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Monday, November 23, 2015

We Do Not Die in a Social Vacuum

Death is an inevitable biological process every human will experience in one form or another. For most who live a typical life span, death involves a long and steady decline. Most Americans state a strong desire to die at home. Few people experience this sort of death. Only 63% of people die at home. Another 17% die in an institutional setting such as a nursing home. Far too many receive hospice or palliative care far too late. Link: Most Americans do not die well. This is an indictment on American society. We hide death and divorce ourself of witnessing the process. We Americans do not even want to talk about death. On the rare occasion we do talk about death it is heavy on raw emotion and light on reason. Death, as discussed in the mainstream news, reflects the fever pitch in which we think about death. Brittany Maynard's death was tragic. She set herself up to be the personification of tragedy and her mission was to vigorously advocate for assisted suicide legislation. Maynard is not unusual, others have asked the court or physicians to end their life. In 1990 Larry MacAfee, a vent dependent quadriplegic, who was not terminally ill asked a Georgia court to allow him to turn off his vent. In 2010 Dan Crews expressed a desire to die in large part because he feared living in a nursing home. In 2011 Christina Symanski starved herself to death. McAfee, Crews, and Symanski were all high level quadriplegics. Aside from being quadriplegics they all shared one thing in common: when they expressed a public desire to die they became media celebrities just like Maynard. The general public loves suffering martyrs. 

I shake my head with wonder when I read stories about people with and without a disability who express a desire to die. Those that want to die get complete and total support in their quest. Ironically, who is discriminated against? People who are terminally ill, elderly, and disabled who want to live. Off to the nursing home for Grandma. Need specialized treatment for an aggressive and fatal form of cancer that will extend your life? Sorry, but that is not covered by insurance. What if you are paralyzed and need a social network of support to live your life? Sorry but institutional care is the best we have to offer. Disabled people, those terminally ill, and the elderly all put end of life issues in focus. The immediate reaction is fear. Foremost among our fears at the end of life is the loss of autonomy. The great value placed on autonomy works against us at the end of life. The same can be said for life with a disability. Autonomy is illusive for those with a disability. It defies conventional thinking. Autonomy is not about walking or the ability control one's bowels and bladder. Autonomy is a cultural ideal that defies definition. I consider myself to be autonomous. That is not how I am perceived by others--others who are bipedal with typical functioning bodies. My body represents the limits of modern medical care. My mere existence is a reminder of all that can go wrong in life. People with a terminal diagnosis  and the elderly make us equally uncomfortable. They represent human mortality. All know we will die and we do not need a reminder of this fact. Hence we segregate the elderly. We place the terminally ill in the care of others. Most of all we avoid talking about end of life. The discussions that are had about end of life focus on the unknown and autonomy. Most desire to die pain free. Most do not want to die cared for by strangers in an institution. People want to die in a humane way surrounded by loving family members. Predicting how this will happen is often pure folly. We humans are not good at predicting the future.

In terms of end of life, I am convinced of one thing: assisted suicide legislation is not the answer to why too many die poorly. Death is a social process. Death does not take place in a sociocultural vacuum. Even the most ordinary death has meaning to others who survive us. Those that lobby for assisted suicide legislation argue that it is about individual choice. People have the right to die as they choose assuming they are not mentally ill and are of sound mind.  Among those that advocate for assisted suicide legislation I am struck by the slogan: "My Life. My Choice. My Death". In the past I have quipped that sure is a lot of my, my, my. What is lost among the my, my, my is the social consequences of death. I read an essay in the Washington Post titled ""The Dangerous Contagious Effect of Assisted Suicide Laws" by Aaron Kheriaty about the rise in suicide rates in states that pass assisted suicide legislation. Link: Kheriaty's article is largely based on the recent findings made by two British scholars, David Jones and David Patton. The Jones Patton article, "Effect of Physician-Assisted Suicide on Suicide Rates" in the Southwest Medical Journal, concluded that in states that had passed assisted suicide legislation the overall rate of suicide increased 6.3 percent. Link: This conclusion led Kheriaty to write: 

