Dying with dignity.
Article Type: Report
Subject: Assisted suicide (Laws, regulations and rules)
Assisted suicide (Social aspects)
Dignity (Laws, regulations and rules)
Physicians (Powers and duties)
Human rights (Laws, regulations and rules)
Author: Byock, Ira
Pub Date: 03/01/2010
Publication: Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2010 Hastings Center ISSN: 0093-0334
Issue: Date: March-April, 2010 Source Volume: 40 Source Issue: 2
Topic: Event Code: 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime; 290 Public affairs Advertising Code: 94 Legal/Government Regulation Computer Subject: Government regulation
Product: Product Code: 8011000 Physicians & Surgeons; 9103550 Human Rights NAICS Code: 621111 Offices of Physicians (except Mental Health Specialists); 92812 International Affairs
Organization: Government Agency: Montana. Supreme Court
Geographic: Geographic Scope: Montana Geographic Code: 1U8MT Montana
Accession Number: 239530617
Full Text: On the last day of 2009, a divided Montana Supreme Court ruled that physicians in the Big Sky state can legally prescribe medications for terminally ill patients to use in ending their lives. Right-to-die activists would have preferred that the court find a constitutional right to assisted suicide. Still, they applauded the narrow decision, which merely exempted physicians from prosecution, as advancing death with dignity. In a separate opinion, Justice James C. Nelson wrote, "This right to physician aid in dying quintessentially involves the inviolable right to human dignity--our most fragile right."

The ruling will inevitably fuel overheated rhetoric on both sides of the physician-assisted suicide debate. But I believe the rhetoric of the debate misappropriates the word "dignity." As used by those who want to legalize assisted suicide, "death with dignity" implies that people who are dying are not already dignified. They are. And that is not merely my assertion or some New Age platitude. The preamble to the United Nation's 1948 Universal Declaration of Human Rights states that "recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world." This language formalizes an anthropological fact: the impulse to honor and care for our most vulnerable members--infants, elderly, injured, and ill--is part of our humanity.

It is easy to see how this unfortunate choice of terms came about. In contemporary Western society, independence and prowess have become the hallmarks of dignity. Being frail or dependent on others can then feel undignified. The feeling is compounded if a person is pauperized by medical bills, warehoused in an understaffed nursing home, and treated as if she were a nuisance and a burden. The suggestion that an incurably ill person may need to end her life to preserve her dignity seems to add insult to injury.

I am a palliative care physician who regularly cares for terminally ill people. What I really know about dignity did not come from text or formal training; instead I learned about dignity from the care my parents gave my maternal grandmother. I was eight years old when Grandma Leah had her stroke. Months of therapy left her barely able to communicate and in need of help to eat and use the toilet. Nursing home placement was advised, but out of the question. My parents took her home.

Even as a boy, I was struck by my father's unabashed tenderness toward my grandmother. After a year, she improved enough to return home with my grandfather. We visited weekends to take her shopping and do household chores. Twice a month for the next twenty years, Dad had Leah soak her feet so he could cut her toenails. All the while, he relayed gossip and bawdy stories until she feigned shock or giggled. She saw her dignity reflected in his eyes.

Decades later, while serving as medical director for a hospice program in Missoula, Montana, I met a fellow I will call John. He was a handful, to put it mildly--a "management problem." Although mostly jovial, he was prone to fits of rage. He required constant attention. He needed to wear diapers but preferred being naked and had occasionally been found urinating behind furniture. But John's family never considered him undignified. The reason was simple: John was the three-year-old son of a hospice nurse colleague.

Many decades further on, if John develops dementia and acts in similar ways, will his wife and children consider him undignified? If so, why? We do not consider infants and toddlers undignified because they are at a stage of life in which they need physical care, nurturing, and patient, loving attention; why are we less tolerant at the end of life?

Our society is aging, and soaring numbers of chronically ill people live among us--the result of decades of medical progress. They do not have to be social problems. They are family members, neighbors, and friends. We have the collective responsibility to care for them with skill and deep respect. We have the opportunity to care for them with tenderness and love. Most of us will be physically dependent and intimately cared for by others before we die. This fact does not destine us to become undignified. It simply confirms that we are human.

Ira Byock directs the Palliative Care Service at Dartmouth-Hitchcock Medical Center and is a professor at Dartmouth Medical School. He is the author of Dying Well (Riverhead, 1997).
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