Map of life expectancy at birth from Global Education Project.

Monday, July 15, 2013

Physicians and dying

Before I get to the question of this post's title, let me make the obligatory George Zimmerman statement. No, I have nothing unusually insightful or unique to add, but neither does anybody else. If you can strap on a gun, see a kid simply walking through your neighborhood, stalk him, and shoot him dead, and have no legal accountability or responsibility whatsoever -- in fact you get your gun  back and you are free to do it again -- we are not living in a civilized country. (Yes yes, the sole, only and single reason Trayvon Martin was suspicious was because he was black. But everything I say here is true regardless.) It seems that according to Florida law, if you claim self defense, it is the burden of the prosecution to prove beyond a reasonable doubt that your actions were not in self defense. I don't think that losing  a fist fight is grounds for murder even if you are, in some sense, defending yourself, but even so: if you live in Florida, and you want to murder somebody, just get them alone, kill them, and claim they attacked you. That's all you have to do.

Okay, now on to business. Bill Noble, a British palliative care specialist, doesn't like a proposal in the land of the bowler and bumbershoot to legalize physician assisted suicide. It might surprise you -- and it did surprise some folks the last time I wrote about this question -- but I'm quite leery of this idea myself. Nothing terrible seems to have happened so far in Oregon, which did legalize it a few years back, but it still raises some distressing problems.

All of these proposals, like the Oregon law, have safeguards. The people must be terminally ill, you can't help a patient die just because the person is suffering. Also, they can't be diagnosed with depression or other major mental illness. But, if you've been reading this blog, you already know that neither of those criteria has the status of a "fact." Doctors are notoriously inept at predicting how long people have to live, and the diagnosis of depression is largely arbitrary. Obviously, if you're very ill, suffering, and don't have long to live, you're probably unhappy. Calling you "depressed" or not is pretty ridiculous either way.

In another vein, it seems to me quite disingenuous to claim that this choice can reliably be assessed as non-coerced. People's opportunity to die a natural death with dignity depends very much on their material and social resources. People are inevitably going to consider, at some level, the burden that their care puts on others -- both personally and financially, no matter what they say or how you talk with them. Palliative care specialists claim that often, not enough is done to relieve suffering and that people will often change their minds about wanting to die if they are given better care.

Noble thinks that even if you do conclude that there are meaningful criteria to distinguish those deserving of help in killing themselves and those who are not deserving, it should not be the job of physicians to make these decisions. He suggests a team of social workers, but I think his real point is that these proposals radically redefine medical ethics and the role of the profession, and a lot of doctors are just very uncomfortable with it.

I'm the first to concede that one of our greatest cultural pathologies is the denial of mortality. Death is not necessarily a tragedy, or I should say that any given individual death does not necessarily add to the overall tragedy of the human condition. Our time will come, and our refusal to accept that is at the root of a good deal of disordered thinking and bad public policy. (Weirdly, it's religious people who believe in an afterlife who seem to suffer from this delusion the most.) But it has traditionally been the job of doctors to delay that time, if possible and worthwhile, not to hasten it. This idea has many implications which people seem to stop short of thinking through. So no, I'm not yet convinced this is a good idea, although I'm willing to listen.

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