A 'right,' but not always a desire to die

July 05, 1996|By Ellen Goodman

BOSTON -- In some ways, pain has always been at the heart of the matter. It's pain that put the mercy in mercy killing. It's pain that makes death seem to many the lesser of two evils.

Videotapes of suffering are what made jurors acquit Jack Kevorkian. Descriptions of suffering are what infuse the right-to-die arguments on their way to the Supreme Court. And pain, unremitting and unrelieved, is what most healthy people imagine when they favor physician-assisted suicide.

But what if most terminally ill people who consider suicide are not driven by pain but, rather, by depression? What if the very patients who are suffering are less likely to favor physician-assisted suicide or euthanasia? What if, indeed, more than a third of those patients said they would be less trusting of a doctor who mentioned aid-in-dying?

These are three of the findings of the first extensive survey of attitudes among American cancer patients.

The world's first law allowing voluntary euthanasia went into effect Monday in the Northern Territory of Australia. Similar laws are in the pipeline in our country. Attitudes are in flux.

But the survey published just last week shows us how little we actually know as we slip and stride across the borders of this new ethical frontier.

For years, Ezekiel Emanuel, an oncologist and ethicist at the Dana Farber Cancer Institute in Boston, has followed the debate over physician-assisted suicide. He's seen the issue driven by anecdotes and assumptions. Now he has surveyed the real ''actors'' in this issue: cancer patients and doctors.

Cancer patients, after all, form the bulk of the potential ''clientele.'' In the Netherlands, 70 percent of those who choose euthanasia have cancer. In America, about half a million people a year, one out of five, die from it.

When he started the survey, Dr. Emanuel expected that patients in pain would be the ones who asked their doctors for help or hoarded pills or read the how-to chapters of ''Final Exit.'' Indeed, cancer patients as a whole strongly approved of the option of assisted suicide for patients in severe pain.

But the patients in pain didn't show the most interest in suicide. The prime candidates were people suffering from depression as well as cancer. Now he says, ''When your hypothesis is disproved, you wake up out of a stupor.''

'Being a burden'

In some ways, this was not so surprising. In the Netherlands, only half the patients who choose euthanasia cite pain as a reason, and only 10 percent cite it as the sole reason. Similarly, a survey of doctors in the state of Washington suggests that these patients are more concerned about ''loss of dignity'' or ''being a burden.''

But this is the first survey to really parse out a question long lingering at the edges of this argument: When is the demand for help-in-dying really a cry for help-in-living?

Depression in terminally ill cancer patients may not be a temporary case of the blues. As Dr. Emanuel says:

''There is this view, of course they're depressed, they're dying. But there isn't any necessary relationship between depression and dying. Nor does it mean that depression can't be treated.''

It does mean we must scan entreaties for a ''final exit'' with deep skepticism before we simply affirm their ''right to die.'' Indeed, Dr. Emanuel wants to study what would happen if we treated depression. Would it affect the patient's interest in euthanasia? If so, how should it affect our policy?

Patients with incurable cancer may not be like patients with Alzheimer's or Lou Gehrig's disease. They face a different dying. And some people experience the precise, unremitting suffering of our worst nightmares.

But if, as the survey suggests, those in manageable pain are less likely to favor euthanasia than the rest of us, it may be a subtle warning. They may be more wary of a health-care system allowed to choose between the complexity of managing pain and the convenience of assisting suicide.

Today, a shaky majority approves of doctor-assisted suicide. We want it for ourselves. We want it in case.

But the very center of the moral consensus rests on the idea of mercy. Real mercy, these days, in this climate, may come only with elaborate safeguards.

We can ensure an easier, gentler death. But beware of society's easier, harsher way out.

Ellen Goodman is a syndicated columnist.

Pub Date: 7/05/96

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