PARIS — We know that dying today is not as well done as it used to be, back when the dying person was at home, a doctor gave something to ease the pain, the family was gathered at the bedside, attention was given to the condition of the dying person's soul, to his or her last wishes, to the goodbyes. One of the Bronte sisters, in 1847, wanted to look at a favorite seaside vista one more time. So the day before her death, her sister, Charlotte, took her on the train to look at the view, and ride in a donkey cart and die in a hotel parlour at tea time, a poignant but dignified end.
Dying now is likely to be preceded by weeks or months of painful and expensive measures, often in an ICU, that, at best, will only add a little life, to the bewilderment and eventual financial ruin of survivors. Expensive and powerful medical technologies sometimes, though rarely, pay off, hence, that glimmer of hope that anxious relatives can't say "no" when the doctor suggests one more thing to try. Doctors don't dare refuse to do long-shot procedures, for fear of lawsuits, charges of neglect and personal reluctance to admit failure. All is complicated by technology, by our unrealistic but characteristically American optimism and, above all, by the general litigiousness of our society. The courts have intruded into the dying process, both in defense of a person's right to die and, sometimes, by prosecuting physicians for defensible medical decisions. Prosecution is often instigated by an ambitious district attorney, or an interfering third party with a religious agenda.
Almost anyone who has recently gone through the death of a loved one following a long illness will agree that too often those left behind are angered or disappointed by hospital rules, insurance demands, a lack of communication with doctors and by their own helplessness. Everyone knows what is wrong, but we seemingly have been powerless to inject some balance and humanity into this last natural event of life.
Patients themselves can refuse heroic measures, but often aren't in shape to do so--hence, the "living will" signed beforehand. But only 15% of people have them and, anyway, they are often ignored by medical personnel who are unaware there is such a will, or by families who override it, in hope. Pain, helplessness and financial catastrophe are the rule in this vacuum of authority. Nature, which once made the decisions, has been dismissed from the deathbed scene, but no one is willing to take its place. Thus, the proliferation of new laws both allowing and forbidding physician-assisted suicide, with a clear tendency toward the latter.
Oregon and New York now have laws allowing the right to a physician-assisted suicide. Oregon's law goes beyond the right to refuse care to give the terminally ill the "right" to hasten death, with all suitable precautions by which society can be sure death is really your wish. In reaction, perhaps to the undeniably creepy Dr. Jack Kerkorian, voters in California and Washington both defeated similar initiatives, and Washington went on to ban assisted suicide. Now, a federal appeals court based in San Francisco has invalidated Washington's ban, similar to California's, clearing the way for other states to enact laws permitting assisted suicide.
At first glance, this seems humane and rational, and probably it is. But a few cautionary thoughts arise on the personal level from the point of view of physicians, and when it comes to public policy. Most of us would agree that people "ought" to be able to die peacefully, and not to be subjected to suffering when possible. The problems arise with the management of some cases, the unevenness of standards and the inequity of medical care. Some people get a more humane death than others.
The Oregon health-care system, even before its suicide law, had already incorporated some guidelines. When my mother, age 90, was discovered in a hospital to have a terminal condition, the hospital, the doctor, or someone--I never knew who made the decision--decided they would send her home, ordered a hospital bed to be delivered and notified the home-hospice personnel. Nurses and counselors appeared; someone gave me a bottle of morphine syrup to be administered by me if my mother seemed to be in pain (she was not entirely conscious to say so herself), and some medicine for any anxiety (hers, not mine). Was this a tacit permission to take matters into my own hands?
In any case, everything was discreet, tactful and considerate--an old-fashioned death at home that could have easily been a hospital nightmare, if it had not been for informed medical personnel and a rational state policy. Left to myself, I would not have known what to do, nor have had the courage or knowledge to veto further hospital measures.