The Question of Dying

Introduction

Christine Fong was a mother of three, a diligent and a hardworking individual who immigrated from China as an adult to raise a family of her own. But she was also a woman with late stage bone cancer a fact that became more and more apparent as her fragile years drew on. Pain became not an occasional discomfort, but a persistent reminder of her mortality as her vertebrae vaporized beyond recognition. Although Christine’s cancer entered remission, she reflected on how the treatment drained her physically and destroyed her mental state. Never again, she would say vehemently after each chemotherapy session. So when her blight inevitably rose again, she chose to embrace that which she had run away from for so long. On a warm afternoon in fall of 2017, Christine’s legally-planned departure succeeded as she drank the concoction that snuffed life out of her frail body – with a content smile on her lips, as her daughter Elaine had remarked.

Christine’s story is one of the many that illuminate a historical taboo in medical science. Avoided, rightfully, because it blurs the lines of morality and undermines hundreds of years of Hippocratic advance. And yet in a society where medicine is evolving at an all-time high, the option to abandon treatment and end it all has gained significant traction. Assisted death, termed “medical aid in dying” by proponents and “assisted suicide” by denouncers, is perhaps one of the most controversial practices in the medical field. It is outlawed in the majority of the states, neutrally authorized in five, and at least by virtue of polls, supported by most practicing physicians. Pro-choice organization such as Death with Dignity and Compassion and Dying have surfaced to challenge America’s perception of how, when, and why someone should die, with equal opposition to boot. So how did the conversation turn from one of preserving life to bestowing death?

The Sin of Medicine

Doctors have always believed that they can save their patients. As an aspiring medical student, even I live with the hope that with the right treatment and research, my mother, friends, and future patients can live without ailment. The mistake is believing we can overcome death. Since the foundation of Hippocratic ideals in ancient Greek times, medicine has been thought of as an objective science. Objectivity lends to certainty after all, and when dealing with precarious life-and-death situations, we want to be sure that treatments will cure disease. But where scientific medicine has ushered in reliability and rapid evolution in health care, it has also brought hubris and pride. If vaccines kill measles and antiviruses defeat Ebola, then perhaps we can cure anything at any given time. The belief that preserving life is a practitioner’s chief priority has sentenced many incurable patients to prolonged agony as they instill treatment after treatment to no avail.

It’s ironic to think that the public health crisis of excessive suffering before death is a result of our attempts to save our patients, but this contrast may serve to better understand why medical aid in dying has risen in prevalence. In two recent studies at the University of California at Los Angeles (UCLA), researchers amassed statistics that suggested terminal patients were not receiving appropriate care for their conditions. The first study found that only 23% of patients deemed incurably sick were admitted to hospice care, a form of medical treatment that focuses on providing comfort and mental wellness to those with life-limiting prognoses. The second study found that excessive radiation treatments were systematically prescribed to patients with bone tumors. More specifically, of 54 patients prescribed a single treatment under the center’s clinical guidelines, only one received the recommended dose. Of the other overdosages, 42 patients received 10 or more treatments. Another similar study examined Medicare beneficiaries with and without hospice care, and found that those receiving hospice care had significantly lower rates of hospitalization, invasive operations, and medical costs in the last years of their life. And yet the Medicare requirement for hospice benefits is a prognosis of six months or less, which severely limits access for many patients.

The case of UCLA, one of the forerunning university medical centers in the country, is an example of the overtreatment culture of American hospitals. Doctors and patients, particularly those in palliative relationships, inevitably engage in an unbalanced relationship of doctors prescribing treatments as the patients sit quiet and accept their expertise. It is unsurprising to see, then, that many doctors routinely overtreat patients as their symptoms worsen without any better results. However, due to the difficulty in securing hospice care, many patients have no option but to continue ineffectual treatment, creating a toxic cycle of pain and agony that lasts until death.

The advent of assisted death, while controversial, has served as an answer to this crisis. In the states of California, Montana, Oregon, Vermont, and Washington, patients with less than six months to live are allowed, pending physician referral, to receive a lethal prescription. Since the implementation of Oregon’s Death with Dignity Act in 1997, the first statute to legalize assisted death, nearly 2000 Oregonians have received prescriptions to end their suffering. As of 2016, the annual Medscape Ethics Report poll has shown that 57% of physicians believe medical aid in dying should be an option for terminal patients. The legal push has been so great that while explicitly legal in five states, nine state divisions of the American Medical Association (including the District of Columbia) have shifted their stance from opposition to neutral. With the Massachusetts Medical Society recently adopting a policy of neutral engagement, there is little reason to believe the political effort will slow anytime soon. But is this the right trajectory?

Doctor’s Duty

The patient-biased perspective is a commonly-held view. At its roots, the doctor exists for the people, serving as a public guardian angel of sorts when the evil of illness plagues our bodies. With the landscape of medicine evolving towards a greater focus on public health and patient benefits, our perception of the doctor has accordingly shifted from that of a miracle worker to a compliant servant. Perhaps this is the reason why the larger public is so comfortable supporting euthanasia – when the focus is what we as patients want, it’s not hard to see why we enjoy the power of choice. Supporters of assisted suicide will inescapably relate anecdotes of loved ones’ suffering, cases told from an agonized patient’s view that would be solved with swift toxin. It’s understandable that we are angered by the mistreatment of our patients and are seeking a solution to unnecessary anguish. However, in offering death to the terminally ill, assisted suicide could also destroy an essential aspect of what it means to be a doctor.

We trust doctors with the duty of preserving our livelihood, but where duty lies, there also exists identity and autonomy. Many individuals within the medical field believe that to be a physician is not only to serve the people, but also to be an innovator, problem solver, and comforter. When historically resilient diseases were thought to be incurable, doctors would not recount resignation, but rather vehement research in a forward push against adversity. And when patients lie hopeless and dejected in hospitalization, it was the doctor’s responsibility to reassure them that hope is not lost, that there is always another way. However, legalizing assisted suicide undermines this fundamental savior spirit of the physician. Instead of owning up to our shortcomings and standing up stronger, we allow assisted death as an acceptance of defeat, a letter of resignation that we are no longer able nor willing to pursue further options for treating a patient. Indeed, the mandate of the Hippocratic oath that a doctor must never harm a patient is an ode to the doctor’s conviction in preserving life whenever possible. In this way, by establishing medical aid in dying as a norm in society, the doctor’s identity could very well be nullified.

The implications of assisted suicide are often as blurry as its ethicality. There inevitably arise moral dilemmas that are difficult to address. What if a terminal patient is in the wrong state of mind or mentally insane, yet requests a lethal injection? What if an incommunicable patient’s decisions are determined by a caretaker? The social implications of assisted suicide can be equally difficult to assess. In a culture where suicide is becoming more prevalent, what impact can the legalization of assisted death have on how we view suicide and self-harm? Though we may speculate on how we might address these concerns, the answers to these types of questions are often empirical, in that we have to witness them in real situations to make a judgment. As of now, we have yet to see any negative social or economic effects from assisted suicide in states where it is legal, and this trend of legalizing assisted suicide has shown no signs of stopping. Perhaps only time will tell if we have made the right decision.