Assisted Suicide and the Need to Reaffirm the Worth of Life

With a legislative vote under the intense lobbying of assisted-suicide advocates, California earlier this month legalized assisted suicide. I asked Dr. Eric M. Chevlen, M.D., who publicly opposed the move and works in the field of palliative care, to discuss where we are headed and our alternatives. Among other things, Dr. Chevlen co-authored the book Power over Pain with longtime National Review Online contributor Wesley J. Smith. — KJL

Kathryn Jean Lopez: Will doctors who comply with the choice to exercise this new legal right be abandoning their patients, as you argued when opposing the law?

Eric M. Chevlen: The foundation of a proper doctor-patient relationship is the doctor’s commitment to the patient’s well-being. That relationship recognizes the intrinsic value of the patient, not a value predicated on youth, beauty, health, or vigor. Strange to say, a doctor doesn’t have to like his patient, but he must love him. A doctor who accedes to a patient’s request for assistance in suicide abandons that commitment. He replaces a commitment to the patient’s well-being with a commitment to the patient’s non-being. Often, too, lying beneath the surface of the doctor’s acquiescence is his own discomfort in observing the patient’s reduced circumstance, his own sense of impotence at being unable to improve the objective health of the patient. Hastening the patient’s death reduces the doctor’s discomfort, and perhaps that of assembled relatives, but at the price of renouncing the intrinsic value of his patient.

Lopez: Can people really get the pain control they need, even in their final days?

Chevlen: Yes. It must be stressed: Pain is not the issue driving the assisted-suicide movement. Pain is controllable. More accurately put, while it is rare that pain can be eliminated completely, it almost always can be reduced to the level of ordinary pain such as we all have experienced in life. In my decades of caring for cancer patients and patients in chronic pain, I have had some patients who took their lives, and some who asked for my help in ending their lives, but never did I witness either of those events motivated by physical pain.

Lopez: What if they just want to go already? Why shouldn’t they take the opportunity for assistance in dying, as it’s being put today, now newly legal in California? What’s your pitch for living life until natural death?

Chevlen: I have observed, as have others, that assisted suicide is usually not a request of the great mass of ordinary people, nor from poor people. Rather, such requests are more likely to come from people who have experienced power and control of their own lives. They have luxuriated, and some have become intoxicated, with their sense of autonomy. Many come to impute their own self-worth to that power they seem to exert over destiny. When they face the end of life, many of these people experience the full force of a power greater than themselves for the first time. Not surprisingly, they rail against it. Since death itself cannot be prevented, the last grasp of power they can wield is to determine the timing and circumstance of their death. These people face a great challenge, and I am sympathetic to it. Their challenge is to recognize that their worth does not lie, and never did lie, in their power. The task, I would say the sacred duty, of the doctor caring for the terminally ill person is to help him recognize that intrinsic value.

That is often not an easy job for either patient or doctor. I remember a particular case that underscored the challenge and the reward of the effort to re-frame the source of life’s value. I was caring for a man in his late 50s who had advanced cancer with a life expectancy of a few weeks. He had some discomfort, but pain was not an issue for him. Rather, in considering his life, he found nothing he could look backward on in pride, nor forward to in hope. He had been a ne’er-do-well and a petty criminal. He was estranged from his children. He saw no reason to exist as he awaited his death. He asked me to give him a lethal injection to end his life.

We discussed it at length. I explained that I still saw value in his life, value in him. He had some weeks of life left to him, I explained, during which he could still accomplish something. I didn’t know what that was. I didn’t have the answer to his life, I acknowledged, but I urged him to consider what that might be.

A few weeks later, shortly before he died, he tearfully thanked me for my refusal. He had used the intervening weeks to forge a rapprochement with his estranged son. To my surprise then — but not to my surprise as I later considered it — he told me that the last few weeks had been the best weeks of his life. Soon thereafter, he died in peace.

Lopez: In making that case, are you forcing extremes?

