This post is one of a series of posts wherein Dr. Bossypants explores that final task we all face: Dying.Consider yourselves warned: Being mortal is challenging, and death is a stressful topic. No doubt you will read these posts with some degree of sadness, despair, and denial. However, Dr. Bossypants sincerely hopes readers will consider such matters thoughtfully, and when the time comes to face our own death or that of a loved one, Dr. Bossypants hopes we can act with wisdom, compassion, acceptance, and bravery.
The adjustments required to age without whining and to die without a sense of failure are difficult in and of themselves, but they are made far worse when cultural values run heavily to overvaluing youth and “saving” lives at all costs. Dr. Bossypants tried to lift the veil of shame promoted by big business in our last blog. Now she turns her wrinkled brow and piercing gaze to the vast enterprise we call modern medicine.
Even before the Covid crisis, healthcare was one of the most fraught issues on the global radar. Is basic healthcare a privilege or a right? How are our medical dollars spent? Should providing such care make people rich? Should pharmaceuticals make people even richer? How many lobbyists are enough? Who deserves the more intensive and expensive treatments? Is basic nutrition a legitimate component of healthcare? These are fascinating and divisive quandaries, but they are only tangentially related to the main focus of these blogs: the right to die on our own individual terms.
In future blogs, Dr. Bossypants will consider psychology, biology, and religion as they interact with our widely shared fear of death, but in some ways, the source(s) of human avoidance of death is a chicken and egg question. There’s little doubt that as a general rule, people don’t want to die, and they don’t want the people they love to die. This has paved the way for not only overactive commercial efforts, but also for medical research and practices that may actually contribute to human suffering nearly as much as they do to human wellbeing.
The Medical Mandate: Hippocratic Oath Run Amok?
Healthcare professionals of all sorts have ethics codes, personal and religious values, and legal constraints that guide their practices. These are highlighted and augmented as people are enculturated into their professional identities. Most people have heard of the Hippocratic oath and likely assume that healthcare professionals (other than dentists) are required to “Do no harm.” Just kidding. Dentists are included. Dr. Bossypants has an uncle who is a dentist. That was a private joke.
So, back to the topic. The original Hippocratic oath has been tinkered with repeatedly over time. Translations vary, and certain politically loaded phrases have been inserted or omitted. This reflects the fact that human morality and professional ethics have an evolutionary fluidity that responds to scientific discoveries and political pressures. The real Hippocratic oath is much more nuanced than the simplistic “do no harm.”
Most of us know a fair number of physicians and other healthcare workers personally and/or professionally, but it is unlikely you’ve had “the talk” with any of them. Do you know their views on suffering and death? We assume they favor neither and have devoted themselves to fighting both. This can be a problem because the frame then dictates that death is the enemy—something to be fought, feared, and avoided.
Even though Dr. Bossypants understands that frame, it is out of touch with reality, and it is wrong. Yes, suffering sucks, but death is not the enemy. It is a natural outcome of being human. When people are near death and medical interventions pull them back, their lives should be considered prolonged, not saved. The possibility of a good, humane death versus prolonging the pain or struggles for a short extension of life should always be openly examined.
As we noted in earlier blogs, physicians are slowly coming around to favoring the legal right to be of assistance in dying, but it’s a struggle for many. Healthcare professionals are dedicated to making lives better, healthier, and longer. For many, healing is a calling. They strive to do no unnecessary harm, and most people think of death as harm. There’s some irony in all this. Neurologist and author, Oliver Sacks wrote, “It is the fate — the genetic and neural fate — of every human being to be a unique individual, to find his own path, to live his own life, to die his own death.” Part of responsible health care should involve providing painfree and dignified ways to die when the time comes. And with dogged determination, Dr. Bossypants will continue to bravely point out: The time will come.
