Glancing across the headlines and tuning in to the sound bites of angry protesters, it is remarkable to witness the various demonstrations of the qualities that make us human. Unfortunately, these demonstrations often display the ugly sides of our nature: the twisting of truths into fear-inspiring slogans, the murder of Kansas abortion practitioner Dr. George Tiller, and the carrying of an unconcealed firearm to the President’s town hall meeting in New Hampshire (legal, yes, but is there any question of the message this man was trying to send?).
The subject of health care – tending to our sick – is called a “deeply personal issue” by some, but it may be more accurately described as a “deeply interpersonal issue”: our distant ancestors, the first humans, broke with thousands of years of prior evolution to abandon the doctrine of strict Darwinism (the survival of the fittest, every man for himself) to care for our injured and sick and thus achieve a different type of community existence. Who will argue with the brilliance of the past few millennia of sophistication, cultural and technological development, and vastly improved quality of life? In the process of healing and caring for others, humankind has learned to shed suspicion and fear in order to trust another to aid one’s return to health. And yet, although we might see ourselves as more evolved, more advanced, more free, many of us still tend toward our old habits: terrified of the involvement of others in personal matters (e.g. invasion of privacy), the need to dominate others in lieu of being overpowered (e.g. shouting down others), and the fear of losing that to which we are entitled (e.g. rationing).
Underlying the landscape of fear is the one thing as of yet unachievable by the American dream, the holy grail of our modern age: immortality. Our people, our society, is deeply afraid of death in all of its forms: we are unwilling to think of it, unwilling to face it, and unwilling to admit that it may one day visit us – our loved ones, our friends, our parents, our children, and ourselves. Is our species a victim of its own success in its everlasting quest to prolong life? Is death so unfamiliar, so foreign, a thoroughly unwelcome stranger in our lives? Coupling our deep-set suspicion of others, of authority, with the thought of discussing the topic of dying, we suddenly work ourselves into a frenzy over state-mandated euthanasia. Who would want to talk about dying? How can any discussion of death be benign? Such are questions asked by those who have never seen excruciating pain in the eyes of someone who cannot speak, someone suffering in a frozen tomb of a paraplegic body. Such are questions asked by those who have not reached a stage of life where they can imagine being satisfied with the years gone by, with a life lived as fully as one can ask for. Such are questions asked in a society where the process of dying is hidden and enclosed within four white walls and the fog of privacy. In our society, families talk about death about as much as parents talk to their children about sex. It’s not prohibited as in some cultures, but it’s not welcomed either. Perhaps no life is lived perfectly, no life has a perfect ending, but every story, every life has an ending. Is it too much to ask to allow those who wish for it to know what’s to come, to plan ahead so that the process of dying is not as prolonged or painful?
One of the most important roles of physicians is the role of the guide: we might not always be able to save a life, but we can guide someone through sickness and death, where most people fear to tread. We save lives when and where we can – and we’re usually very aggressive about it – but there are times when our life-saving techniques and technologies lead to more suffering and pain. There is no role for physicians in assisting or intentionally causing death, but there is definitely a role for physicians in advocating for a patient with respect to minimizing suffering and pain. Most people would agree that they wouldn’t want to live the rest of their lives on a ventilator, with a needle in the neck and one in each arm, with a plastic tube through one’s urethra and another into the rectum, and the lowest likelihood of ever leaving this state of existence while alive. Of all the people in the world who can comment on life and death issues, physicians are the only ones who know whether or not their methods and treatments can help a patient recover some quality of life, whether independent or supported. Who honestly thinks it is a good idea to discourage physicians from taking this role as guide, leaving patients to squander in confusion and despair in the last months or years of their lives without any direction?
We may imagine that we are invincible, that we are immortal, but our bodies are more fragile than we would like them to be. It is not without reason that it is common for medical students to go through a hypochondriac phase: how can we live life knowing the hundreds of debilitating mistakes we can make with each passing moment, the thousands of ways in which our bodies can deteriorate and fall apart? The most common and adolescent response at our disposal is also the first stage of the grieving process: denial (that we, and our loved ones, will die). Many of those making headlines today have reached the next stage: (irrational and misplaced) anger – at the government for trying to “get between me and my doctor,” at doctors and hospitals for trying to “tell my mom and dad that they won’t receive care at the end of their lives so that they can save money,” and at everyone else for “taking my health insurance away from me.” It may be a very long time before our nation, as a whole, comes to the last stage, acceptance: that we all must die, that death is not shameful, that dying is natural – some even argue for the “right to die.”
The human body is an amazing creation, but like all machines, it will eventually reach a stage when it is irreparable and unable to function meaningfully. Determining what is irreparable is in the hands of the doctor; determining what is meaningful is in the hands of the patient. Finding the overlap between these two is the purpose of end-of-life discussions. At this time, these discussions don’t occur frequently enough, and not enough patients have living wills or powers-of-attorney to clearly designate their wishes. What many people do not understand is that doctors are not required to “do everything”: a patient or his family may “ask for everything,” but physicians can proclaim life-preserving measures futile and discontinue medical support. There are, of course, measures in place to prevent this power from being abused, and furthermore, physicians are in the practice of saving lives: the default is to do everything. If a patient can communicate and is conscious and competent (e.g. not delirious, suicidal, etc.), there is no problem: he or she can clearly say “I want to live” or “I am ready to die” and we can continue to do our work either way. However, too often we enter situations where a patient temporarily or permanently unable to communicate is stuck in limbo in the Intensive Care Unit: unable to survive without aggressive (and either painful or uncomfortable forms of) life-support from ventilation, intravenous fluids and nutrition, etc. Out of habit, the children and spouses of these patients often want everything done to keep their loved ones alive – at any cost. Unfortunately, that cost is not only paid in dollars but also in pain and suffering for the patient.