The New York Times
November 9, 2001

Separating Death From Agony

By JEROME GROOPMAN, M.D. 
BOSTON

Not long ago, a cancer specialist I know faced a situation
that chilled those of us who care for people with terminal
illness. A young woman close to death lay suffering in a
hospital bed, her husband at her side. Her leukemia had
defied bone marrow transplant and experimental drugs. She
had begun to bleed into her lungs and was gasping for air. 

Months earlier, following common practice, the oncologist
had had a frank discussion about dying with the woman and
her husband. The greatest terror for her, as for most other
patients, was that the final days of her life might be
spent in unrelenting pain. An understanding was reached
among the patient, the doctor and the family that if the
time came when there was no real hope of surviving and she
faced only pain and debility, no extraordinary means would
be taken to sustain her and sufficient doses of drugs like
morphine would be administered to ease the pain, even if
that meant reducing her breathing or lowering her blood
pressure and thereby expediting her death. 

That time had clearly come, but when the doctor ordered
morphine, a respiratory therapist at the bedside vehemently
objected. He asserted that the morphine, because it
inhibited her breathing, was nothing more than a thinly
veiled disguise for physician-assisted patient suicide. The
patient's husband, aghast, reiterated the promise given to
his wife. The doctor was not deterred and prescribed as
much morphine as was required to alleviate the painful
suffocation that occurs when the lungs fill with blood.
Within a day the young woman peacefully died. 

The physician felt that he had fulfilled his moral and
professional obligation to relieve suffering, and the
family was satisfied that their loved one's death occurred
with as much dignity as possible. But the respiratory
therapist then accused the physician of nothing less than a
crime, and the husband of being an accomplice. The charge
was judged unfounded first by a hospital review board and
later by the district attorney's office. Yet the step by
Attorney General John Ashcroft this week in response to
Oregon's legalization of physician-assisted suicide could
have dictated a different outcome. 

Mr. Ashcroft authorized the Drug Enforcement Administration
to take punitive action against physicians who prescribe
lethal drugs for terminally ill patients; the doctors'
licenses would be suspended. This action, which is being
challenged by the state, represents a striking lack of
understanding of how physicians help patients to die, and
it risks making the last days of the terminally ill a time
of panic and pain rather than calm and comfort. While this
legal policy may be directed at a single state where
patients can obtain prescriptions for the lethal drugs
under certain circumstances, Mr. Ashcroft endangers what
has become a compassionate, if tacit, mode of dying
throughout the United States. 

Nothing could be further from the truth than Mr. Ashcroft's
statement that a federal drug agency could readily discern
the "important medical, ethical and legal distinctions
between intentionally causing a patient's death and
providing sufficient dosages of pain medication necessary
to eliminate or alleviate pain." In fact, it is medically
impossible to dissociate intentionally ameliorating a dying
patient's agony from intentionally shortening the time left
to live. 

In the case of the young woman with leukemia and pulmonary
hemorrhage, the doses of morphine needed to ease her
suffering also depressed her breathing. And death is rarely
a gentle process of simply closing one's eyes. Rather,
there are potent physiological reflexes, graphically termed
"agonal." Narcotics like morphine are essential in
dampening these death throes, and in doing so, they
facilitate death. 

Mr. Ashcroft's action also threatens the very essence of
the hospice care that in recent years has allowed so many
terminal patients to die at home, with doctors and nurses
easing the passage through the prudent use of pain
medications. 

Some opponents of the attorney general invoke states'
rights, arguing that federal agencies should not meddle
with Oregon's law. This skirts the more fundamental issue.
Helping nature take its course is not criminal, and it
should be outside governmental regulation. Decisions about
when and how to die are best left to patients, families and
health professionals, not legislators and litigators.
Committees of doctors and nurses already exist in hospitals
and hospices that can exercise sound judgment in
controversial cases and advise on the parameters for the
process of dying. 

If the Justice Department's action is a political bone
thrown to religious conservatives, it shamefully miscasts
health professionals as disciples of the devil rather than
angels of mercy. If it represents an earnest attempt to
protect the dying, it in fact makes them more vulnerable.
Death will ultimately come, but without the skilled hands
of physicians and nurses to ease the release of the soul. 

Jerome Groopman, a professor of medicine at Harvard, is
the author, most recently, of "Second Opinions."

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