“It would be a great thing to understand pain in all its meanings.1
—Peter Mere Latham
Every physician, sooner or later, faces the difficult question: when is enough enough? Extreme suffering need not be endured endlessly, which is a maxim I established for myself early in my career.
I met Ruth, a 50-year-old accountant, for the first time when she came to ask me about a unilateral facial paralysis. On examination, I noticed a mass in her parotid gland with enlarged nodes on the same side as the mass. I questioned her about the enlarged gland and she said that she had noticed for some time, that there was a swelling on the side of the paralysis. We discussed the likelihood that she had a parotid tumor. She elected not to have surgery, not even a biopsy, and no radiation. She was not in pain at that time, could continue her work, and was only slightly inconvenienced by the paralysis.
Several months went by before she returned. I was distressed by her obvious weight loss, and the mass, which was considerably larger than when I first saw her. The skin on the left side of her face was tight and shiny, and I was concerned that it might ulcerate. She complained of difficulty with swallowing and a feeling that there was some obstruction to her breathing. The nodes in her neck were hard and she had limitation of her neck movement. We discussed tracheostomy as a temporary measure and she agreed to this. She was still working and planned to continue, despite the increasing discomfort she was experiencing.
A few weeks after the tracheostomy, I received a notice that she had closed her office. Not long after that, her husband called to ask if I would come to the house to see her; she was hesitant to come to the office because she was embarrassed to be seen by other patients in my waiting room. When I visited her, what I had dreaded had happened. She had a salivary fistula with constant drainage, which had led to a large ulcer on her cheek. Despite this she greeted me with a smile on the right side of her face and asked if she could have some pain medication. Of course I gave her a prescription and suggested that she let me arrange for visiting nurses. She declined, stating that she and her husband could manage. We agreed that I would come to see her regularly and that her husband would call if she needed me sooner than the appointed time.
It was only a few weeks after that visit that I was called to the house. When I entered, I heard a constant low moaning. In its tenor and intensity, the sound reminded me of the pitiful wail of a dog that, some years before, had been hit by a car in front of me. The voice of that animal was filled with the same unrelenting pain as the moaning that emitted from Ruth’s bedroom. My patient’s husband told me that his wife was unable to sleep or lie down and that she seemed to be in constant severe pain. She also could no longer speak, although she wrote messages. She could still swallow liquids if her husband used a dropper to administer them. A large piece of her cheek had eroded, and instead of an ulcer, there was now a hole. As soon as I pulled up a chair and sat down next to Ruth she printed on her clipboard, in large letters, “HELP!”
“How can I help?” I asked.
“Let me die” was the instant answer.
We communicated for some time; she wrote, I talked. I asked her whether she was sure that she wanted to die? Did she have anyone she needed to talk to before she decided to end her life, a religious advisor, friend, relative? She wrote that her good-byes had been said, that she needed relief. I wrestled with my conscience. Was it morally permissible to shorten this woman’s life by a day, an hour, a minute? That she would die within a week’s time I had no doubt, but should I let her wait until her heart stopped, enduring the time allotted to her? One look at my patient and my scruples dissolved; I was sure that if I were to act as a physician, in the true sense of the profession, I would release Ruth from her torture. As Dr. Gordon points out, my duties and obligations as a physician, my covenant with my patient, seemed to demand that I not abandon Ruth at this time but to be faithful in attending to her needs.2 I had to help her to escape from her pain.
I felt deep compassion for this courageous, brave woman. I saw no need to extend her suffering since there was no hope of recovery. Yet I was torn, ambivalent; however, I wrote a prescription for enough pain medication that she could end her misery and instructed her husband on how to use it. I told her that just because she felt desperate now, she did not have to use the medication. She could and should delay using it if she had the least doubt about her decision. Then I suggested that she might want to be alone with her husband at the time of death; with this the couple emphatically agreed. When I prepared to leave, Ruth took my hand and patted it and then we embraced. Her husband accompanied me to the door and with tears streaming down his face told me that he could no longer bear to witness his wife’s suffering; he thanked me for my understanding. I told him I would return in 36 hours, but I did not need to. My friend and patient died during the night.
This happened many years ago, but I have not and cannot forget Ruth. When I read the pros and cons for assisted suicide, Ruth always comes to mind. I am as convinced today as I was when she was alive that there was no ethical choice other than to give her the means by which she could end her life and her intolerable pain.
My action was, of course, illegal. I knew about the double effect principle, that if I was only trying to relieve Ruth’s pain and she died secondary to that, then I was not really guilty of killing her.3 As stated by the President’s Commission, “It is already apparent that health care professionals may provide treatment to relieve the symptoms of dying patients even when the treatment entails substantial risk of causing an earlier death.”4,p.90 That did not seem to me to be an honest way of stating my problem, Ruth’s problem. Her and my aim was death for her, not lingering in agony or stupor, the only other two choices. I was also well aware of those who considered my act immoral. Grisez and Boyle stated, “The proposal is to bring about death as a means to ending suffering. This proposal, if adopted and executed, is an instance of killing in the strict sense. It can never be morally justified.”5 I did not feel that I was a killer, I felt that I was a physician intent on relieving pain. My inclination was to agree with the President’s Commission: “the acceptability of particular actions or omissions turns on other morally significant considerations, such as the balance of harms and benefits likely to be achieved, the duties owed by others to a dying person… . ”4, p.61 I felt that in the balance, my action achieved more benefit, more good, than harm. Given the same circumstances, I would not act differently today, and I would regard any physician who evaded the responsibility of helping Ruth as lacking in compassion and courage. That for me also meant accepting the responsibility for her death, abetting and aiding in killing her. There are times when all the arguments for and against assisted suicide seem specious and theoretical.6 Ruth chose to end her suffering as well as her life; was I to judge this impermissible? Only the person who has the pain knows how severe it is and whether death is preferable to enduring one more minute of life.
Ruth’s last note thanked her husband for his faithful and understanding care. She ended with, “I love you. Let me die in your embrace.” When Ruth’s husband and I talked after her death he told me that she seemed more at peace and relaxed while she was awaiting death than any time during the weeks and days before. There needs to be an end to suffering; there are times when enough is enough.
The poet Eugene Hirsch has expressed my view of the physician’s role in a dilemma such as Ruth’s in his poem “Physician.” Physician
(for Robert Arnold, MD, and his patient with AIDS)
I saw you weep
as you spoke
with the patient
whom you’ve grown
to love
beyond the vows
that you took
as a child.
As souls join in peril,
you share her illness
though you cannot
suffer her pain
and you will not
die her death.
Still, you anguish
to watch her grow weak
and waste the substance
of her body.
Yet, you feel comfort
as she, silently smiling,
without pleading
or thrashing,
as she gently
holds your hand
as you walk with her
to the edge of life
and bid her goodbye.7
- Received for publication September 23, 2002.
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