Saturday, February 14, 1998
Is euthanasia a testament to cynicism
and lost hope? Or is it the ultimate act of caring
and sacrifice, a graceful parting that
eases the sting of death for both
patient and loved ones?Two Hawaii doctors have different views...
Leave room for memories,
hope and a few miracles
By Dr. Edgar A. GamboaLetting go with dignity
can be our finest hour
By Dr. Norman Goldstein
Leave room for memories,
By Dr. Edgar A. Gamboa
hope and a few miracles
Special to the Star-BulletinGrandpa is transferred to the ICU, attached to monitors and IV drips, breathing with mechanical ventilatory support, slowly dying of terminal cancer. What's wrong with pulling the plug and letting the old man die with dignity? Such was the compelling argument showcased by euthanasia proponents in state initiatives. The public saw nothing wrong with "dying in dignity."
In Oregon, home state of the Hemlock Society, where physician-assisted suicide was presented as a matter of choice and personal autonomy, voters in 1994 passed the euthanasia proposal by a narrow 51-to-49 margin. Similar initiatives were voted down in California and Washington. (Editor's note: Oregon voters in 1997 revoted on the euthanasia measure and approved it by a 60-40 margin.)
But the contemporary movement toward legalization of active euthanasia had begun, fueled by the perceived fear that life prolonged by medical science and technology would inevitably lead to a painful, futile and disgraceful death.
My experience in trauma surgery and critical care has brought me face to face with the many issues and variations of death and dying.
I had to console a medical student whose mother was found hanging from the garage ceiling.
I sat down with parents wracked with intense grief, as their only son, a straight-A university student, arrived brain dead after falling from a hotel window while celebrating spring break.
I saw the horrified faces of a mother and her daughter as they rushed into the ER to view the lifeless body of their 13-year-old son and brother, stabbed in the heart for guarding his sister's birthday party from rowdy gate-crashers.
In over 20 years of surgical training and practice, I have seen death's many faces. My work has also involved me in near death situations.
I watched a Russian emigrant who had fallen off a 10-story building emerge from a six-week coma just as the neurosurgeon had informed the wife that her husband was hopelessly to remain in a persistent vegetative state for the rest of his life.
I took care of an engineer who broke his neck in a car accident and, paralyzed, now visits schools in his wheelchair, motivating high school students to make the most of their lives and their futures.
I rejoiced with a family as their beloved 86-year-old grandmother, given up for dead due to multiple injuries sustained in a car accident, was discharged from the hospital -- radiant and smiling.
Do these experiences make me an expert on the subject of death and survival? Of course not. However, my encounters with death and near death experiences have given me the opportunity to examine at the trenches, so to speak, the issue of medically directed suicide.
The issue is complex, yet the national debate over euthanasia is often simplistic, as Dr. Scott Peck observed in a March 1997 Newsweek article.
We don't even have a consensus on the definition of the word. If euthanasia consists of not embarking on heroic measures to save or prolong life, how does one distinguish between heroic measures and standard critical care treatment?
Is it important to distinguish between physical and emotional pain or depression? Peck also asks about the relationship between euthanasia and pain, and points out that our differing views about the existence or nonexistence of the human soul make euthanasia a subject for passionate ethical and moral debate.
Since the days of Hippocrates, physicians have been ethically bound to preserve life and 21st-century science and technology have extended this traditional and sacred trust.
Yet in the movement for medically assisted suicide, who have become our heroes? The critical care physicians who stay up all night in the ICU treating and monitoring complicated patients? Or the traveling pathologist with a lethal syringe of morphine?
To me, and to most physicians, the push for physician-assisted suicide is a major step in the wrong direction.
"The movement for legally sanctioning physician-assisted suicide is not a victory for personal rights. It is a sign of society's failure to address the complex issues raised at the end of life," Dr. Lonnie Bristow, past president of the American Medical Association, told the Commerce Committee's Subcommittee on Health during a hearing held in March 1997.
"The AMA believes," Bristow testified, "that physician-assisted suicide is unethical and...inconsistent with the pledge physicians make to devote themselves to healing...Laws that sanction physician-assisted suicide undermine the foundation of the patient-physician relationship that is grounded in the patient's trust that the physician is working wholeheartedly for his or her health and welfare."
Indeed, physicians are sworn to uphold the ideals of the Hippocratic Oath, to preserve life, "to keep (the sick) from harm and injustice...to give no deadly drug if asked for it...nor to make a suggestion to this effect."
Dignity in dying, patient choice, etc. are catch phrases attractive to a society and a culture which places individual rights on its highest pedestal.
How often we forget that life is a treasured gift, that it has been given to us to spend meaningfully, ideally in the service of others, and that even when the sun sets on it, life still is full of meaning and mystery.