Philosophy, Morality, and Medicine
In the fascinating domain of bioethics, a concept called “the technological imperative” is often discussed. In one version, this means if we can do it, we should do it. Applied to medical interventions, this could mean that because we can keep a person in a coma alive indefinitely, we should. Because we can use chemo to control the tumor for two more weeks, we should. Because we can revive a person with extensive brain damage, we should. Given human ingenuity, it is assured that we will continue to develop ways and means to keep severely injured, massively disabled, and/or terminally ill people alive longer than they would have been without these interventions. In many contexts, this is a wonderful testament to the human spirit. But it is not a mandate. It is an option. The real moral mandate is respect for human autonomy.
People have the right to request life-extending medical procedures, and they have the right to refuse these interventions. They should also have the right to request assistance to die (though in many states, this last request will be denied). There are significant physical and economic costs to consider, and everyone has the right to engage in thoughtful conversations with professionals and loved ones to weigh the options. Just because a liver transplant or life on a ventilator is possible, it is not a moral obligation to undergo the procedures that could extend life. Loved ones occupy a certain space in these considerations and most of us value and are influenced by their input, urgings, and permissions. Professionals should provide whatever information anyone wants or needs. It is not morally correct for them to urge anyone to stay alive; it is not morally correct for them to urge anyone to die; and it is not morally correct for them to withhold information or lie about anyone’s condition.
On the other hand, should physicians be required to be of assistance if someone has chosen to die and asks for their help? Of course not. They should neither be required to help nor restrained from helping. Some physicians believe that the short version of the Hippocratic oath, do no harm, disallows them from helping someone die. But how do we define harm? Is it harmful to cause prolonged pain? Is it harmful to force someone who wishes to die to instead lay in a bed, unable to move, sometimes for years? Death is the natural outcome of life. Ernest Hemmingway observed that every human life ends the same way. It is only the details of how the person lived and how the person died that distinguishes one from another. Some people will choose to live for as long as they possibly can, using every method available. But some will choose otherwise. Within their worldview and life experiences, prolonged life is not their highest value.
Qualities of Life
As mentioned in previous blogs, my years as a rehabilitation counselor taught me a great deal about the value of life—even life with significant restrictions and chronic pain. I respected and admired the hard-fought daily battles my clients faced to live as naturally and comfortably in their limited bodies as possible. Over the time I served them, a few chose to end their lives, presumably because the difficulties were too daunting, or they were simply tired of life. They did not inform me ahead of time. If they had, or if I had even suspected they were planning to end their lives, by law I would have had to intervene. They knew this. Thus, they had to enact their deaths alone and in ways that seemed risky, painful, and traumatic.
This quandary has been dramatized by Hollywood many times. For instance, consider the attempt to die by Hilary Swank in the movie Million Dollar Baby. Paralyzed from the neck down, Swank’s character tried to bite her tongue so deeply that she would bleed to death. In the movie, no medical professionals would listen to Swank’s requests to end her life. In fact, legally, they probably could not have helped even if they had been willing.
In the last blog, Dr. Bossypants pointed out that humans are terrible self-forecasters. Many of us like to make fun of weather predictions, but meterologists are a lot more accurate about the next day’s highs and lows than people are when they try to forecast what they might be worse than death for them.
In one study, psychologists Dan Gilbert (of Harvard University) and Tim Wilson (of the University of Virginia) observe that most (healthy) people say that if their quality of life is low, they would rather not have medical interventions designed to give them more time. “However,” as the American Psychological Association’s website notes, “when medical researchers interviewed people who were slowly dying and experiencing a very low quality of life, such people almost unanimously reported that they would go to great lengths to add even a few days to their lives.”
This worries Dr. Bossypants. Why? Because we are all susceptible to the forces at work on us. First, we want to believe we will live forever—other people die; not us. So when we are near death, we’re shocked and have no game plan. Second, big business has invested heavily in making us ashamed and afraid of dying. Third, the medical world is over-identified with prolonging life and less equipped to provide aid and comfort in the dying process. These are huge factors, but of course, there’s more. We have yet to tackle religion, government, psychology, and biology. We are, indeed, complex beings. Stay tuned.