would be returned to me with a terse note from some official record-keeper informing me that I had broken the law…” (Page 43)
When I consider the debate about medically-assisted death, physicians-assisted suicide, euthanasia – any or all of those prickly topics- I want to be clear that the terminology is not being well-defined and this is always the wrong way to start a debate. Whatever euphemism (also from the Greek, for good omen) you intends to use, define it, and start the debate at that point. I have many colleagues who believe that the euphemism “dying with dignity” has stolen dignity from the deaths of those who cannot and will not make this choice, either as a person or as a physician. Like Nuland, again, I believe that “the importance of airing different viewpoints rests not in the probability that a stable consensus will be reached but in the recognition that it will not.” (Page 156)
If medicine’s failure in the debate about the end-of-life is that medical science has, by its success, allowed the myth that death is not a natural part of life to be promulgated, then the media’s failure is that it focuses the debate not on the death that most of us want but rather on the death that only a few have chosen, even in those countries where the voluntary ending of life is not illegal. (WHO statistics are that Euthanasia accounts for 1 % of all deaths in the Netherlands. It should be noted that Euthanasia is still illegal in the Netherlands but physicians will not be prosecuted when certain guidelines are followed.) Also, if you want to confirm that the media is not, in fact, reporting equitably on the debate, Google the term “euthanasia statistics” for a flavour of the press focus. This focus upon euthanasia polarizes the discussion away from the need to develop strategies that strive to ensure comfort at the end of life, especially in old age when it is clear than the body is failing. I want my death to honour the life I have lived and it is not an honour to me personally to have my life extended by futile measures.
Nuland is a medical specialist. He had been Clinical Professor of Surgery at Yale University but he makes a “plea for the resurrection of the family doctor.” He stresses that this “longtime medical friend” is the best guide at our time of dying. I also agree with this. I am confident that my family doctor knows who I am, just as my family do, and I want these people making the decisions at the end of my life, if I can no longer make them for myself.
The final reason that the current debate on the end-of-life does not resonate for me is that, so far, the only people talking about faith in the debate are those who have no doubts about faith at all. I have many doubts about my faith although, like Madeleine L’Engle, I try to “base my life on my beliefs”. I will seek a blessing at the time of my death, although the blessing I want most is the company of my family and their love. I will be buried in consecrated ground – the plot is already paid for. For Dr. Nuland, as for me and many others, faith has sustained us and I want those chaplains who provide comfort to the dying and their families to bring their wisdom to this debate. If we don’t seek out these opinions, I fear only the opinions of the most extreme chaplains will be available to us. That will not be helpful: there are not so many damned as they think. Nuland quotes these lines from a poem by R. M. Rilke, which are spoken as a prayer and I leave this as a last thought from this wise book:
“Oh Lord, give each of us his own death,
The dying, that issues forth out of the life
In which he had love, meaning and despair.”