Going Gently into that Good Night

Oct 17, 2014

IPFW Associate Professor and medical ethicist Abraham Schwab.
Credit Abraham Schwab

Brittany Maynard recently announced her decision to end her life. By all accounts she’s an articulate bright young woman who is afflicted with an aggressive brain tumor. Her prognosis includes prolonged suffering and a loss of control. In part because of how vocal she’s been and in part because she is young and looks so vibrant, she has brought national attention back to the question of physician assisted suicide (PAS). Brittany Maynard has not yet committed suicide, but if she does it will be legal (she now lives in Oregon) and at a time of her choosing.

Gillian Bennett committed suicide not so long ago, also because of expected loss of control and possible suffering. But Bennett was much older than Maynard, and her diagnosis was Alzheimer’s, not cancer. Much like Maynard, Bennett proclaimed that the risks and harms of a prolonged dying process was not what she wanted. Instead, she lay in the garden with her husband by her side and passed away painlessly.

Geoffrey Holder also died recently. I don’t know if we should call his death a suicide or not (whatever we call it, I’m convinced by his son’s account that no other death will be quite like his). Like Bennett, Holder decided the struggle would no longer be worth it. Like Bennett, Holder’s last moments were of his own choosing. Unlike Bennett, his illness was the most proximal cause of his death.

These stories continue a conversation about what it means to have a good life and a good death. Throughout most of the United States and Canada, we routinely let patients like Geoffrey Holder determine the end point of their treatment. But we are much more hesitant to let the Brittany Maynards and the Gillian Bennetts determine the end point of their lives. All can refuse treatment as Holder did; but, in most places, we refuse medical assistance to suicide.  

These three stories will not change, in any fundamental way, the discussion about what it means to have a good life and a good death. Over twenty years ago, Dr. Timothy Quill told the story  of ‘Diane’ and her physician-assisted suicide. He raised then the very same questions these cases raise today: How much freedom should we give people in determining the end of their life? And what role should we allow medicine to play at the end of life? Indiana and 46 other states give limited freedom to patients and allow medicine only a passive role. The arguments (patient autonomy, coercive burdens on the poor and disabled, and the aims of medicine) have not changed. 

But perhaps the background conditions have.

In the 20 plus years since Dr. Quill made headlines, increasing emphasis on palliative care and hospice has started to shift the culture of medical care. No longer simply attempts at aggressive cures, good medical care can be just symptom management. Accepting the inevitability of death, of going gently into that good night, has a foothold in medical practice. Recognizing the patient’s right to refuse  medical treatment strengthens this foothold. And the question that Brittany Maynard raises, that Gillian Bennett raised before, and that Timothy Quill raised 20 years before that, asks, “Why, when the loss is inevitable, does the patient have to wait for the disease to kill them?”

Should physicians be allowed to help patients choose the time of their passing when the end is near and the harm inevitable? It’s not a new question but it’s one being asked again.

I wouldn’t presume to know the will of the people of Indiana on this issue. But perhaps it’s time to ask them.

Abraham Schwab is an associate professor of philosophy and medical ethicist at IPFW.

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