How We Die (26 page)
Authors: Sherwin B Nuland
Suicide, especially this newly debated form, has become fashionable lately. In centuries long past, those who took their own lives were at best considered to have committed a felony against themselves; at worst, their crime was viewed as a mortal sin. Both attitudes are implicit in the words of Immanuel Kant: “Suicide is not abominable because God forbids it; God forbids it because it is abominable.”
But things are different today; we have a new wrinkle on suicide, aided and perhaps encouraged by self-styled consultants on the limits of human suffering. We read in our tabloids and glossy magazines that the actions of the deceased are, under certain sanctioned circumstances, celebrated with tributes such as are usually reserved for New Age heroes, which a few of them seem to have become. As for the pop cultural icons, medical and otherwise, who assist them—we are treated to the spectacle of those publicized peddlers of death willingly expounding their philosophies on TV talk shows. They extol their own selflessness even as the judicial system seeks to prosecute them.
In 1988, there appeared in the
Journal of the American Medical Association
an account by a young gynecologist-in-training who, in the wee hours of one night, murdered—
murder
is the only word for it—a cancer-ridden twenty-year-old woman because it pleased him to interpret her plea for relief as a plea for death that only he could grant. His method was to inject a dose of intravenous morphine of at least twice the recommended strength and then to stand by until her breathing “became irregular, then ceased.” The fact that the self-appointed deliverer had never seen his victim before did not deter him from not only carrying out but actually publishing the details of his misconceived mission of mercy, saturated with the implicit fulsome certainty of his wisdom. Hippocrates winced, and his living heirs wept in spirit.
Journal of the American Medical Association
an account by a young gynecologist-in-training who, in the wee hours of one night, murdered—
murder
is the only word for it—a cancer-ridden twenty-year-old woman because it pleased him to interpret her plea for relief as a plea for death that only he could grant. His method was to inject a dose of intravenous morphine of at least twice the recommended strength and then to stand by until her breathing “became irregular, then ceased.” The fact that the self-appointed deliverer had never seen his victim before did not deter him from not only carrying out but actually publishing the details of his misconceived mission of mercy, saturated with the implicit fulsome certainty of his wisdom. Hippocrates winced, and his living heirs wept in spirit.
Though American doctors quickly reached a condemning consensus about the behavior of the young gynecologist, they responded very differently three years later in a case of quite another sort. Writing in the
New England Journal of Medicine
, an internist from Rochester, New York, described a patient he identified only as Diane, whose suicide he knowingly facilitated by prescribing the barbiturates she requested. Diane, the mother of a college-age son, had been Dr. Timothy Quill’s patient for a long time. Three and a half years earlier, he had diagnosed a particularly severe form of leukemia, and her disease had progressed to the point where “bone pain, weakness, fatigue, and fevers began to dominate her life.”
New England Journal of Medicine
, an internist from Rochester, New York, described a patient he identified only as Diane, whose suicide he knowingly facilitated by prescribing the barbiturates she requested. Diane, the mother of a college-age son, had been Dr. Timothy Quill’s patient for a long time. Three and a half years earlier, he had diagnosed a particularly severe form of leukemia, and her disease had progressed to the point where “bone pain, weakness, fatigue, and fevers began to dominate her life.”
Rather than agree to chemotherapy that stood little chance of arresting the lethal assault of her cancer, Diane early in her course had made it clear to Dr. Quill and his several consultants that she feared the debilitation of treatment and the loss of control of her body far more than she feared death. Slowly, patiently, with rare compassion and the help of his colleagues, Quill came to accept Diane’s decision and the validity of her grounds for making it. The process by which he gradually recognized that he should help speed her death is exemplary of the humane bond that can exist and be enhanced between a doctor and a competent terminally ill patient who rationally chooses and with consultation confirms that it is the right way to make her quietus. For those whose worldview allows them this option, Dr. Quill’s way of dealing with the thorny issue of assent (since then elaborated in a wise and outspoken book published in 1993) may prove to be a reference point on the compass of medical ethics. Physicians like the young gynecologist, and the inventors of suicide machines, too, have a great deal to learn from the Dianes and the Timothy Quills.
Quill and the gynecologist represent the diametrically opposed approaches which dominate discussions of the physician’s role in helping patients to die—they are the ideal and the feared. Debates have raged, and I hope will continue to rage, over the stance that should be taken by the medical community and others, and there are many shades of opinion.
In the Netherlands, euthanasia guidelines have been drawn up by common consensus, allowing competent and fully informed patients to have death administered in carefully regulated circumstances. The usual method is for the physician to induce deep sleep with barbiturates and then to inject a muscle-paralyzing drug to cause cessation of breathing. The Dutch Reformed Church has adopted a policy, described in its publication
Euthanasie en Pastoraat
—“Euthanasia and the Ministry”—that does not obstruct the voluntary ending of life when illness makes it intolerable. Their very choice of words signifies the churchmen’s sensitivity to the difference between this and ordinary suicide, or
zelfmoord
, literally “self-murder.” A new term has been introduced to refer to death under circumstances of euthanasia:
zelfdoding
, which might best be translated as “self-deathing.”
