November 9, 2001

Separating Death From Agony

By JEROME GROOPMAN

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.

Jerome Groopman, a professor of medicine at Harvard, is the author, most recently, of "Second Opinions."