Assisted Suicide: More Urbane Than a Pillow

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assisted-suicide-2

By Stan Dundon

My Aunt Agnes is an old and frail relative who has willed me her $6 million estate. Dr. Leonhard Smith is her PC physician. His marriage is on edge over his pernicious gambling addiction and its huge debts. I approach Smith with the question: “Can a case be made that Agnes’ frailty is traceable to some potentially lethal disease?” He finds my question odd and looks at me guardedly. Much to my surprise he announces: “As a matter of fact I have been suspecting liver cancer. She used to be quite a party girl and still likes a snifter of B&B. I’m having some tests done now. Liver cancer is certainly a potential killer. She’s probably Stage B going on C. But do you mean like soon?”

Our state has legalized suicide, so the doctor’s eyebrows rise when I answer: “Like six months.” His brow knits now and grim lines form around his mouth. “What are we talking about here?” says Smith. Getting his attention with a pause, I say pointedly:“Your gambling debts,” and follow it quickly almost as an afterthought with: “Did you know that when a ‘terminal’ patient gets the lethal potion legally they can store it indefinitely?” “Really?” says Smith, “and what’s your point?” I continue grimly: “Yes, and they need no witnesses when they use it and are required to use it in private.” Smith shifts his feet uneasily and is breathing very carefully. I let the silence hang in the air. He has known me professionally for years and, I believe, has thought of me as committed to ethically good behavior. I am a “public representative” on an ethics board he serves on. It’s obvious that he doesn’t want to ask what’s clearly on his mind. And, as if to relieve the tension, I add almost light-heartedly: “And get this, as her attending physician you would be legally required to report Agnes’ ‘cause of death’ as liver cancer regardless of the lethal potion.” The color drains out of his face and he looks at me with disbelief. I mutter: “I couldn’t have planned it better myself.” When he reads the seriousness in my eyes, his turn to pleading. He says: “Look, I know my gambling has made a mess of my life but it doesn’t make me a monster.” “Yes, but it will shortly make you wifeless and an absentee father.” “For God’s sake, she has been my patient for years and she trusts me.”

I press on: “Look, this is not something I can do by myself. I’ll take care of both ends and most of the middle.. I’m her favorite and she is plenty sharp. I will make the perfectly valid point that taking care of the red tape of getting the ‘aid-in-dying medication’ in the fridge or bathroom cabinet in advance is the best way to avoid any suffering and indignity. She’s not shy. If I convince her, she will make the two verbal requests quite forthrightly. She might even want me there. But in any case, you can tell me when she has made the requests. You won’t have to cajole her or even lie to her or anyone. Saying she has only six months to live is already being understood to mean ‘if we were to discontinue the fairly aggressive regime we have you on.’ Tell me if I am wrong: Alice will die if her cancer is not fought. There is no penalty if the prognosis is not precise. And she will know the whole thing is just a precaution. The law is very clear that having the drugs at home does not imply any obligation to use them.”

My effort to make this seem completely above board is not succeeding with Smith. He is getting more indignant. He retorts: “Being flippant here does no good. I can’t help but worry that you might be careless with my reputation.”   I get his point. This is a serious negotiation. A lot is at stake. It is not like either of us has done anything like this before. All I bring to this process is an awareness of the danger of lying. What Smith sensed as flippancy was really part of my plan, a serious part. I need to win his confidence on that.

I say: “I’m sorry, let me be more open. The precise part I am asking you to help with is essentially not wrong. It’s just to get the drug in the house legally.. And that makes such good sense that no one could object. The context, though, is not comfortable. I just feel that your role can prescind from the context. My flippancy is, was, dishonest. I should have argued it out openly. The plain meaning of the legislation is to give people a sense of security that they will not lose a critical part of their autonomy—and that’s ALL you are doing.” Smith is not mollified. He scoffs: “That’s not all you’re doing!” I shoot back: “That’s what ‘prescind’ means. My behavior is based on the conviction that you will be able to function in a way the inspires confidence if you are confident that you are neither lying nor breaking the law. It was foolish of me to imagine that nonchalance could create that confidence.”