Euthanasie en Pastoraat
—“Euthanasia and the Ministry”—that does not obstruct the voluntary ending of life when illness makes it intolerable. Their very choice of words signifies the churchmen’s sensitivity to the difference between this and ordinary suicide, or
zelfmoord
, literally “self-murder.” A new term has been introduced to refer to death under circumstances of euthanasia:
zelfdoding
, which might best be translated as “self-deathing.”
Although the practice remains technically illegal in the Netherlands, it has not been prosecuted so long as the involved physician stays within the guidelines. These include repeated uncoerced requests to end the severe mental and physical suffering that is the result of incurable disease which has no other prospect for relief. It is required that all alternative options have been exhausted or refused. The number of patients undergoing euthanasia is approximately 2,300 per year in a nation of some 14.5 million people, representing about 1 percent of all deaths. Most frequently, the act is carried out in the patient’s home. Interestingly, the great majority of requests are refused by doctors, because they do not meet the criteria.
Involvement
is the essence of the thing. Family physicians who make house calls are the primary providers of medical care in the Netherlands. When a terminally ill person requests euthanasia or assistance with suicide, it is not a specialist to whom he is likely to go for counsel, or a death expert. The probability is that doctor and patient will have known each other for years, as did Timothy Quill and Diane, and even then consultation and verification by another physician is mandatory. The length and quality of Quill’s relationship with Diane must have been major considerations in the decision of a Rochester grand jury in July 1991 not to indict him.
is the essence of the thing. Family physicians who make house calls are the primary providers of medical care in the Netherlands. When a terminally ill person requests euthanasia or assistance with suicide, it is not a specialist to whom he is likely to go for counsel, or a death expert. The probability is that doctor and patient will have known each other for years, as did Timothy Quill and Diane, and even then consultation and verification by another physician is mandatory. The length and quality of Quill’s relationship with Diane must have been major considerations in the decision of a Rochester grand jury in July 1991 not to indict him.
In the United States and democratic countries in general, the importance of airing differing viewpoints rests not in the probability that a stable consensus will ever be reached but in the recognition that it will not. It is by studying the shades of opinion expressed in such discussions that we become aware of considerations in decision-making that may never have weighed in our soul-searching. Unlike the debates, which certainly belong in the public arena, the decisions themselves will always properly be made in the tiny, impenetrable sphere of personal conscience. And that is exactly as it should be.
Into all of this, an organization called the Hemlock Society has intruded itself. These pages are not the forum in which to critique the problematic way in which this well-meaning self-help group of generally intelligent people has publicly validated the suicide decisions of those who may suffer from impaired judgment. Nor is it my intention to ventilate more than just a bit of my disdain for the misguided way in which the Hemlock Society’s founder, Derek Humphry, has represented himself in the limelight of the media during promotion of his ill-advised cookbook of death,
Final Exit
. But no one should make a final judgment on
Final Exit
without being aware of a startling statistic: A 1991 survey conducted by the United States government’s Centers for Disease Control found that 27 percent of 11,631 high school students had “thought seriously” about killing themselves in the previous year, and that one in twelve had actually attempted it. More than half a million young Americans are known to try suicide each year, plus an undiscoverable other huge group of those whose attempts are never disclosed.
Final Exit
. But no one should make a final judgment on
Final Exit
without being aware of a startling statistic: A 1991 survey conducted by the United States government’s Centers for Disease Control found that 27 percent of 11,631 high school students had “thought seriously” about killing themselves in the previous year, and that one in twelve had actually attempted it. More than half a million young Americans are known to try suicide each year, plus an undiscoverable other huge group of those whose attempts are never disclosed.
In a June 1992 letter to the
Journal of the American Medical Association
, two psychiatrists at the Yale Child Study Center advised: “With its lurid examples, explicit instructions, and vigorous advocacy for suicide,
Final Exit
may have an especially pernicious effect on adolescents, who, with their high rate of attempted and completed suicide, appear susceptible to imitative influences and cultural factors that glorify or destigmatize suicide.”
Journal of the American Medical Association
, two psychiatrists at the Yale Child Study Center advised: “With its lurid examples, explicit instructions, and vigorous advocacy for suicide,
Final Exit
may have an especially pernicious effect on adolescents, who, with their high rate of attempted and completed suicide, appear susceptible to imitative influences and cultural factors that glorify or destigmatize suicide.”
