The crime of keeping worn-out bodies alive

N. J. Berrill,Medical miracles often bring only needless suffering to those who are beyond real hope. Here a distinguished Canadian scientist speaks for every man’s final right — the right to die in peace February 11 1961

The crime of keeping worn-out bodies alive

N. J. Berrill,Medical miracles often bring only needless suffering to those who are beyond real hope. Here a distinguished Canadian scientist speaks for every man’s final right — the right to die in peace February 11 1961

The crime of keeping worn-out bodies alive

N. J. Berrill

Medical miracles often bring only needless suffering to those who are beyond real hope. Here a distinguished Canadian scientist speaks for every man’s final right — the right to die in peace

MOST, INDIVIDUALS who get safely born now live to grow old, and of these a high proportion live to become truly aged before death supervenes. But it is becoming commonplace to put up a rearguard action against that final confrontation.

Keeping worn-out bodies alive for an extra few months by means of modern medical techniques has become a challenge to all concerned. Surgeons and physicians are inclined to regard the business as a test ot their personal skill or of their updated hospital equipment. Families are understandably loath to relinquish their hold on their loved ones, no matter how little remains truly alive to hold onto.

Between them, the relatives and doctors play into each other’s hands in mutual encouragement to do everything possible to prolong the final agony. In such circumstances families are usually wrought up and lack judgment, while the surgeon or doctor fears to hold his hand lest it be said he failed to do all he could to keep grandpa alive. Yet in most such crises there is usually one silent voice, that of the soul who has received death’s calling card. Granted that premature death is tragic, that there is tragedy in unfulfillment and bitterness in loss, the death that comes at the end of a long life is inevitable, is rarely entirely unwelcome at the time it comes, and is naturally a part of life as birth itself. To a truly old person, death comes as a friend bearing the gift of peace. Let him come as such, without rebuff, and allow the one he calls on to leave with quiet dignity.

This is what we now deny to the aged, so far as possible. More and more we have come to look upon the body as the person, as though everything and anything that can be done to keep the body functioning is right and proper,* no matter what misery is inflicted upon the owner of that body or even if the owner is no longer aware of being present.

Two moral crimes are commonly committed: keeping worn-out bodies alive after the personality has ceased to be, and going to untold lengths to repair the bodies of aged persons who know better but are too weak to assert themselves.

Too many doctors are anxious to try out their skills, and too many families expect it. So much can be done, and so too much usually is done. As a doctor recently wrote in the Canadian Medical Association Journal, many patients in extremis die in a tangle of glass jars, pipettes, tubes and needles in veins, mouth and nostrils and bladder, or strung up on a cot with ropes, bars, pulleys and weights, like some kind ot fowl. There is no end to this business and once we ignore the person and concentrate on the body, all manner of things becomes possible.

If only the body matters, it is possible to keep it alive for a time with an artificial heart or kidney if such organs are no longer operating, and it is certainly not necessary to have a functioning brain. All this is a nightmare world, and what may be useful in an emergency to save the life of a young person is sheer horror when inflicted upon the aged who are about to die. An old person has the right to die and to die decently, and not with all the indignities and insults to the body it is possible to inflict on it in the name of medical science. That right is as inalienable as the right of a child to grow, for the two belong together.

“While there is life there is hope” is a familiar phrase. During much of a lifetime it is true enough. But no amount of tinkering with the human body, by any means at all, can prolong the natural life span. Aging is a process that all living things undergo from the first moment of their individual existence. What you are to begin with sets your course thereafter, apart from accidents of one sort or another. The best that can be accomplished is to enable an individual to live to the age at which he or she naturally begins to break down.

What this age happens to be is determined right at the start, as studies of identical twins have shown. If one twin dies of heart failure at 66, the other is most likely to die from the same cause in the same year. If in another couple one twin dies from kidney breakdown at 73, the other almost certainly will do the same. When your time comes, it comes. When it comes, we need fortitude, not the shattering impact of last-ditch hospital procedures; as the psalmist said: “O spare me, that I may recover strength before I go hence and be no more.” Old age is no time for serious, painful

operations and their miserable aftermath. The unnatural prolongation of life, beyond what is reasonable or genuinely hopeful, has no sanction either in the Hippocratic oath of medicine or in Christianity. The Anglican bishop of Exeter, speaking at a British Medical Association congress, stated that while there is a moral obligation to maintain life by all ordinary means, there is no obligation to use extraordinary means, that to subject very old people to the acute discomfort of a serious operation or of feeding by intravenous drip would seem to be morally wrong, and that there is truth in the line “Thou shalt not kill, but needst not strive officiously to keep alive.”

We should not add to the suffering of the aged by employing heroic measures, for it is the person who is important, not the body. Nor, by the same token, should bodies be kept alive after all consciousness has been lost, which is too often the case following a succession of strokes.

As another theologian. Professor J. F. Fletcher of the Episcopal Theological School at Cambridge. Mass., has said, it is an error to view life on any terms, at any level, as the highest good. For “this betrays us into keeping ‘vegetables’ going, and to dragging the dying back to brute life just because we have the medical know-how to do it.” When consciousness is gone, it is false value to hold the body if that is all that can be held, and for the rest, medically resurrecting the dying is cruel beyond words since it requires the person to die twice over and perhaps more often than that.

Supposing heart, blood vessels, liver and kidneys are so healthy that they sustain the body and mind in good state into the eighth and ninth decade, the chances increase that malignancy will appear, simply because you have stayed alive longer than most. Cancer is the most dreaded of all diseases, and it commonly gives difficult passage to the dying. How far should one go in attempting to fight it in the aged?