It is widely acknowledged that the law is a teacher: Laws shape the ethos of a cultural by affecting cultural attitudes toward certain behaviors and influencing norms. Laws permitting physician-assisted suicide send a message that, under especially difficult circumstances, some lives are not worth living--and that suicide is a reasonable or appropriate way out. This is a message that will be heard not just by those with a terminal illness but also by anyone tempted to think he or she cannot go on any longer.

In part this explains why strangers will accost me with such statements such as "I would rather be dead than use a wheelchair". To them, life with a disability is a fate worse than death. Suicide for them is the only real option. What is not addressed is the fact that suicide is a public health care crisis. Suicide is the tenth leading cause of death in the United States. In 2013, the most recent year stats are available, there were 41,149 suicides. To me, the Jones/Patten findings and unacceptably high rate of suicide undermine the argument that assisted suicide is about nothing more than personal choice. Like  Kheriatry, I think we are at a cross roads. I too wonder what sort of society are we? Do we as a nation want to legalize a practice that will worsen an existing public health care crisis? 
 Let me contrast the above questions with a lesson from the past. 1951 and 1953 witnessed the most severe poliomyelitis pandemics in American history. Everyone knew those saved in the United States would never return to normalcy. This was a given. Rehabilitation units were established nationwide. School gymnasiums were turned into wards for those dependent on an iron lung. The response was extraordinary. Tom Koch in his book Thieves of Virtue wrote:

Nobody asked the cost of the new technologies that permitted patient survival. No one warned that the continuing care and rehabilitation for those left with withered limbs would be economically unsustainable. No body suggested that the folk saved by these extraordinary interventions would be a social burden whose public cost of care could never be recovered. Nor did anyone whisper that the long-term severity  of even the best anticipated outcomes would leave the afflicted with a quality of life so intolerable that they would be better off dead. Medical and social ethics demanded society and its physicians do all that was possible to save and, after saving, to rehabilitate polio's fragile survivors. Cost was not an issue because to not spend the monies, to not save the poliomyelitis patient, was unthinkable. 

I find the thought of assisted suicide legislation equally unthinkable. In place of the millions of dollars spent advocating for assisted suicide legislation we could use those funds to engage in a nationwide discussion about end of life. Why are there so few social supports for those who are elderly, disabled and terminally ill? Why are the elderly shunted off to nursing homes?  These are the sort of questions that could frame a nuanced and necessary discussion of end of life.  Don't be mislead by the highly emotional nationally known figures used to promote so called death with dignity laws. Dignity exists for all humans and it is our responsibility to value all lives. 


SteveR said...

When my 83-year-old father was dying of ALS, with tubes in his arms and one down his throat to let him breathe, he was unable to speak. In his weakened state, all he could do was pull vainly at the tubes, trying to pull them out. He did not have any dementia, by the way. After a couple of days of this, I asked him, "Dad, is there something important you want to tell me?" He then pulled his head up and stared at me angrily, wide-eyed as he hadn't before. I said, "yes, but I have to talk to Mom." He rolled his eyes and let his head drop back on the bed and closed his eyes, clearly defeated. He died a couple of days later.

I didn't say that he nearly died in his sleep at home a few days earlier, but was resuscitated and brought to hospital.

Living in a bed with tubes down your throat, unable to talk or breathe on your own, is no way to live.

william Peace said...

Steve, I am sorry the end of life for your father was so hard on him and your family. I would merely like to point out life on a vent is possible. Life on a vent can be quite good. Ed Roberts, the founder of Independent Living, lived most of his life vent dependent and in an iron lung.

Unknown said...

Powerful piece. Everyone should have the right to the best treatment, and the right to choose no treatment. Ability does not define happiness.