Depression, the periodic despondency of the chronically ill, and the death fascination of some segments of our society are not strong enough justifications for teaching people how to murder themselves, to help them do it, or to bestow a blessing on it. No one with impaired powers of judgment is in a position to make a critical decision about ending his or her own life—on that point, there is no disagreement, even among the ethicists who argue most persuasively for the concept that has recently come to be known as “rational suicide.” In no way, as Dr. Quill has pointed out, does Derek Humphry’s death primer “resolve the profound moral, ethical and personal uncertainties it raises about the meaning of euthanasia and assisted suicide.” As with all issues that deal with human life, there is no universal answer, but there should be a universal attitude of tolerance and inquiry. It is perhaps too much to ask that there should also be a universal method of decision-making that is more specifically stated than the guidelines already described. Until a better one is available, Dr. Quill’s way—of empathy, unhurried discussion, consultation, questioning, and challenged assumptions—will do just fine.
Though Humphry’s philosophy can be condemned, his method cannot. The by-now-well-known technique of swallowing a quantity of sleeping pills just before enclosing one’s head in a firmly secured airtight plastic bag does work quite as well as Humphry suggests, even if not by exactly the physiological mechanism he describes. Because the bag is so small, the oxygen is used up quickly, well before the rebreathed carbon dioxide has any significant effect. Rapid cerebral failure ensues, but what really causes death
is
that a low blood-oxygen level slows the heart quickly to a complete standstill and the arrest of circulation. There may be some symptoms of acute heart failure as the rate of ventricular contraction decreases, but it hardly makes a difference, because dying is so efficiently accomplished. Although one would assume there might be terminal convulsions or vomiting inside the bag, this apparently rarely, if ever, occurs. Dr. Wayne Carver, the chief medical examiner of the state of Connecticut, has seen enough of such suicides to assure me that their faces are neither blue nor swollen. They look, in fact, quite ordinary—just dead.
is
that a low blood-oxygen level slows the heart quickly to a complete standstill and the arrest of circulation. There may be some symptoms of acute heart failure as the rate of ventricular contraction decreases, but it hardly makes a difference, because dying is so efficiently accomplished. Although one would assume there might be terminal convulsions or vomiting inside the bag, this apparently rarely, if ever, occurs. Dr. Wayne Carver, the chief medical examiner of the state of Connecticut, has seen enough of such suicides to assure me that their faces are neither blue nor swollen. They look, in fact, quite ordinary—just dead.
Each year, some thirty thousand Americans commit suicide, and most of them are young adults. This figure refers, of course, only to those whose deaths can with some certainty be attributed to self-destruction. The stigma that still attaches to suicide is sufficient that families, and the subjects themselves, will often disguise the circumstances. Survivors sometimes appeal to a sympathetic physician to write something else on a death certificate. Elderly males, as indicated earlier, kill themselves at the highest rate per thousand, giving in to the stress of physical illness and loneliness, and being particularly prone to depression.
The great majority of suicides still use the old-fashioned methods of firearms, stabbing, hanging, pills, and gas, or a combination of several. Not infrequently, a poorly planned suicide is botched, especially when attempted by an emotionally distraught individual. In desperation, such people sometimes keep trying until they succeed, resulting in a body being discovered that has been lacerated, shot, and finally poisoned or hanged. When Seneca ultimately did take his own life, it was not by choice but on the order of the emperor Nero. Although one might think his many years of contemplation on the subject had made him something of an expert on its accomplishment, that was not the case—he was a renowned statesman, but he did not know much about the human body. In his determination to make an end of things, he plunged a dagger into the arteries of his arm; when the blood did not come fast enough to suit him, he cut the veins of his legs and knees. That not sufficing, poison was swallowed, also in vain. Finally, records Tacitus, “He was carried into a [heated] bath, with the steam of which he was suffocated.”
Barbiturates, a more modern agent of suicide, kill in several ways. The coma they induce is so profound that the upper airway may become obstructed because the head droops into a dangerous position, cutting off the intake of air. That, or the aspiration of vomit, then results in asphyxia. Barbiturates in very high dosage also cause a relaxation of the muscle in arterial walls, allowing the vessels to dilate enough so that blood is lost to the circulation by pooling. In such large amounts, the drugs suppress the contractility of the myocardium and can thus cause cardiac arrest.
In addition to barbiturates, there are several other common pharmacologic agents of dispatch: Heroin, like some of the other intravenous narcotics, kills by causing rapid pulmonary edema, although the mechanism that makes it happen is not known; cyanide inhibits one of the biochemical processes by which cells use oxygen; arsenic damages several organs, but its ultimate way of killing is to produce irregularities of cardiac rhythm, sometimes with coma and convulsions.
When a would-be suicide hooks up one end of a hose to an automobile’s exhaust pipe and inhales at the other, he is taking advantage of the affinity that hemoglobin has for carbon monoxide, which it prefers by a factor of 200 to 300 over its life-giving competitor, oxygen. The patient dies because his brain and heart are deprived of an adequate oxygen supply. The color imparted to the blood by the carboxyhemoglobin makes it significantly brighter and paradoxically even more vibrant than its normal state, with the result that the skin and mucous membranes of a person who dies by carbon monoxide have a remarkable cherry-red tinge. The absence of the typical bluish discoloration of asphyxia may deceive those who discover what appears to be a pink-cheeked body in the bloom of health, but dead nevertheless.
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