My own father died of cancer four years ago. Toward the end of his life, he developed painful intestinal obstruction and debilitating liver failure. We gathered by his bed, children and grandchildren, as he slowly ebbed away in peace.
The priest came to administer the sacrament of the sick and the last anointing. My father smiled weakly and then reminded my sister that perhaps it was time to start the prayer for the dying.
We all knew he was dying, but God forbid if my brother, an anesthesiologist, or my wife and I, both physicians, or my sister, a nurse, would have started a morphine drip or a potassium infusion.
My father wanted to be able to see his wife, children and grandchildren until the end, and clearly spoke his final words: "Love one another as I have loved you."
My father died with dignity and in peace. He had no use for physician-assisted suicide.
Dr. Edgar A. Gamboa is chairman
of the Department of Surgery at the
North Hawaii Community Hospital
in Kamuela on the Big Island.Leave room for memories,
hope and a few miracles
By Dr. Edgar A. Gamboa
Letting go with dignity
By Dr. Norman Goldstein
can be our finest hour
Special to the Star-BulletinMany terms are associated with the controversial topic of physician-aid-in-dying: euthanasia, assisted-suicide, right-to-die. The debate has been raging for aeons. Perhaps the most appropriate acronym for today is DADD -- doctor-assisted death with dignity.
Physicians have learned that relatively few individuals actually take their own lives, even among the terminally ill who are suffering greatly. The real issue to debate is how to provide solace to these patients, with assurance that they will not be forced to die alone while experiencing excruciating pain.
Although there are physicians who voice opposing views, often making reference to the "slippery slope" concept, many are in favor of advocating DADD as a compassionate course of ethical action.
Under the leadership of Hideto Kono, the state of Hawaii Blue Ribbon Panel on Living and Dying with Dignity meets monthly to discuss this most critical medical/legal/moral topic confronting the nation today. The panel will soon present its recommendations to the governor and our state legislators.
Recently Chairman Kono gave me a three-part "homework assignment" to help explain the sensitive issues faced by physcians and loved ones of those facing death.
I. Personal experiences and opinions
I am a physician specializing in conditions of the skin, but one equally concerned with the welfare of the whole person. I suppose that this overarching level of concern has given my patients the confidence to ask about medical problems unrelated to my specialization.
Over the years, an increasing number of elderly patients continue to inquire about any available medications to ease their painful, final phase of life. What's a doctor to do?
When my 86-year-old father moved to Hawaii to live in our home, I had the opportunity to talk with him and care for him every morning, evening and weekend. It was wonderful getting to know him again. Having lost the use of half of his body two decades before as a result of a stroke, he was now confined to bed with very little bodily movement possible.
Dad was also consumed with extremely painful, terminal lung and prostate cancer. He repeatedly emphasized that he wanted "no pipes, no tubes, no surgery, no hospital." He just wanted to be pain-free at the end of his life.
As a physician, I had no difficulty getting his gerontologists to prescribe a strong, long-lasting pain medication that enabled him to remain conversant, comfortable and content, even on his last day at home.
On that day, my children, my wife and I were sitting around his bed "talking story" for several hours. As always, he remained mentally very alert and witty.
When the sun began to set, Dad told us that he was beginning to get tired, and suggested that the rest of us go out to a neighboring restaurant to enjoy dinner, so we did.
Half an hour later, his caretaker called to say "he went to sleep."
Dad passed away in his own time, naturally, peacefully, pain-free and at home, just as he had hoped that it would be, and we continue to remember him with the twinkle in his eye.
No matter what the U.S. Supreme Court determines on this issue, we in Hawaii must be prepared to care for our elders and the terminally ill with compassion and love, allowing them to retain their dignity and following their heartfelt wishes until the end.
II. Expectations
Because of Hawaii's multicultural population, we have a special obligation to be empathetic to all of our people with admiration and respect for their diversity. This may be difficult for some. That's why laws need to be enacted to protect physicians who support their patients' will and wishes during the dying portion of life.
It is understood that when rational, terminally ill patients have effective pain medication, and the knowledge to self-administer it, only rarely do they choose suicide over living. Just the security of knowing that they have control, to end their agony, is a real blessing for them.
III. Issues needing more discussion
The necessary discourse between physicians and clergy to examine all aspects of death with dignity: The family as well as the patient, has pain. Family physicians, internists, geriatricians and others should be made more aware of the suffering everyone experiences in end-of-life situations.
The vast generation of baby-boomers will be next in line and in need of our comfort and support.
Dr. Norman Goldstein is
Clinical Professor of Medicine (Dermatology),
John A. Burns School of Medicine,
University of Hawaii at Manoa.Leave room for memories,
hope and a few miracles
By Dr. Edgar A. GamboaLetting go with dignity
can be our finest hour
By Dr. Norman Goldstein