Chevlen: No. Medical interventions must occur only with the informed consent of the patient. Treatments, whether they be chemotherapy or mechanical ventilation, which the patient experiences as burdens far beyond their potential benefit, are legitimately refused, and usually should not even be recommended. A doctor must recognize the distinction between doing something for the patient and doing something to the patient. Making that distinction is both good medicine and good medical ethics.

Lopez: What does the world of palliative care look like?

Chevlen: Palliative care is emerging as an independent discipline within medicine. It focuses on reduction of symptoms and maximization of patient function in settings where the underlying disease resists treatment. The discipline offers help not just to cancer patients, but also to those with other advanced illnesses such as emphysema, liver failure, AIDS, etc.

Lopez: Why is palliative care an attractive, compelling, or humane choice when many today believe there is a “dignity” to and a mercy in assisted suicide?

Chevlen: Palliative care has as its goal maximizing the quality of life. Assisted suicide has as its goal ending life. Palliative care is merciful to the life of the patient; assisted suicide is indifferent to that life.

Lopez: What if you don’t have the money for hospice and that’s the only way to live? Do medical realities today necessitate and speed up death from a health-care-industry perspective as well as that of struggling families?

Chevlen: Hospice care is designed to give supportive care to people in the final phase of a terminal illness, and to focus on comfort and quality of life, rather than cure. The goal is to enable patients to be maintained in comfort and dignity so that they live each day as fully as possible. Hospice care is a covered service of Medicare, Medicaid, and all health-insurance plans. The hospice for which I served as a medical director never sent a bill to a patient or family. We accepted insurance payments as payment in full. Patients who had no insurance coverage of any kind were treated without charge as part of our mission. Most hospices operate in similar fashion. Hospice care may not be as cheap as a quick lethal potion, but it is relatively inexpensive, and available to virtually all.

My experience as a hospice medical director also taught me the limit of prognostication. Patients are eligible for hospice care when two doctors conclude that the patient’s life expectancy is six months or fewer. This is the same standard that now qualifies patients for assisted suicide in California. Nonetheless, 15 percent of hospice patients live longer than six months. Eight percent live longer than a year. (How many live longer than the doctors who had assessed their prognosis is not reported.) We’ll never know how much life will be lost by patients who chose suicide, assisted or otherwise, upon learning such a prognosis.

Lopez: What did your own battle with cancer teach you about pain and life and death in a whole new way?

Chevlen: Mankind is more in need of reminding than instruction. My own illness reminded me of many things which I knew intellectually, and which I had frequently observed in my career, but which I had not yet personally experienced. Like many patients, I was at first reluctant to have my pain treated with the full dose of morphine prescribed by my doctor — a dose identical to that which I myself have prescribed countless times — because I was concerned about possible side effects. (And like many of my patients, when I realized that the feared side effects didn’t occur, I gratefully accepted the full prescribed dose.) I was reminded that a doctor’s knowing that pain makes people grumpy does not in fact prevent pain from making a doctor grumpy.

When I was quite a bit sicker, I recognized and considered the possibility that the complications of my illness might soon take my life. I was weary from illness at that point. I recognized that, although not suicidal, I was indifferent to the prospect of dying. Of course, I had a loving, supporting family to encourage and/or nag me as needed. And intellectually I understood that my long-term prognosis was good. But now that I am healthy again, I think back on that time and try to learn from it. I was blessed that my cancer had a good prognosis, and that my excellent medical care was supplemented by the unconditional love of my family. But I think about patients whose prognosis is not good, or who go from indifference to death to an actual longing for death. No less than I, these patients need steadfast affirmation of the intrinsic value of life until and after the crisis of their despair abates.

— Kathryn Jean Lopez is senior fellow at the National Review Institute and editor-at-large of National Review Online. She is co-author of the new revised and updated edition of How to Defend the Faith without Raising Your Voice (available from Our Sunday Visitor and Amazon.com).