Separating Fact from Fiction: Palliative Care vs. Assisted Suicide
Misconceptions continue to swirl around the topic of Palliative care vs. Assisted Suicide, particularly with regard to the use of morphine in hospice settings. The average American has not been properly educated about the benefits of Palliative Care, nor do we understand the common reasons why a patient might choose euthanasia or physician assisted suicide (PAS) over hospice care. This article is intended to assuage common fears regarding end of life issues.
Fear and Control
Let me begin by stating that the one of the most common reason given by patients who have requested PAS or euthanasia is fear the unknown, or rather, fear of how much the quality of their lives may be diminished, as well as how much pain the patient may endure as the illness progresses. Additionally, many patients maintain a great desire and need to control every aspect of their lives and deaths. Consequently, those who believe strongly in never losing control may be more open to designating their death to the minute and the hour.
I recently posed a question about this very subject on this site. I asked, "Why choose euthanasia or assisted suicide when palliative care can relieve suffering?" I went on to ask if a society should consider the question of the soul when contemplating end of life issues. I used the word soul, believing that most people relate quite well to the term. Perhaps I was mistaken given that my question ignited a religious debate. That had not been my intent. The term soul is intended to signify the collective consciousness of all individuals, which generally include perceptions of right and wrong. In fact the word, soul and consciousness are often used interchangeably.
The decision to control one's death is a personal decision, but make no mistake....all of society, not to mention the family unit, is affected by how one chooses to die, particularly in cases of suicide. Thus, the question of euthanasia or PAS is primarily a social and secular debate, and in some cases, a religious debate.
The Definition of Soul
- The spiritual or animating presence of a human being, regarded as immortal.
- A person's moral or emotional nature or sense of identity.
- The quality that arouses emotion
Contemplating the Implication of Choosing Death
Therefore, the purpose of this article is to encourage all readers to consider the societal and personal implications of how we are all affected by death, even if the death is not our own. At any rate, each person inhabiting this planet wishes to die with dignity, and in order for the terminally ill to effect a "good death" one must first ask oneself salient questions. For example:
- How does one die with dignity and have a good death if one is suffering from an incurable illness? Is a good death even possible in these circumstances?
- Can excruciating pain be managed, perhaps even eliminated before death?
The more we know, the easier it is to come to grips with our fear of death and/or suffering. Every single person on this planet is of value, even if one has outlived his or her ability to "contribute" to society. More precisely, nobody's worth should be based upon whether an individual’s monetary contribution to society has expired, or whether a terminally ill person is perceived as having a lesser "quality of life" than someone who has greater health.
Thus, whether our bodies have, in a manner of speaking, betrayed us due to illness or old age, we still retain our emotions, our individual consciousness and our inherent dignity. Thus, the decision of how to die, while still an individual decision, is also a decision that will dramatically impact the family and ultimately, all of society. In short, dying is a momentous process.
The Definition of Euthanasia
- The intentional putting to death of a person, by a physician; to remove suffering from those with an incurable or painful disease, intended as an "act of mercy."
- Intentionally causing death by not providing necessary and ordinary (usual and customary) care or food and water.
The Definition of Physician Assisted Suicide (PAS)
- A person self administers a lethal drug prescribed by a physician in order to effect a quick and painless death.
Note: Euthanasia is illegal in the United States. However, PAS is legal in Oregon and Washington state. Montana killed a bill to allow for physician assisted suicide.
The Definition of Palliative Care/Hospice Care
- Focuses on the management of symptoms, as well as psycho-social support, and has the potential to improve the quality of care and reduce the use of medical services.
- Offers intervention for the family and patient because the family is very taxed by the illness of a loved one and may be prone to anxiety which can cause the patient to feel unnecessary guilt.
- The emphasis on hospice care is on living, not dying.
A Good Death as Described By The Medical Community
- A natural death, not a result of suicide or homicide.
- Physically painless (with or without the use of medication)
- The person dies with the sense of reconciliation and forgiveness of those who live on.
- The person is not in denial of death, and is consciously ready to die
- The person has said their goodbyes.
- The person has worked through existential suffering required for acceptance of death.
The New England Journal of Medicine also states that palliative care is traditionally used later in the disease, but that in order to enhance life it must be introduced into a patient's life much earlier to be of optimum effectiveness.
France, for example, is making these crucial changes in palliative care education.
For more information: http://pallcare.ru/File/NEJMoa1000678.pdf
Many deaths actually do meet all of these components, which is why family gather around the bedside of their dying loved ones for final goodbyes, forgiveness, etc. According to the medical community, a good death is about acceptance, rather than fear or control.
