The Physician by Luke Fildes
Jack Kevorkian, MD
In the end, I was left to reflect on what I would want in the face of my own death.
– Gov. Jerry Brown, on signing assisted suicide law, 2015
I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give a woman an instrument to produce abortion.
– Hippocrates, Physicians’ Oath, c. 400 B.C.
Governor Jerry Brown thought about what would be good for him. Hippocrates, in contrast, thought about what would be good for all patients. A different of point of view can be decisive.
California just followed in the footsteps of Oregon and Washington in legalizing physician-assisted suicide. But where is this path leading? Are we headed uphill or down? Jerry Brown, nominally a Catholic, signed the bill, commenting that he might avail himself of its provisions if he were in intolerable pain. He confused his fear of disability and pain with what was good public policy.
When severely brain-damaged Terry Schiavo was slowly dehydrated and starved to death over 13 days, people said, “I wouldn’t want to live like that.” Neither would I. But I also wouldn’t like to live like homeless persons. That doesn’t give me the right to drive to a freeway overpass and start shooting them. My fear doesn’t give me the equivalent of James Bond’s double-zero license. It doesn’t empower me to violate the laws of either God or man.
We can question whether it is wise – or safe – to conflate the role of healer with the role of executioner. We can question whether we will be able to see someone in a white coat enter our hospital room, and not feel a pang of doubt about whether he is there to help us get better – or to help us die sooner.
Specifically, we can ask this question: Why is taking an overdose of barbiturates – prescribed by a physician with the approval of the state – somehow a beautiful and uplifting way of leaving this world, while taking pills or shooting yourself on your own is unacceptable? Why does the first supposedly have no ill effects on surviving loved ones, while the second may lead to an increased suicide risk among family members?
Here is a related question: Why is an overdose of barbiturates “terribly painful” and so fraught with error that a federal judge banned its use in California to put convicted murderers to death, yet at the same time it is an easy and sure way to kill medical patients? Logic? We don’t need no stinkin’ logic. We’re progressives!
And we can ask these questions:
● Why is there is no mention of verifying the diagnosis except by “reviewing the chart”? Reviewing the chart gives us a good idea of the chart, but not of the patient. I spent 25 years in medical oncology at a university medical center. For every patient, we reviewed the biopsy slides with our pathologists. Usually the referring diagnosis was correct. But sometimes it wasn’t.
The most glaring example I saw was a woman referred with a diagnosis of breast cancer. The microscopic slides indeed showed cancer, but it was not connected to the normal breast tissue. The pathologist suspected it was a “floater” – that is, that someone else’s cancer tissue floated off her slide in the preparation process, and floated onto our patient’s slide. He was correct. Our patient didn’t have cancer. The other patient biopsied that morning, who had been told she was okay, in fact did have cancer.
If it were not for a second pathologist reviewing the slides, we would have treated the healthy woman unnecessarily, while the woman with cancer would have been left untreated. “Reviewing the chart” would have caused us to perpetuate the error.
Similarly, patients with neurologic disease should be evaluated by an independent neurologist, patients with heart disease should be evaluated by an independent cardiologist, and patients with intractable pain should be evaluated by an independent specialist in pain management. Why is this not required?
● Why is there is no requirement that the patient be seen by an independent psychiatrist or psychologist to rule out depression? True, anyone contemplating suicide is by definition depressed. The question is whether the physical disease or the depression is the chief reason for suicidal thoughts.
The treatment for depression includes psychotherapy, antidepressants, and family support. Suicide is not a treatment for depression. Suicide is the result of failure of treatment for depression.
On the other hand, availability of a “way out” may help some sufferers to endure their problems. Some patients expressed gratitude, even when they decided not to commit suicide. Honesty requires that we recognize this fact.
Advocates for assisted suicide or euthanasia often talk about respecting the patient’s “autonomy.” To me, this word means that I decide whether or not to end my life. And if my answer is yes, I take responsibility for ending it my way, and don’t ask others to do it for me – of course, unless I am quadriplegic. “Autonomy” should mean what it says.
Suggesting suicide to a patient should not be called “respecting autonomy.” In many cases, a more honest term would be “cost containment.”
● Why is there is no comment on possible errors – that is, facilitating the deaths of patients who were not “terminal”?
“Terminal” used to mean “in the actual process of dying.” But now, “terminal” means “expected to die in six months.” Such predictions are often inaccurate. Cosmologist Stephen Hawking was told he had two years to live at age 21 – that was 51 years ago.
The most glaring example I saw was a young man with rapidly growing tumors. We expected him to die in days. Nevertheless, we began high-dose chemotherapy. The tumors shrank and eventually disappeared. The biopsy was reviewed to be sure it was cancer. It was. The young man went on to finish college, get married, and father a normal child. But if we had caused his death, we never would have discovered our error – and we would have repeated the error again and again.
● Why do the Oregon and Washington plans provide no feedback to the referring doctors? Of the patients reported in the New England Journal, 30 did not actually take the lethal medication – either because the decided not to, or because they died before they could. But of these 30, 11 lived longer than the expected six months, in one case 97 months – that is, eight years after he or she was expected to die. So much for prognostic accuracy.
● Why is it that under these laws, the doctor makes out the death certificate to indicate the underlying disease as the cause of death, but omits assisted suicide? The cases are supposed to be reported to a central authority, but may not be. The most reliable – though not completely reliable – source for a cause of death is the death certificate. If assisted suicide is praiseworthy, why conceal it?
The bias of physicians from the time of Hippocrates, 24 centuries ago, until only a few years ago, was for the continuation of life. The bias is now shifting. Unless we do something, soon the bias will be for the cessation of life as soon as it becomes inconvenient to others. In an era of “cost containment,” this thought should trouble all of us.
We are all going to die sometime in the future. In that sense, we are all “terminal.” Let us act accordingly – by doing the best we can in however many or few days remain to us, rather than denying reality by attempting to control death, the final proof that we are not in control.
It’s our choice. On one side we have The Physician. Note the distraught mother, her head down in prayer. Note the father, trying to be strong. Note the sick child, lying on a makeshift bed composed of two dissimilar chairs. And note the physician, sitting up all night with his young patient, though the family cannot pay a large fee, or perhaps any fee at all, because that is what his oath requires.
And on the other side we have the late “Doctor” Jack Kevorkian, with his weird eyes and incongruous smile. He was obsessed with death and spent years trying to control it by killing patients – some of whom had non-fatal diseases, or no disease at all.
But we have to choose. If we don’t, the choice will be made for us. If we don’t choose The Physician, by default we get Jack.
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