Smith is fighting my making this an abstract discussion. He muses bitterly: ”You are ignoring the fact that we both know that Alice is not suffering. And the law is aimed at that.” “Hardly,” I say, “almost none of the Oregon cases were in any kind of physical pain. And the law does not require it!” Smith goes on: “Talking this way almost makes me sick. How can a law change the whole nature of a relationship? I always thought of doctoring as a form of friendship. That’s why, at least a big part of why I became a doctor.”   “Look, I’m really sorry about that but this new law hardly did that by itself,” I say.

“OK” says Smith, “so how am I supposed to deal with asking a patient of many years to put a request for death in writing?” “You’re off the hook,” I say. “ You don’t even have to be there. They even have a fill-in-the-blanks form. It’s just getting rid of the red-tape. I will deliver the filled-in form to you. Then you make out the prescription and I will get it filled and deliver it to Alice. Then she just keeps it.” Smith looks at me with distaste: “I can’t believe how ruthless you are.” I say: “Look, she’s almost dead anyway. Her being willing to sign up should give you some idea of how much she is enjoying life.” Smith is not buying it: “So what am I getting paid for?” he asks.   I remark.: “You haven’t read the law, have you? You and your ‘consulting physician’ have several hours of paper work to fill out which has to be based on quite a few actual observations, multiple precautions, documented recommendations and carefully plausible responses. Consider it payment.”

Smith says: “You’re doing it again. Stop pretending this isn’t serious! She’s sick but I can keep her comfortable most of the time. It’s not just B&B she enjoys. There is actually an old philosophy professor in the retirement home she visits who flirts with her outrageously. I was there once and saw her actually blushing. And the Visiting Nurse finds her delightful even when she gets cantankerous.” I feign penitence: “I’m just trying to make this easy for you.” Smith: “Well, forget it. It’s never going to be easy.” From the verb I sense that he is coming to terms with his options. I try to soften things as much as possible: “Doctor, I am not going to set anything in motion until Alice gives me strong signals that she is tired of living.” I am not sure how true that is and I hope my eyes do not reveal it. I add: “Let’s talk again. There is no hurry on this.”

This I know is a lie because my financial situation is pretty unstable. I am not a monster either and feel not a little guilty for exploiting Alice’s fondness for me. Her other relatives never, well hardly ever, visit. I visit because I like her. Unfortunately her promised kindness to me got me used to thinking of myself as really rich and not as verging on homelessness.

I can’t really see myself as a murderer. That’s not what this is. I can’t see it that way. It is a legitimate option. I have to get my head around what I am doing, what I am going to tell Alice. Something like this:

“Every human should have the right and ability to escape serious pain and not just physical pain. Also the pain of loss of dignity, loss of control of one’s bowels, needing to be cleaned up, being unable to dress oneself, food slopping down one’s face and crusting up on one’s pajamas.”

In the following weeks I overcome my scruples and start to talk to Alice about the process of getting the “aid in dying medication” in the house. I have to keep reminding myself that “there is no hurry on this” and telling Alice that “this is just a precaution.” I say to her: “Alice, just bring it up with your doctor Whatshisname. I don’t know him very well. He will tell you that the whole process will take weeks. And if he suspects you’re just depressed he would be bound by law and his professional ethics to refer you to a psychotherapist. Then you’re talking months. Let’s get it done now and then forget about it.”

I have to be careful so that if some relative does visit and she mentions the plan it will sound persuasive and above board. If it happens I will contact whomever it is and ask them to oversee the process since the law does not want potential heirs to be deeply involved. I think they know I’m an heir, probably not how much though.

Sure enough, Leonhard, Dr. Smith, calls and asks if we can have coffee on my side of town. I suggest a third location away from both sides. We meet and he seems much more together. I am surprised what a lift that gives me. “She made the first verbal request and immediately set up the appointment for the second one two weeks later,” Smith says.

