Writer Kevin Williamson, with whom I’ve tangled before on these pages, offers this take on assisted suicide and Brittany Maynard, the young woman who recently committed suicide in Oregon. He acknowledges the difficulty in formulating an argument against assisted suicide that doesn’t rely strictly on religious moralizing, and in the end seems to come out less against suicide and more against the suicide industry — doctors and pharmacies making above-the-board, legal tender on ending a human being’s life.
He seems to imply support for a more old-fashioned ending of the terminal patient’s life without the law’s official blessing, and this brings to mind an interesting rule I learned in med school.
One of the basics of pharmacology for any physician or med student is learning a drug’s maximum dose. Makes sense, after all. It falls in line with that do-no-harm thing. So, for Tylenol for instance, a patient can get no more than 4,000mg per day lest they risk liver damage. For amoxicillin, it also is 4,000mg. Levaquin, 750mg. For prednisone, the rule is 2 milligrams per kilogram of patient weight, and so on. Now there are cases where a doctor might exceed these limits, but if he does, he better well have a damn good reason that he documents well and that he is prepared to answer for in court, if it comes to it.
Which brings us to the rule for morphine. What is the maximum dose of morphine for a terminal patient?
And the answer is, there is no maximum dose of morphine for a terminal patient.
The implication of that should be clear to even a layperson.
Not once were we instructed on how to end a patient’s life sooner. In fact, we had plenty of lessons on just the opposite, on how nothing we do can actually end a patient’s life, due to legal reasons and also that whole “do no harm” thing mentioned above. But the reality is, for generations, physicians and nurses have indeed gently nudged their weary, end-stage cancer patients a little closer to the Pearly Gates with an extra dose of morphine or fentanyl which, perhaps, might have been a bit more than the patient could handle. And when such a patient experienced respiratory arrest, well, since they have a DNR order anyway…
It is repeatedly emphasized that at no time should any physician or nurse ever have the intention of ending a life when giving a dose of morphine — as that would be euthanasia which is strictly prohibited. In addition, a direct request by the patient for a lethal dose should always be completely rebuffed. Rather, the painkiller is given because such patients are invariably in great pain, as anyone can see. And when they do arrest, the cause of death is listed as the cancer, or complications thereof. Nobody asks the uncomfortable questions. Nobody doubts the intentions of the physicians or nurses, and no mention of untoward motivation is breathed by anyone or recorded on any chart.
This is (or was) the traditional manner of handling such things. Unofficial, grey-zone, and unmentioned.
Of course, hospital regulations have become far more onerous over the past several years, so perhaps things have changed. I do not work in a hospital and I do not take care of end-of-life patients, so I cannot speak to how things are now. That said, I do remain reasonably confident that Oregon hospitals now have official end-of-life consent forms with lines for many signatures, and required inservices on assisted suicide, and standard protocols devised by committee, and nurse-managers dedicated to handling such matters when they arise. The pharmacies will have special medicine order request forms, and they too must recheck everything in triplicate. Special billing codes will have been created and the relevant charges will have been remitted to the insurance companies. It will be inevitable that all physicians, nurses and pharmacists involved with dispensing the lethal dose of a barbituate will have to have official certification in end-of-life care, and will be able to append the relevant letters to the end of the name, joining an already lengthy alphabet soup there.
I don’t know what the answer is. I am glad that Brittany Maynard was able to choose the method of her exit, and with the advice of professionals, without having to resort to a homemade concoction or a 9mm bullet — or having to endure weeks or months of agony before the inevitable conclusion came anyway. On the other hand, the idea of our increasingly over-credentialed, over-regulated health care system handling such private matters gives me pause too.