Easy Death as a Viable Option

Philip G. Ney, MD, MA, FRCPC, FRANZCP, RPsych

April 1987

"I will neither prescribe a deadly drug to anyone if asked for it, nor will I make a suggestion to this effect." This injunction of the Corupus Hippocraticum[1] was intended to restrain early Greek physicians. Influenced by their cultural belief that illness was evil, those doctors might abandon or poison patients who did not improve. Some modern physicians with confidence in the predictable efficacy of antibiotics and surgery have the same difficulty in dealing with patients who will not respond or whom nobody wants anymore. When the “quality or life” for a patient is hardly worth the effort, some physicians believe providing easy death is a “viable option”.

Medicine does not have an entirely honourable record. It has been susceptible to popular and political demands to provide swift death rather than support difficult living. Individual physicians have not always asserted their utmost on behalf of their patients. Physicians assisted with the establishment of hospitals of final solution and helped develop the technology that Hitler used for genocide. “In 1941 the psychiatric institution, Hadamar, celebrated the cremation of the ten thousandth mental patient in a special celebration. Psychiatrists, nurses, attendants and secretaries all participated. Everybody received a bottle of beer for the occasion.”[2] After analysing the socio-political preconditions in Germany in the period 1933 - 1945, von Spaete and Thom[3] had to admit that dark chapter of contemporary history of psychiatry had been overcome only when the preconditions had been radically dealt with. In Russia, psychiatry has been used for politically repressive purposes. North American physicians are not free of the same pressures to normalize mavericks.

Under certain conditions, technology will determine ethics more than ethics guide technology. We must wonder whether our ability to evaluate the general drift of medicine is accurate enough to quickly control a regress that is not in the best interest of the patient. Recent history teaches us to avoid the comfortable belief that physicians and professors know what is best. Medicine may be succumbing to social factors that are eroding the ancient ethic of striving to provide life and health for everyone to the limit of resources. With present tends in the direction of making death easier and more acceptable, it is important to examine the reasons why physicians may consider administering easy death more appropriate than sustaining uncomfortable life.

Are we any Wiser because we have More Power?

Technology has given medicine a measure of ultimate power, the control over life and death. With the common exercise of that power, physicians begin to believe that they also have wisdom to determine who should live and who should die. With a respirator, physicians can sustain a life that would end, and with the suction curette terminate a life just begun. But are we able to judge who qualifies for life and who deserves to die?

Can we Substitute Popularity for Diminishing Trust?

If the size of the medical damage suits, the demand for informed consent, the pressure for patients’ rights and the questioning of medical funding are any measure, then it would appear physicians are losing patients’ confidence. When physicians swore never to poison, abort or have sex with their patients, they gradually gained an aura of trustworthiness that allowed them to poke into even those areas considered very private. Physicians are now losing trust because patients are no longer sure of their physician’s selfless commitment to preserve everyone’s life. Recognizing they are gradually losing the confidence of patients, some physicians are hoping to substitute trust with popularity. “If they won’t let me do this because they trust me they may let me because they like me.”

To depend on popularity in order to practice makes physicians very vulnerable to shifts in popular morality or political pressure. Since people especially protect the privacy of their mind, they distrust psychiatry more than other branches of medicine. To avoid legal constraints but to gain patients’ cooperation, psychiatry tried hard to be liked and appreciated. This makes psychiatry most vulnerable to forces that shift medical ethics.

Since the majority of voters and the majority of patients are women, physicians will be more susceptible to supporting women’s point of view. If it appears that women favour abortion on request, physicians will be inclined to accept that ethic. A well-liked physician may practice with greater ease but can popularity replace confidence? How far will physicians go in adopting popular demands that oust ancient ethics?

Should we hold a Utilitarian Attitude to Life?

Materialism is encouraging physicians to adopt a utilitarian attitude to life. Behind the question “What can this patient contribute to society?” are the real ones: “What can they do for me?” “Could he every become a good consumer and help to keep industry rolling?” It is inferred that if he can contribute little to our enjoyment of life then life is not enjoyable to him. If a person is of little value to society, their life must be of little value to them. Thus the old, the handicapped and children will be the first to lose in value. As their value declines, so will their standard of medical care.

Science seems to have removed the mystery of “life”. “We know how to make babies. We just add this to this in the test tube.” Though science is not much nearer to an explanation of life, the media make it sound like the unravelling of the double helix; the major mysteries have to be solved. They haven’t but that which is no longer awesome is treated with less respect.

A Right to Rest or a Determination to Work?

physicians are gradually accepting the common attitude that we have a right to recreation. Technological medicine has the wonderful capacity to heal illness in the absence of the physician. A good doctor need only diagnose and prescribe correctly before going home to watch TV. We forget that until very recently physicians have had to struggle alongside the patients. Instead of simply giving the patient the cure, our forefathers also gave them hope, support, wisdom and comfort, all of which took time and energy.