I look at him sternly: “Make that two weeks and a day.” “Of course,” says Smith. I say, “You get zilch of your percentage if you violate one tiny regulation.” Smith winches a bit. I guess M.D.s aren’t used to hearing tough talk from mere B.A.s. To recover his balance he says: “What percentage of what?” I say: “15% of probably $6 million.” “Holy s—,” he says, a carefully controlled smile spreading over his face.”I’ve got him,” I think to myself. “Another 1% if you can get the consulting doctor to accept a standard consultant’s fee.”

I decide to use the standard form for the written request and let Smith select an “outsider” witness, probably his secretary, and have Alice choose one, probably her Visiting Nurse.

In three weeks it is done. Smith has an out-of-state pharmacy Fed-Ex the drug to me. Next time I visit Alice, while playing gin with her, I mention, as if in passing, that it has arrived and I’ll try to remember to bring it over next time. I usually visit twice a month or so. I “forget” the next time and Alice doesn’t even bring it up. I forget again but this time Alice brings it up. “I’m just curious,” she says. “It’s still in its Fed-Ex box.” I say.

I make sure I bring it next time. Alice looks at the box and puts it in the towel cabinet. My financial ice is getting thinner but I have to keep up the nonchalance. I call Leonhard’s office and tell his secretary: “Tell Dr. Smith that if my auntie needs to see him, I’ll call and he should definitely make sure he comes right away. I’ve noticed her health has seemed sketchy. Please get him to stay in town. It’s critical. Alice will be upset if it’s not him who shows up.”

Meanwhile, I have been “grooming” Alice to enjoy those exotic new soft drinks while we play cards. She’s still better at gin than I am. I need her to enjoy some drink flavors that will cover the taste of the drug. This drink comes in six different “cactus flower” flavors. With Alice I use the rationale that I can sock back a good scotch if I drink a quality NA beer with my meal. “This way you could still watch your favorite sit-com with a snifter of B&B after I leave.” She bought it. She likes the flavors we tried so far. For me they smell like something the girl at the boutique sprays on your collar. I dissemble.

One thing I learned about lying is that a single lie cuts off that part of a story, however small or trivial, from an infinite number of real-world details almost impossible to remember and which have to fabricated and remembered as if real. Good detective writers know and exploit this fact delightfully, as did Daniel in defending Susanna. I am resolved not to let this happen to me. I will truthfully keep every possible rule in the suicide law. And there are at least forty-four, some appearing to be duplicative. If any are broken, what then? Like the witnesses to the written request for the drug. What if Alice left some money to the Visiting Nurse? Alice would still be dead. If the “sample” of suicide reports which the state’s Health Officer looks at each year includes Alice’s, I intend that he/she will find a squeaky clean and complete file, no lies a all!

Two weeks later it’s finally time to bring all the parts together. We get out the cards and I ask Alice if she would like to have her soft drink. She nods “yes” and I excuse myself to use the toilet. I retrieve the drug, which I was able to determine would be in powder form, and come out to get the soft drink from the fridge. Alice is a bit fastidious and refuses to drink from a bottle. I pour the drink in the kitchen, mixing the drug. The package insert indicates that dilution will not affect potency if an adequate dose is imbibed. “Adequate” is defined relative to body weight with a healthy margin of error. I don’t know how much Alice weighs. She is very modest but cut quite a figure when she was young, by all accounts. I could be off by 20 lbs either way. Now she always wears puffy clothes.

I can’t just err on the side of overdose. Did Smith tell the pharmacist how much Alice weighs so that he got the quantity right? What if Alice or I spill the drink? I would need a back-up dose. What if it tastes funny and she refuses to drink it? And what about all those execution-by-injection cases that went wrong? I am starting to sweat now, profusely. Alice will notice. I feign a cough and go back to the bathroom. In the mirror I am flushed. To cover it I feign violent, nearly convulsive, coughing. Alice is startled and calls out in concern. I say I’m OK. “Just gimme a moment.” Alice is on her feet. Like a lot of people these days, she has no drinking glass in the bathroom. “I’ll bring you a bottle of water,” she calls out.

The concern in her voice makes me feel guilty. Out of the corner of my eye I can see the doctored drink sitting on the kitchen counter.