However, In some cases, the process of dying may be incomplete. The following true story illustrates how control issues may override (some) pertinent existential questions about living and dying and how the decision to suicide affects those who live on.
A Son's Response To His Mother's Death
Andrew Solomon wrote a compelling piece in 1995, for The New Yorker, entitled, A Death of One's Own. Mr. Solomon describes how his mother, who had terminal ovarian cancer, made the decision to obtain "a cache" of prescriptions (for Seconal) from various doctors, with the intent of killing herself, in order to avoid unnecessary suffering in the later stages of her disease.
Solomon describes how his mother "was expressing a sense of outrage at the indignity of what lay ahead and a profound fear of losing control of her own life...as though she wanted vengeance for the snub of nature." Mrs. Solomon was a true matriarch. She controlled every aspect of her life, and ultimately, her death.
In the end, she did indeed die peacefully, through a passive form of assisted suicide, at the exact time of her choosing and with her family surrounding her. Her final words were, "I got my wishes so often." Andrew Solomon goes on to note that his mother was of sound mind, but as a cautionary word, he recognized that there are some individuals whose minds may be clouded by depression and that some patients may be treatable with medication, while some may not.
Yet Solomon also writes, "The fact is that a suicide is a suicide, over-determined, sad, somewhat toxic to everyone it touches." Solomon states how he, his brother and father "hardly talk about the suicide," and how they seem to be in "a kind of denial all their own."
But, having been raised to maintain a very "rational" mindset, Andrew further states that he also intends to use physician assisted suicide if needed, to hasten his own death, rather than suffer excruciating pain from a terminal disease. When asked, Andrew Solomon gave no indication whether he had contemplated matters of the "soul."
When asked how he felt about his mothers determination to die through PAS, Solomon admitted to "feelings of ambivalence." He also stated that "you tend to accommodate the ill," and "do as they demand," but that he and his family, at one point, had asked their mother to reconsider her decision to suicide.
Common Reasons Given By Patients for Choosing Euthanasia or PAS.
- Fear of the unknown and quality of life (69%)
- Loss of function (66%)
- Pain and unacceptable side effects from pain medication (40%)
- Loss of sense of self (63%)
- Having the wish and need for control (60%)
In Mrs. Solomon's case, control and fear were the biggest factors in her decision to suicide. In the following paragraph we will discuss the safeguards that have been established by most countries to avoid abuse by doctors and hospitals. We will then discuss the "slippery slope" argument against euthanasia by citing data from the Netherlands and Belgium, where the issue of euthanasia has been argued for over 30 years.
Unlike the popular assertion promoted by the Hemlock Society (that the ancients advocated for suicide), in truth, the Greeks, by and large, condemned suicide, considering it the "worst form of death." Among those who despised suicide were Socrates, Plato, The Stoics (of the Roman era), the Pythagorean's, Sophocles and Thebes.
How Safeguards are Being Ignored:
- To date, although euthanasia is practiced elsewhere, only the Netherlands, Belgium, and Luxembourg have legalized Active Euthanasia. (Physician-administered death by lethal drugs.)
- The United Nations has found that the Netherlands is in violation of the Universal Declaration of Human Rights Treaty because of the risk it poses to the rights of safety and integrity for individual lives.
- Dutch euthanasia has moved from being done as a last resort to being one of early intervention, such as for a 70-year old who is "tired of living."
- Oregon legalized PAS in 1997. In 2007, none who died of lethal injection had been treated for depression, even though evidence shows that patients successfully treated for depression are likely to rescind their requests for PAS. **One in 6 patients who requested a lethal drug had clinical depression.
- Assisted suicide, is also legal in the states of Washington, Montana, Vermont and New Mexico.
In order for a patient to be euthanized or choose self-administered suicide (PAS), certain safeguards have been established by law makers. They are as follows:
- Voluntary Written Consent. A person must give written consent and be of sound mind.
- Mandatory Reporting. Physicians are required to report all cases of euthanasia or PAS.
- Only by Physician. Only a physician can administer a death inducing drug. Nurse's are not allowed to administer these drugs. In the case of PAS, a physician instructs a person on how to kill themselves, and writes the prescription for the patient. He also instructs the patient on what to do in the event the drug is self administered improperly, such as having a family member tie a plastic bag over the patients head to cause the patient to asphyxiate.
- Second Opinion and Consultation. All jurisdictions, except Switzerland (which allows PAS, and turns a blind eye on euthanasia), require a second consultation to make sure all safeguards have been met. This includes that patient be made aware of all options, including palliative care and consultation for depression.
The Slippery Slope
Percentage of Safeguards Followed
In The Netherlands
3 in 5 cases: No written consent given
1 in 5 cases: No written consent given
50% of cases go unreported.
