The Patient Was…

The concept of “Death with Dignity” has undeniable appeal. It reflects nobility, sensitivity, morality, and humanity.

Why, then, does such a noble and appealing idea generate controversy? How could there be any argument with the notion of a dignified passing?

My problem with the concept of dying with dignity is that it has been co-opted by those advocating for assisted dying, euthanasia, and refusal of medical care. And in that case, resistance to any of these ideas must, therefore, automatically be considered an undignified way of dying.

It’s notable to me that from a philosophical point of view, the ideas of assisted dying and euthanasia conflict with an equally, if not more, powerful concept: the sanctity of life, the principle that human life is inherently valuable and must be protected. Major religions emphasize this sacredness of life, especially human life. In Christianity, the idea that humans are created in the image of God underpins the importance of preserving life at all stages. In Judaism, there is a moral obligation to protect life; saving a life essentially overrides all other laws. In Islam, all life forms are sacred, with particular emphasis on human life; and saving a life is equated with saving humanity.

Moving away from the philosophical, theoretical, and religious spheres, I don’t have an argument with those who believe in ending life on their own terms, in appropriate circumstances. These include unquestioned medical evidence of terminal illness, intractable pain and suffering, and decisions made with clarity of mind and freedom from coercion.

But, again, why is a choice to terminate life even under suitable, acceptable circumstances called “dignified,” when choosing to extend and preserve life using any means available is not entitled to the same “dignity” designation?

Progress in the science of life support and preservation of organ function and organism viability provide alternatives to many decisions to terminate life prematurely. Advances in pain management can change intolerable situations to manageable ones. Circulatory support can maintain adequate organ perfusion in many circumstances. And respiratory technology can often provide sufficient oxygenation to sustain life.

So, are these measures “undignified?” Does relying on technology and scientific progress carry with it the condemnation of indignity. The answer must be no, because we rely on these techniques in so many circumstances.

Think of patients undergoing many types of surgery. Their breathing may be controlled mechanically. Their circulation is supported. Brain activity is artificially altered. Nerve and muscle function is suppressed. Is this undignified? In no way!

We applaud the use of technology in medicine every day. New drugs, new devices, new techniques, new strategies, all play a role in preserving and enhancing life. We laud those who employ the latest and best that science can provide. There is nothing undignified about any of it.

Why would using it near end of life change our view? Why would we choose to consider the products of scientific progress to be anything but admirable?

One circumstance in which critics of artificial life-sustaining treatments are particularly vocal is where patients are in a comatose or otherwise unresponsive state. Terms like cruel, inhuman, wasteful, and immoral are bandied about. These patients, they say, are incapable of recognizing anything or anybody, and are totally unaware of the presence of family, friends, or caregivers.

In truth, we do not know if at least some of these patients are capable of perceiving anything of the world around them. People who have undergone near-death experiences and have been apparently devoid of cognition can often recite exactly what was said during that time. I have personally cared for a patient in a prolonged deep coma, whose neurology consultant advised discontinuing life support because of futility, who suddenly woke and cursed at the family member who had been berating him for creating a family crisis.

Perhaps the best description I have read of this situation is in a police novel (written by Joseph Wambaugh), where an alcoholic priest tells a policewoman whose friend is in a coma, “Doctors don’t know everything. I believe that people in comas are like dolphins that dive deep into the waters, fathoms deeper than we can imagine, but they are still capable of receiving signals from the surface. You keep talking to your young friend, and she will hear you in ways that we cannot understand.”

Ultimately, some may choose, as end-of-life approaches, to take advantage of the autonomy granted to them to prematurely end their life. I do not quarrel with their decision if it is made under appropriate circumstances and with safeguards against undue influence. But I do take issue with their co-opting the notion of “dying with dignity”. It is no more dignified to end one’s life by choosing to refuse available medical alternatives than it is to preserve life as long as possible using every therapeutic possibility.

The end of life is perhaps the one certain finality of human existence. And one way of facing that should not be considered more dignified than another.