Psychiatry, with less predictable technology can still practices in the ancient mode. A psychiatrist knows that his patient’s well being is dependent on the amount of time they spend together. Psychiatrists envy their colleagues who with predictability effective biochemicals are more able to assert their right to leisure. We are all prone to resent spending energy on, or forfeiting recreational time for, patients who refuse to improve. When technological medicine no longer effects a cure or when the patient will not cooperate by getting better, we would like them to see another physician or go away or die. The presence of the chronic, dying patient with low quality of life reminds us of our continuing obligation to treat everyone to the limit of our abilities, regardless of their prognosis and our fatigue. Chronic patients force us to examine limitations on our skills that we may not wish to recognize.

Is It Easier to Die or are Physicians Justifying Their Complicity with Killing?

Modern methods of dying appear to be much more pleasant. We have begun to understand the process and are encouraged to work through saying that final goodbye. We have drugs that relieve most of the pain and chemicals to tranquillize our fears. Modern facilities provide a warm and comforting atmosphere. Unfortunately dying is still the most painful and frightening experience for the majority of people. Although it is helpful to gradually let go of all that is near and dear, it is not abnormal to not accept death, as Kubler-Ross seems to imply.[4]

Knowing there are a number of colleagues who are terminating life, we all tend to justify what is more for the comfort of the physicians by stating it is in the best interests of the patient. We have become adept at rationalizing our attitude towards death for other people. We have the verbal facility to sound very convincing to relatives who also might want to justify sending Granny on her way. But the arguments which support euthanasia, the right of the woman to abortion, the importance of not encumbering parents with retarded children and the social benefits of amniocentesis, are tainted with the obvious selfishness of those who are most likely to gain. In spite of the careful rhetoric,[5] it is hard to believe the unborn infant gains much by being aborted.

CREDO

Since I’m not sufficiently wise to know who qualifies for life and who deserves to die, I will seek to preserve the lives and improve the living of all my patients. Since I cannot practice good medicine without my patients’ trust, I promise not to poison or hasten the death of anyone. Since I suspect my own motives in asking of what value is a life, I must treat everyone to the limit of my resources. Since I never know when a patient really wants to die, or truly understand under what duress they appear to accept their fate, I will seek to give them all hope for a slightly better life.

Though some people cannot tolerate living as they are, I must assume no one really wants to die. Since I am unable to differentiate, “Doctor, I want to die” from, “Doctor, I can’t live this way anymore”, I must believe that all my patients would prefer me to improve their living rather than hasten their dying. Since technology tends to change morality, I will hold to an ethic that is independent of time and culture. I can only believe that since everyone is made in the image of God, I must love my neighbour as myself, therefore, I will treat everyone as well as I am able.

October 10, 1963

MY DECLARATION FOR LIFE

Reasons

Almighty God, With You all life begins and ends.

I know my life entirely depends on You.

By You, all human life is loaned for a season.

I cannot give life to, or take life from anyone.

For You, I must hold in careful stewardship

My life, and the lives of all my neighbours.

You created mankind a little lower than the angels

And have given me Your life and love giving Spirit.

Through Jesus Christ You have made me Your child,

Now my first priority is to show people their hope is in You.

You have honoured me with Your challenging friendship

Thus, what I am becoming is more important than what I achieve.

You have conquered death and will soon destroy it.

Since I am Your servant, Your enemy is my enemy.

It is Your creation but death is seeking to ruin it.

I must fight death on its doorstep or it will attack me on mine.

There are no innocent bystanders in matters of life and death.

Unless I am fighting death, I am aiding and abetting its terror.

Without forgiveness and reconciliation between those who injure and are injured,

The triangles of tragedy must be reenacted from generation to generation.

Unresolved bitterness will kill us and those we hate.

Unless forgiving and forgiven, our sins and illness will remain.

With love, You are always healing the weak and wounded,

By helping the smallest and weakest I learn to love like You.

Every person was wonderfully made in Your image,

So how could I ever benefit at the expense of another.

No, I benefit when I give my neighbours what they need,

For we are intrinsically bound together in the bundle of life.

Commitment

I will love You more than my life; as long as I live

I will always promote and enhance life for everyone

Not regarding their wealth or rank, sex or race, ability or disability,

Their size or completeness, I will love them as myself.

I will seek my neighbours' physical, mental and spiritual wholeness.

Treating them equally, I will help distribute

Health and life maintaining resources fairly throughout the world.

I will help each one to the limit of my abilities and resources.

If because of circumstances I must choose who I will treat first

I will treat those who most likely will benefit from what I can offer.

I will seek to know all the needs of all my neighbours

And help find and apply new remedies.

I will try to untangle the tragic triangles that injure and kill.

Starting with myself I will exemplify and promote reconciliation.

I will not kill or hasten death or just let anyone die

But will seek to remedy all factors that lead to the destruction of life.

I will oppose abortion, euthanasia, murder and genocide

And help heal all those affected by these tragedies.

I will fight death in all its guises

And avoid compromise with any form of evil.

Prayer

Please Lord, help me to do what I say I believe.

Give me the courage to love life and live it fully.

Remind me that my struggle is but for a short time.

Forgive me for vanity and pride in my accomplishments.

Remind me You alone heal and I am privileged to be your helper.

Keep me from fearing death or the consequences of serving You.

Grant me sufficient strength to bring hope, healing and joy to others.

Make me determined to loan my life without interest for

The most complete life of each and all of my neighbours.