“I have to slow this down,” I think. I sink into the couch and Alice gives me the water. I sip it, clearing my throat. I smile sheepishly: “I’m the one who’s supposed to be helping here.” “I know, dear,” she says, and pats my cheek. I didn’t see it coming and nearly jump out of my skin. Now she is really worried. She sits on the far edge of the couch, looking at me intently. “Maybe we should skip the cards today,” she says. I grab my panic and squash it down. “How fast this could all go south,” I think. “ And wouldn’t I love to put this off, but I can’t. I have only one dose and it’s already mixed.” Now I am not just sweating but I can hear my pulse pounding in my ears.

Leonhard should see me now if he thinks I’m coolly ruthless. For a moment I begin to waver but that brings to mind what brought me, not here because I actually love Alice and had been her pal for a handful of years before anyone even imagined medical suicides. No, it’s what brought me to this point: close enough because I love her, wicked enough to use the closeness to poison her, the precise mix which the Hippocratic Oath was meant to be a bulwark against, moving physicians from being witch-doctors to professionals. Poison! It’s the money and it’s not optional. I’ve got to do it and now.

But how do you start to murder someone? I had imagined we would be playing gin, she would be beating me, she would drink more of the drink than usual because I brought some really great flavored popcorn. She would slip into a faint. I would make her comfortable and she would go into a coma. I’d call the doctor and that would be that.

But here I am, a shambles being tended by his victim. I see the drink on the counter. If it goes down the drain I have to start over. This is still fixable. I say to Alice: “Auntie, I’ve had a rotten week and playing gin with you is one of the few relaxing things I do. [This is not a lie.] Just give me a few minutes.” She smiles warmly. We start playing. Her conversation is less lighthearted than usual. She wants to know what made my week rotten. I can’t tell her of course, so I vaguely mention “finances.” She looks me in the eyes. I look back, almost pleading. “My boy, I knew you were in trouble that way. When were you going to tell me?” I ask how she knew. She says: “Your shoes are nicely polished but when you cross your legs or sit on the couch the bottom of the shoes show. The soles are so thin I can nearly see the socks.” She laughs gently.

This woman loves me. Why didn’t I ask for her help? I didn’t have any good reason not to let her know. Instead I got started wondering how much longer she would live. And then when this suicide bill passed, waiting seemed to be just one of several options. One of those is sitting on the sink. I am staring at the card table, a sickening weight, like a cold dead hand, on the back of my neck. I look up at Alice. She’s waiting for me to answer her question. I am wondering whether I can carry on with the plan. “I was ashamed of making a mess of my finances.”

“I didn’t ask you, my boy, because I didn’t want to embarrass you. You have to let people help you, especially people who love you. I have willed you everything, why wouldn’t I give you some help when you really need it?” I want to reach over and hug her. I know she would love it, but I feel so rotten about myself that touching her would be like a sacrilege.

Instinctively I know I must slow down the pace of this entire thing. Am I still thinking of going ahead with this? I’ll play cards for a while and get my head together. I really do not want to kill this woman. I remember once thinking about it. Like: Is it possible to smother an old person without a violent struggle? Fingernails digging into my hands, raking my face with accusing welts. The thoughts return. My heart starts pounding again. I feel like I am going to faint and explode at the same time. Alice can see it. She says: “My boy, you just don’t look good. I want you to lie down on the couch and drink some more of that water.” Instead I get up from the card table, stumble into the kitchen and clumsily knock the drugged drink into the sink, breaking it.

THE END

PS: The state of Oregon’s Health Department has stated publicly that it has neither the budget nor the authority to check compliance with its Physician Assisted Suicide law. SB128 got past the Appropriations Committee by claiming the law would have little fiscal burden. This ignores the stunning increase (40%) in conventional suicides in Oregon and similar increases in Washington. This rise involves huge public expenditures.

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11 thoughts on “Assisted Suicide: More Urbane Than a Pillow”

    1. Paul Thober

      I also assume that this is fictional, but how would one know?

       

      All I see in this piece is that some people will conspire to murder for money. If you can find a physician who is open to committing murder for money you certainly don’t need an assisted suicide law to cover it up.

