We are all going to die. If we had a say in how it happened, what would most of us choose?
Recently I began asking clients, friends and family members this straightforward question and the results of this unscientific survey are very telling. Of the fifty or so people I have asked, all but three said, "In my sleep." One said, "By a heart attack." While a bit of a surprise, she was doing research in cardiology and explained that such deaths are often very quick. "No time to think about it," she added. One said, "Doing something I love like scuba diving or skiing." Another chose skydiving. The pattern is clear. People want quick and ideally painless deaths.
So far no one has chosen, "I'd like to die after lying in bed for two or three years, in a diaper, and barely aware of my surroundings." Yet isn't this scenario -- or a variant of it -- how a large percentage of us will die?
Let's face it, most of us will die at an advanced age. This is a good thing. Modern medicine has greatly increased our life expectancies. But this also implies that most people will die of diseases that strike the elderly. This means cancers -- never pleasant -- cognitive decline and dementia -- never pleasant -- or some other form of physical decline usually related to musculoskeletal or cardiovascular problems -- also never pleasant. While people with these conditions will technically die in their sleep, I don't think anyone hopes for death to be preceded by such misery.
Our nation is beginning to come to grips with end of life issues and physician-assisted death. It isn't a pleasant topic but no debate over a change of values and practices can be complete without considering the result of inaction. There are pros and cons with any position, including the status quo.
If I gave you a choice to live an extra day, would you take it? Of course. But what if I said that you would have to spend that extra day lying in bed without the strength to roll over? Now what? Would you still opt for the extra day? We all want to live as long as possible on this earth but quality of life will always trump pure time.
And what of time with our loved ones? I would still love to have my 92-year-old father in my life for many more years. But at some point I have to consider his needs more than my own. Seeing him open his eyes and smile at me is a pure joy but I'm not the one who has to lay there, unable to move, 24 hours a day, week after week and month after month.
Nursing homes can be inspiring places. The residents are often treated like kings and queens. But I bet there isn't a single person who visits a nursing home and says, "Yes, this is where and how I want my life to end." Yet if we do not give people choices we force them into the default option.
In discussing end of life issues, former Canadian Medical Association president, Dr. Louis Hugo Francescutti lauded quality palliative care saying that, "If I'm going to pass away, that's the way, other than dying in my sleep of a heart attack, that's the way that I would like to go."
So, like the vast majority of us, Francescutti seems to prefer dying in his sleep. So why then do we deprive people of their first choice except in a few lucky cases?
In palliative care, morphine can be administered in ever-increasing amounts to control terminal pain. But morphine depresses breathing at high doses. Does that not imply that as the person needs higher and higher doses to control pain, the morphine will eventually kill the person before the cancer would? Are we just debating how quickly we should euthanize people?
The most important thing I learned chairing the Clinical Ethics Committee at the Douglas Institute in Montreal was that ethical debates are not about right vs. wrong decisions. These debates arise when equally strong values clash. The only unethical decision is one that does not examine all our values together. Preserving life is without doubt one of our most sacred values. But so is the absence of suffering. In our single-minded focus on preserving life we have lost sight of some of its perverse consequences. The ethics of assisted dying cannot be debated without also considering the ethics of not allowing it.
In the end I believe the debate comes down to a simple question: We have no choice in THAT we will die. Do we want to give ourselves a choice in HOW we will die?