On trial -- how we die

Timothy E. Quill

September 28, 1993|By Timothy E. Quill

AS Dr. Jack Kevorkian faces trial -- and another hearing this week -- on a charge of breaking Michigan's law against physician-assisted suicide, one might ask what should really be on trial: Dr. Kevorkian, the law or our treatment of dying patients?

The disturbing background of this case has been chronicled extensively in the media -- 16 desperate people directly assisted in suicide by Dr. Kevorkian, a pathologist with no clinical training; a law specifically enacted to control him, then blatantly violated when he continued his chilling crusade by openly helping two more people to die.

Dr. Kevorkian's provocative actions have helped to galvanize people in this country who are trying to take charge of the way we die, which has become increasingly dehumanized.

Many in our society regard him as a hero. He has brought new attention to the suffering of dying patients and has challenged medical and legal establishments that have We should all be troubled that he helped put to death 18 people whom he barely knew, and did so evidently without doubt or personal struggle.

been slow to address troubling ethical dilemmas intensified by technological advances in medicine. He is a man with a mission who keeps his actions in the public eye and is willing to risk imprisonment for his beliefs.

Yet there is a distressing arrogance and superficiality in Dr. Kevorkian's approach. He has little experience working with or learning from severely ill people who are finding other ways to face death.

He acts with seeming ease and rapidity that trivialize what should be the most profound of human decisions. In the news stories about Dr. Kevorkian, there is often more focus on his suicide machines and on his personality than on the actual experiences of the people who seek him out. He reinforces our society's penchant for seeking quick technological solutions to complex human problems.

We should all be troubled that he helped put to death 18 people whom he barely knew, and did so evidently without doubt or personal struggle. We should also wonder about a medical and legal system that could leave suffering patients so desperate.

The Michigan law, hastily enacted in response to repeated provocations and mounting public pressure, is clearly an ineffective response to a complex social dilemma. The law does not begin to address any of the underlying legal uncertainties that contribute to doctors' inadequate treatment of dying patients. Consider these four facts:

It is legally safer for a physician to confront death with an automatic technological fight for life, even when it overrides the wishes of a dying patient or his family, than to help the patient die comfortably.

It is legally safer for a physician to undermedicate a dying patient in severe pain than to risk being accused of deliberately hastening death by using high-dose opiates.

It is legally safer for physicians to turn their backs on suffering patients who want to die than to thoughtfully discuss options with them.

In those rare circumstances when a patient is suffering intolerably and desperately wants to die, and all alternatives have been exhausted, the doctor willing to help must act in secret collaboration with the patient, without the benefit of outside consultation and support.

Such patients must often die alone to avoid implicating their doctors.

Michigan's legislative quick fix does nothing to clarify these issues. When considering the real needs of dying patients, one must ask questions of both Dr. Kevorkian and the Michigan law.

Does either promote a committed relationship between doctor and dying patient? No. Dying patients need doctors who will unflinchingly stay by them to the end, increasing their choices as much as possible.

Do they promote better medical care for the dying? Again, no. Hospice care, which can offer good palliative treatments for the dying at home or in a homelike setting, ideally with the participation of nurses, members of the clergy, social workers and others, should be the standard of care for the dying.

Yet hospices remain underfinanced and underused.

Assisted death should not be an alternative to hospice care; it should be considered only in the rare, troubling cases when suffering becomes intolerable.

Neither Dr. Kevorkian nor the Michigan law has much to teach us about translating the ideals of palliative care into legally acceptable approaches to the complex dilemmas of dying.

Those dilemmas are merely evaded by Dr. Kevorkian's actions. And legal prohibitions tell doctors what not to do but provide little direction for what they should do.

Finally, do Dr. Kevorkian and the Michigan law increase or decrease the options available to dying patients? They do neither.

Kevorkian has shown us the option of a quick and easy death and has been a lightning rod for public fear of being medically abandoned if dying becomes intolerable.

But a patient's request for death is a cry for help, and just what kind of help can be discovered only through careful exploration. In my experience, only rarely do such inquiries reflect a true desire to commit suicide.

We need to resist the wish for a simple solution. Between Dr. Kevorkian's quick fix and rigid laws like Michigan's lies the hope of improving humane care and increasing options for the dying.

But we must have the courage to keep searching for the landmarks of a middle ground.

Timothy E. Quill, a physician, is author of "Death and Dignity: Making Choices and Taking Charge."

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