  1. Biddlin

    Now this is offensive! This is an affront to anyone who has had to watch a loved one suffer a lingering painful death, pleading for help to end the pain.

    ;>)/

  2. Don Shor

    Dr. Dundon’s CV: 
    http://www.standundon.com/about-stan

    From his website:

    Medical Ethics
    Although history and philosophy of science is my defined area of expertise, pure chance made one of my earliest publications focus on end-of-life issues: the controversy over Karen Quinlan and her “persistent vegetative state.” Since I continue to teach in this area, mainly to Catholic audiences, I have scant motivation to hide my conviction that all patients benefit from traditional Catholic constraints on medical behavior both in the ethics of life’s beginning and in its ending. The Hippocratic oath contained most of those constraints centuries before Judeo-Christian ethics became dominant in Western culture. In a purely secular culture suicide might be seen as rational, but putting the power to kill with legal approbation into the hands of doctors would still be a real threat to patients. I will include many of my writings on the topic of the sacredness of life
    A second focus is the issue of biological engineering and assisted reproductive technologies. I treat these topics in my current teaching and will place links to my Power-Point presentations in this Medical Ethics category. Few people realize that fertility restoration treatments are entirely unregulated by government agencies and entirely untracked by normal scientific methods. The field is experimental, except that the basic ethics of experimentation is absent: keeping records of the outcomes.

  3. Tia Will

    “I have scant motivation to hide my conviction that all patients benefit from traditional Catholic constraints on medical behavior both in the ethics of life’s beginning and in its ending.”

    I am very concerned about any fundamental medical decision making being determined by any specific set of religious beliefs. We have a separation of church and state in this country for a number of reasons, one of which is to ensure that one set of religious beliefs cannot be forced on those of another religion, or of no religion at all. As a member of the latter group, an individual with very deep and personal spiritual belief, but non adherent to any organized religion, I find it it equally as offensive that my life and death ( since I view them as part of one ongoing process) choices would be constrained by the Catholic system of beliefs as much as I would if they were to be constrained by Sharia law, Orthodox Jewish law, the beliefs of Hindus, Buddhists or any other group to whose belief system I do not adhere.

    Opposition to the concept of assisted suicide is frequently based on the fear that the rights of the individual will be abridged. What this ignores is that the rights of those of us who strongly believe that the life of the individual is their’s alone to determine are all ready being abridged resulting in unnecessary suffering.

  4. Tia Will

    Few people realize that fertility restoration treatments are entirely unregulated by government agencies and entirely untracked by normal scientific methods. The field is experimental, except that the basic ethics of experimentation is absent: keeping records of the outcomes.”

    On a completely separate note, this statement is misleading on several counts.

    1) Medications used by assisted fertility providers are subject to the same FDA guidelines, testing requirements and reporting requirements as any other drug.

    2) The field is experimental. True in the sense that all medical fields are experimental. Academic trials of fertility experiments are kept, recorded and reported in the same way as those of other medical ,drug and procedure trials.

    3) The implication is that there is no record keeping, which is false. Record keeping is handled in the same way as all medical record keeping. Independent practitioners doubtless keep only individual patient records and do not as a matter of course participate in large trials as is the case for any other individual practitioner unless they specifically agree to pool data for study purposes. Large groups do keep records of both individual and practice outcomes over time.

    Based on his fanciful story and these inaccuracies in his information, I would take this individual’s post with a block of salt.

  5. Napoleon Pig IV

    Not a badly written short story, but clearly motivated by a desire to create effective propaganda. The many ways to commit murder, and the many motivations to do so, do not eliminate the need to compassionately address the extreme suffering that some patients endure near the end of life. Many short stories, more emotionally compelling than this one, could be written about that aspect of human drama.

    As for basing any medical judgment on religion, why not just base it on some randomly selected psychotic episode that is not shared by large numbers of people? The outcome would undoubtedly be just as rational. Oink!

  6. Tia Will

    TBD

    Is this a version of the “death panels” which Sarah Palin pinpointed?”

    I can’t tell if this is an attempt at humor or if you are asking a genuine question.

     

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