Pubdate: Fri, 09 Nov 2001
Source: New York Times (NY)
Section: Editorial/Op-Ed
Copyright: 2001 The New York Times Company
Contact:  http://www.nytimes.com/
Details: http://www.mapinc.org/media/298
Author: Jerome Groopman
Note: Groopman, a professor of medicine at Harvard, is the author, most 
recently, of "Second Opinions"

SEPARATING DEATH FROM AGONY

BOSTON  Not long ago, a cancer specialist I know faced a situation that 
chilled those of us who care for people with terminal illness. A young 
woman close to death lay suffering in a hospital bed, her husband at her 
side. Her leukemia had defied bone marrow transplant and experimental 
drugs. She had begun to bleed into her lungs and was gasping for air.

Months earlier, following common practice, the oncologist had had a frank 
discussion about dying with the woman and her husband. The greatest terror 
for her, as for most other patients, was that the final days of her life 
might be spent in unrelenting pain. An understanding was reached among the 
patient, the doctor and the family that if the time came when there was no 
real hope of surviving and she faced only pain and debility, no 
extraordinary means would be taken to sustain her and sufficient doses of 
drugs like morphine would be administered to ease the pain, even if that 
meant reducing her breathing or lowering her blood pressure and thereby 
expediting her death.

That time had clearly come, but when the doctor ordered morphine, a 
respiratory therapist at the bedside vehemently objected. He asserted that 
the morphine, because it inhibited her breathing, was nothing more than a 
thinly veiled disguise for physician-assisted patient suicide. The 
patient's husband, aghast, reiterated the promise given to his wife. The 
doctor was not deterred and prescribed as much morphine as was required to 
alleviate the painful suffocation that occurs when the lungs fill with 
blood. Within a day the young woman peacefully died.

The physician felt that he had fulfilled his moral and professional 
obligation to relieve suffering, and the family was satisfied that their 
loved one's death occurred with as much dignity as possible. But the 
respiratory therapist then accused the physician of nothing less than a 
crime, and the husband of being an accomplice. The charge was judged 
unfounded first by a hospital review board and later by the district 
attorney's office. Yet the step by Attorney General John Ashcroft this week 
in response to Oregon's legalization of physician-assisted suicide could 
have dictated a different outcome.

Mr. Ashcroft authorized the Drug Enforcement Administration to take 
punitive action against physicians who prescribe lethal drugs for 
terminally ill patients; the doctors' licenses would be suspended. This 
action, which is being challenged by the state, represents a striking lack 
of understanding of how physicians help patients to die, and it risks 
making the last days of the terminally ill a time of panic and pain rather 
than calm and comfort. While this legal policy may be directed at a single 
state where patients can obtain prescriptions for the lethal drugs under 
certain circumstances, Mr. Ashcroft endangers what has become a 
compassionate, if tacit, mode of dying throughout the United States.

Nothing could be further from the truth than Mr. Ashcroft's statement that 
a federal drug agency could readily discern the "important medical, ethical 
and legal distinctions between intentionally causing a patient's death and 
providing sufficient dosages of pain medication necessary to eliminate or 
alleviate pain." In fact, it is medically impossible to dissociate 
intentionally ameliorating a dying patient's agony from intentionally 
shortening the time left to live.

In the case of the young woman with leukemia and pulmonary hemorrhage, the 
doses of morphine needed to ease her suffering also depressed her 
breathing. And death is rarely a gentle process of simply closing one's 
eyes. Rather, there are potent physiological reflexes, graphically termed 
"agonal." Narcotics like morphine are essential in dampening these death 
throes, and in doing so, they facilitate death.

Mr. Ashcroft's action also threatens the very essence of the hospice care 
that in recent years has allowed so many terminal patients to die at home, 
with doctors and nurses easing the passage through the prudent use of pain 
medications.

Some opponents of the attorney general invoke states' rights, arguing that 
federal agencies should not meddle with Oregon's law. This skirts the more 
fundamental issue. Helping nature take its course is not criminal, and it 
should be outside governmental regulation. Decisions about when and how to 
die are best left to patients, families and health professionals, not 
legislators and litigators. Committees of doctors and nurses already exist 
in hospitals and hospices that can exercise sound judgment in controversial 
cases and advise on the parameters for the process of dying.

If the Justice Department's action is a political bone thrown to religious 
conservatives, it shamefully miscasts health professionals as disciples of 
the devil rather than angels of mercy. If it represents an earnest attempt 
to protect the dying, it in fact makes them more vulnerable. Death will 
ultimately come, but without the skilled hands of physicians and nurses to 
ease the release of the soul.
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MAP posted-by: Beth