When a friend asks to die, heart and head conflict
When I read NPR host Diane Rehm’s account of the unnecessarily slow death that her husband, John, had to endure because his doctor refused their request for assistance in ending his life, I was reminded of the time a similar request was made of me.
In July 1998, I received a call from an old friend. She was in intensive care in a New Hampshire hospital, where she lay, nearly quadriplegic, with a halo brace screwed into her skull to buttress her broken neck and shocked spinal cord. An avid horsewoman and competitive carriage racer in her mid-70s, she had been devastatingly injured when her horse spooked, flipping the carriage over on top of her.
“The surgeon wants my permission to operate if I improve neurologically but the fracture does not heal. Will you promise me that if I remain a quadriplegic you will come and put me down?”
I did not hesitate in my answer to her. “Yes,” I said.
Put me down.
This phrase sounded perfectly natural coming from my friend, a farmer-poet and animal rights advocate who raised horses and cared for a coterie of rescue dogs. Her vet bills were always higher than her medical bills. She was well acquainted with death as part of the natural order of things on the farm.
I, on the other hand, am a doctor, a geriatrician. And at the time, I had witnessed all too many deaths among my patients and friends. As is common with the elderly in particular, most came after a long struggle with illness and decline. Usually I was able to offer adequate comfort and pain relief, even in those days before palliative medicine and enlightened hospice care became mainstream.
But I’d never been asked to help a patient die. Not the young father with widespread lung cancer who took himself out with a shotgun. Or the elderly man who killed his wife — she who suffered for months with intractable post-shingles facial pain — and then turned the pistol on himself.
But when my friend with the broken neck asked if I would “put her down,” I didn’t hesitate. Why had I said yes? Putting a person down is very different from doing so with a pet. Vets don’t refuse to euthanize an animal whose owner has requested it, but doctors almost never agree to do such a thing. What terrible line had I crossed?
Maybe because she was my friend, and not my patient, did I feel that somehow the professional commandment to “do no harm” did not apply? That because I knew her, loved her and respected her, and because she and her family trusted me, I should use my skills to end her suffering if necessary?
Perhaps I was just hoping that she would get better. What she wanted from me at that moment was reassurance that I would be there if she needed me. She was desperately afraid, and she turned to me for support.
One might ask: Why did she not turn to her own doctor? I suspect it was for the same reason that my patients who contemplated suicide did not turn to me: They knew they would be asking me to do something that could put me and my medical career in jeopardy. Euthanasia of humans is murder, after all. Even if one uses veterinary nomenclature to describe it.
A year before my friend broke her neck, Oregon passed, by referendum, the Death With Dignity Act. While the law is controversial, three other states have followed by adopting similar legislation. In Oregon, a competent adult with a terminal disease — certified by two doctors — can request a prescription for a fatal dose of drugs to be taken orally. After a waiting period, the medication can be obtained. The patient must be able to self-administer the drug. Doctor participation in the program is voluntary.
My friend would not have been a candidate for physician-assisted suicide had it been legal in her state. Quadriplegia is not a terminal illness, despite that she did not want to live that way. Many people, after all, do live with that condition.
She would have had to turn to a group like the Hemlock Society, the rifle over the fireplace mantel or — as hospice often recommends for the terminally ill in their care — cessation of food and water intake. This takes a week or two and seems cruel, but most patients can be made quite comfortable with state-of-the-art symptom management. This is, indeed, the means by which John Rehm ended his life.
But, my friend had turned to me. Fortunately for both of us, she made a very nice recovery, never required an operation and spent the next 16 years on her farm writing, gardening and enjoying the natural world, her family and many friends. She had her horses put down when the time came. When I visited her just after her 88th birthday, she was in chronic pain from severe arthritis and debilitated by several end-stage medical conditions.
“I’d like to be put down,” she said. “But my doctors just won’t do it.” Thankfully, she did not make this request of me again. She lived almost one year more.
Jerald Winakur is a clinical professor of medicine and associate faculty member at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center at San Antonio. This column first appeared in The Washington Post.