Morality Versus Dignity

His head was supported by a thin pillow on a narrow hospital bed.  A distinct pungent odor permeated the air.  Rapid breathing was accompanied by a background rattle.  His lips glistened from remnants of Vaseline swabbed over them to slow the inevitable drying and cracking from air whistling by.  Thin grey hair liberally covered his scalp. His face and neck were pasty and creased.  His eyes were closed.  A thin institutional blanket covered both arms mottled with bruising and pooled blood.  Death was stalking the ninety-two year old man. The struggle was nearing an end.

The nurse leaned over the bed and spoke to him in reassuring tones.  She listened intently to his tortured gasps while her hand softly caressed his shoulder.  Her focus was to ease his suffering.  Her face was twisted with concern.  She placed a syringe in the corner of his mouth and slowly pushed the plunger a third of the way down.  A small amount of solution dripped out.  He reflexively swallowed it.  It was morphine.  His inhalation eased within a few minutes. It was seven P.M.  The curtain’s fall was postponed – for hours or perhaps days.

He was profoundly debilitated by Alzheimer’s disease.  Alzheimer’s begins by robbing a human being of their independence and then their dignity.  Over time, victims lose their sense of the world and their place in it. Near the end, motor skills atrophy and mental function ceases.

Signs of the disease were present for a decade.  They started as mere speed bumps that challenged, but did not interfere, with his enjoyment of life.  The middle years were marked by increasingly angry denials of infirmity that paralleled his deteriorating condition.  His final years were notable for his unrelenting agitation, misery and confusion.  The quiet, content and vibrant man vanished.  A deteriorating physical shell remained, but his spirit was gone.  His last two years were spent in an assisted living facility.  It was a caring humane home for victims of an inhumane disease.

Periodic trips to the cardiologists and internist’s dwindled and then ended after he entered the nursing home. His pacemaker was eventually turned off.  Medications for his chronic medical conditions were discontinued.  His status was DNR – Do Not Resuscitate.  He continued to live.  He lived as Alzheimer’s robbed him of his physicality after eradicating his cognitive function.  He fell frequently.  His spontaneous outbursts caused injuries that necessitated multiple visits to emergency rooms.  He was bathed and toileted. He became increasingly incontinent.  He could not eat without assistance during his final few weeks.  He became what he never would have wanted to be.  Yet he lived on.

We are governed by laws. The laws are a codification of our morality – our sense of right and wrong.  For the most part, laws govern how we relate with each other.  They create a functioning society.  However, where is the line between society’s interests and individual freedom?  When does the dignity of the individual trump the morality of the community?

Euthanasia is a controversial topic in all cultures, no matter the form of government. It can be passive or active.  Passive euthanasia involves withholding medical care and/or food.  No aggressive measures are taken. The patient is kept comfortable as life slowly drains.  Active euthanasia encompasses all assistance intended to cause an immediate voluntary death.  The helping hand brings immediate relief rather than drawn out drama.

The legal battles surrounding Dr. Kervorkian and Terry Schiavo highlighted the struggle between society’s morality and the dignity of death.  Dr. Kervorkian practiced active euthanasia. He assisted terminally ill patients who chose to end their lives. He viewed himself as a crusader for individual rights. He eventually was convicted of second degree murder and served eight years in jail. Terry Shiavo was a young women that was hospitalized with a serious medical condition.  Subsequent medical errors  left her in a comatose vegetative state.  There was no realistic hope for her recovery. There was no living will that could have provided direction with regard to the withdrawal of life prolonging measures.  An epic legal struggle commenced between her husband, who advocated for the withdrawal of life support, and her parents, who wanted them continued. Enormous medical expenditures were made on her behalf while the issue wound through the Courts. A nation’s attention was diverted on a sustained basis, and both husband and parents suffered emotionally and financially. Years of litigation and legislation ended with support measures being withdrawn. Terry Schiavo died shortly thereafter.

The tension between the needs of a moral society and the dignity of the individual surfaced when the morphine drizzled into the old man’s mouth.  He was more lethargic than ever before when the day began.  He began breathing deeply followed by fifteen seconds or more of stillness at nine A.M.  That pattern is called Cheyne-Stokes breathing.  It is a clear precursor of imminent demise. When the morphine was administered later in the evening, his suffering was alleviated, but was also extended into a certain future of uncertain duration.  It would have been so easy to push the plunger all the way to the bottom of the syringe.  His death would have been immediate.  His suffering would have been over.  It would have been a gift.  But it also would have been wrong – a violation of law.

Why do most States tacitly or pro-actively permit passive euthanasia, but only three legitimize a more active approach?  Shouldn’t an individual of sound mind have the opportunity to dictate the manner of their death when all hope is gone?  Should a decayed mind preclude honoring dictates from when it was vibrant?  Is easing suffering during a drawn out death more humane than an immediate peaceful death?

Generals have a responsibility for making life and death decisions on the battlefield. They weigh the importance of the objective against its cost in lives.  First responders and emergency room nurses, when overwhelmed, triage patients that need their help.  Those with a chance of living have priority over those with no chance to survive.  Why do our ethics honor their decisions over individuals but fail to respect the individual’s decision for themselves?

There are many reasons for resisting codification of the right to both passive and active euthanasia.  The Supreme Court ruled in 1997 that the “..right to assistance in committing suicide is not a fundamental liberty interest  protected by the Due Process Clause.”  Abuse and unscrupulous influence is a significant concern.  Many fear euthanasia is a slippery slope to State mandated murder. Others fear the big government implications of any State validation for end of life decisions.  Some would impose their religious beliefs on all. A few argue that assisted killing is a violation of the Hippocratic Oath.  Perhaps there is even an argument that a euthanasia law could be considered discriminatory if specific social or ethnic groups exercised their right to choose death more frequently than others.  All of these concerns are valid.  They raise difficult questions that cannot be resolved with one hundred percent confidence that no injustices will result. However, neither can our criminal justice system guarantee that an innocent citizen will not endure the terror of a wrongful conviction under the “beyond a reasonable doubt” standard.  Thus, the difficulty of articulating a set of principles should not be permitted to cloak our cowardice to confront the needs of the terminally ill.

Many people do not want their lives sustained past the point when they have lost all dignity and ability to enjoy life, when they are suffering, and for whom the future is a steep slide into oblivion. Twenty-five percent of Medicare’s
expenditures drain into the last year of life. Most patients are cared for by ten or more physicians in their final days.  Our society cannot afford to waste resources on those with no hope and who have expressed a clear desire for an end to the detriment of those in need. Unfortunately, the old man on the bed never had the right to make a choice, he had to endure.

The old man’s rapid forced breathing returned hours after the morphine infusion. It is said that unconscious patients near death are sometimes comforted by the voice of a loved one.  His disease robbed him of even that opportunity. His recognition of family disappeared well before that day. For days, all that remained were reactions to sensations such as pain and discomfort.  We will never know if the traumatic battle for life in those hours passed with no pain or fear for its victim.

Next morning the nurse checked him once again.  She turned him. His soiled clothing was changed.  I arrived ten minutes later. It was five minutes too late.  He was my father.  When he was of sound mind he never would have wanted to extend his life beyond the day he no longer could appreciate the world around him.  He certainly would not have seen any purpose in his last few weeks.  Regrettably, he had no means to assure otherwise.  I hope I will.

Comments

  1. MichaEL Laric says:

    You have described, eloquently, my experience with, and thoughts about, the morality and dignity surrounding death. I witnessed both my father’s (a lawyer and holocaust survivor), and my wife’s (an artist and educator). I would have preferred to see more dignity for both.

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