Here, perhaps more than in any other, the situation needs to be faced and understood in terms of hope and gain, in relation to the price to be paid. If the required operation is a major one, which is usually the case, death will probably be postponed, though generally for less than a year, after which the cancer is likely to reappear elsewhere and in a grimmer form.

And the gain? Let me quote the words of a dying English surgeon, recorded in the British Medical Journal: “The surgical part of my case was trivial and painless. I would not wish my worst enemy the prolonged hell 1 have been through with radium neuritis and myalgia for over six months.” His obituary ran: “He formed the opinion that the treatment he had undergone had increased his suffering and made his passing more difficult, and he wished in his love for humanity to save others from a like fate.”

This point of view, that so much of the suffering inflicted upon the aged is uncalled for, has been put forth publicly by Dr. Gavin Miller, until recently the chief of surgery at the Royal Victoria Hospital in Montreal. .Speaking for himself, he said: “I would beg that if I became a ‘vegetable’ or if 1 had inoperable cancer that 1 be allowed to die in peace without any medication other than sedation.”

A family with a stricken person, however, must realize that a doctor is under pressure. He is under pressure from his own conscience, which tells him that if he doesn’t try every procedure and the patient dies, he is guilty of neglect. And he is under pressure from the family, which is under the double impact of the same sort of conscience and of the genuine, if thoughtless, desire to keep the loved one before them in some tangible form as long as possible, no matter what the cost to all concerned.

Yet it is a poor mind that cannot stand some disquieting thoughts, and in any case, who has asked the patient what are his or her thoughts about it all?

In his book The Torch, Dr. Wilder Penfield, one of the most understanding of living surgeons, puts these words into the mouth of an old woman who has been treated by the physician Hippocrates, the revered father of medicine: "You saved my life, I suppose, when you came to mend Photograpl, by my broken leg. Now when you return to view CONTINUED ON PAGE 29 Huyh Thompson


The crime of keeping worn-out bodies alive

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The question of further treatment boils down to: How much life can be bought for how much pain?

\our handiwork, there are two things that TOIL should study, the leg and me. . . . Would you still be proud of what you have done if 1 said I do not thank you fpr saving my life? 1 did not enjoy these endless days in bed. My time had come to die; I was ready to go. you see.”

All this may be very well, yet in every case the difficult question» becomes direct and personal to an individual, a family, and a physician. What should or should not be done? Much depends, for instance, upon the age and vigor of the stricken person. If all goes well, how much life expectancy is left? How much life, and what sort of life, can he bought for how much misery suffered? The answer. 1 think, is that there should be a reasonable chance that treatment will result in recovery. and that a significant amount of time will be left for the enjoyment of life.

The life doesn't belong to them

If the odds are heavily against recovery, such odds would be taken without hesitation in early life or even at the usual age for retirement, hut when age is so advanced that there is no real life expectancy left, drastic treatment of any kind shoidd be withheld. If the victim is sound in mind, if not in body, he or she would generally be the first to say “leave well alone,” and most physicians and surgeons would privately agree. In such cases it is not for the family to say that life must be prolonged aí any cost, for tho life in question, though cherished by them, does not belong to them.

How much suffering, through treatment. for how much life? Maybe you. the victim, or you. the family, do not know. Then it is the business of your physician to tell you.» If you have an incurable cancer, you have the right to be told, in spite of frequent medical practice to the contrary. If you merely suspect but prefer not to have it spelled out. that is your business too. In that case your family undertakes the burden of decision, but even then the only consideration should he what is worth while to the patient, and not what the thought of impending loss may he to the family. If.the desire, then, is to die in peace, what should be done? Alleviation of pain and discomfort as much as possible, through sedation and attention, with love and understanding. No more and no less.

Circumstances unfortunately may be far more difficult than this. An old person may be far from being mentally able to cope with the situation. Suppose, for instance. that there is a senile will to die, if you can call it that. If such is the case, no one else has the right to deny it. Whether it comes from weariness or from actual brain and nerve deterioration, it is nobody's business to bar the door. So much interference derives from the relatives’ desire to clear their own consciences so that they can forever afterward pacify themselves by saying over and over that they did everything possible, which is a natural but nonetheless unmistakable form of selfishness. An overwillingness to meet death is but one extreme, however The other could be a fear of death so

great that any amount of suffering would seem preferable. Perhaps then the individual has the right to suffer and postpone a little the final reckoning.

If all the medical aid we offer to the aged who are incurably ill is sedation, is this very different from euthanasia? The answer is yes. it is different, for euthanasia means bringing about death, gently but inexorably. The withholding of essentially futile operations and other harrowing treatments cannot conceivably be a sin of commission, nor is it, in my opinion, even a sin of omission. The question of euthanasia arises only when active steps are taken to bring on a death. It is however a problem to be faced, and in specific situations.

If a person is in the terminal stages of cancer, under such heavy sedation to reduce the pain that little consciousness remains, and that little consciousness is aware only of pain, the question is whether it is morally and ethically justifiable to administer so much sedation that not only is the pain killed but also the person. Of course it is! And it is practised, though never admitted, more often than we know. But what about the human vegetables, those unfortunates who have suffered cerebral haemorrhage to the extent of total paralysis and often uncon-

sciousness? Should they be fed through their veins until some further misfortune intervenes to kill them, or should they be allowed to die as they would have done until fifty years ago? If the latter, what then? If there is no chance of recovery, then I say that nature should be allowed to take its course and that the question does not arise, that keeping mindless flesh alive is indecent and uncalled for. More than this I do not suggest: that suffering of the aged be not unduly prolonged, by man or by nature.

As the writer of Ecclesiastes said: “To every thing there is a season, and a time to every purpose under the heaven: A time to be born, and a time to die: a time to plant, and a time to pluck up that which is planted. . . .” Let us leave it that way. and let the departing spirit go in peace when the time has come. ★