20% of cases go unreported
By Physicians Only
45% of nurses administered lethal drug in cases, without explicit consent
No current information
Second Opinion and Consultation
No specific percentage is available; evidence suggests this regulation has been partially ignored.
Consultation not sought in 35% of cases. In 2010. No psychiatric evaluation was given.
Palliative Care Philosophy and Intent
- Intends neither to hasten or postpone death
- Provides relief from pain and other distressing symptoms
- Affirms life and regards dying as a normal process
- Uses a team approach to address the needs of patients and their families
- Integrates the psychological and spiritual aspects of patient care
- Offers a support system to help the family cope
- Will enhance quality of life and positively influence the course of the illness
To date (2013), France, Scotland, England, South Australia, and New Hampshire have chosen to improve hospice care services, and to better educate doctors and the public about the practice and benefits of Palliative Care.
Meet a Special Family
Do you think euthanasia should be legalized?
Myths and Facts About Pain & Medication
Myth: Pain can't be relieved and dying is always painful.
Fact: Some pain requires combined medicinal approaches for pain relief. Pain can be relieved safely and rapidly. Nerve blocks may be also used to entirely eliminate pain.
Myth: Pain medication always causes heavy sedation.
Fact: Morphine and codeine cause initial sedation (about 24 hours) which is useful in that patients who have experienced pain and anxiety need to catch up on their sleep. But afterward, patients are able to carry on normal mental activities.
Myth: Once you start pain medication, you always have to increase the dose.
Fact: The opposite is true. Once the pain is under control, the dosage can be lowered safely.
Myth: Pain medication always leads to addiction.
Fact: When prescribed on a regular dosage to relieve pain, there is absolutely no evidence that opioids lead to addiction. In fact, when patients self-administer morphine in hospitals, they actually use less of a dosage than doctors use when prescribing scheduled formulas.
Myth: Enduring pain will enhance one's character.
Fact: Suffering unbearable pain does not necessarily enhance character, though it can be a testament to one's resilience. But needless pain can and ought to be avoided as it merely brings about a horrible death and needless anguish for those who live on.
Myth: Once you start taking morphine, the end is near.
Fact: Morphine does not initiate death. Rather, morphine provides relief of severe, chronic pain; it provides a sense of comfort; it makes breathing easier; it does not cloud consciousness.
Myth: Chronic pain occurs alone (as a solitary phenomenon)
Fact: Severe pain is usually accompanied by anxiety, fearfulness, insomnia and loss of appetite. Anxiety can be triggered by memories of pain previously experienced which then exacerbates current pain. Many who are treated for depression, and who had requested PAS, will change their minds about hastening their deaths once their mood has been elevated through medication to alleviate feelings of hopelessness.
Each of us will die and chances are we will die only as well as we have lived. I propose that in dying well, there is more to be considered than deciding upon the hour and minute of our deaths, for in knowing that pain can be relieved we can do much to quiet our fear of suffering. I am not at all a proponent of needless suffering. But I do suggest that death is complex.
I choose to believe that death involves our emotional being, i.e., our collective souls. Death also involves the living who remain behind. A good death requires releasing that which is no longer applicable in our lives, such as emotional wounds and hatred. Furthermore, dying well involves acceptance, love, and having a sense of peace about what does or does not await us beyond this life.
It is imperative, now, that all nations truly understand the inherent dignity in dying, especially now that so many misleading notions have arisen regarding euthanasia, physician assisted suicide, and palliative care. Regardless of how legislators choose to govern, let us make certain, if possible, that the methods of death we choose for ourselves and others will ultimately avoid becoming a slippery slope into "death on demand" for the sake of convenience.
In truth, this trend toward convenient deaths has already begun in the Netherlands, and even in Oregon (In the United States) where many safeguards for thorough consent of PAS are being ignored by hospital staff. However, in realizing the true worth and dignity of each and every individual, should we not question whether convenience and death make good bed fellows? The ethics of dying is a question we must all determine if we are to respect the significance of the human life, a life in which the vulnerable and the elderly have no fear of having dying without their absolute consent.
Current Oncology, a respected, peer-reviewed, Canadian based and Internationally distributed journal.
A Stone Boat by Andrew Solomon
Current Oncology Website: http://www.current-oncology.com/index.php/oncology
Denial of the Soul by M. Scott Peck, M.D. Spiritual and Medical Perspectives on Euthanasia and Mortality (Author of The Road Less Traveled)
New England Journal of Medicine. http://pallcare.ru/File/NEJMoa1000678.pdf
Hospice Foundation of America: http://www.hospicefoundation.org/painmyths
Death As A Salesman, by Brian P. Johnson