Pain and America's Culture of Death

Article excerpt

Throughout history, people have called for medical practitioners to assist in the deaths of patients suffering from intractable pain as a result of advanced disease. But while many doctors themselves have advocated such assistance, including those of ancient Greece, Western medical practice has generally cleaved to the view of Hippocrates, who argued firmly against physicians' "giving a deadly drug to any patient."

Not that the Hippocratic view has reigned unchallenged. Today in the United States support for mercy killing is widespread and growing both among the general public and health-care professionals. A 1991 collaborative study undertaken by the Boston Globe and the Harvard School of Public Health found that 64 percent of its 1,004 respondents believed that physicians should be allowed to give terminally ill patients a lethal injection. And a 1988 survey of physicians in the San Francisco area found that 70 percent believed that the terminally ill should have the option of active euthanasia (left undefined), while 54 percent felt that the physician should administer the lethal dose.

Not surprisingly, attitudes toward this most troubling of subjects vary greatly according to shifts in social conditions and values. As Daniel Callahan shows in his eloquent book, The Troubled Dream of Life (1993), support for euthanasia and doctor-assisted dying increases sharply in times when the bonds of community are weak and the insistence upon individual rights is strong. Ours is such a time. And the cry for medically assisted dying grows ever louder under the pressure of conditions peculiar to our age. These include advances in high-technology life-support systems, growing numbers of cancer and AIDS patients struggling under the Damoclean diagnosis of fatal illness, the "graying" of the population, and limitations on health-care resources, particularly for patients with terminal illness.

But there is yet another factor that should not be ignored: the inadequate treatment and understanding of pain. Reports of the undertreatment of cancer pain have received considerable press recently, but unfortunately the phenomenon they address is nothing new. The failure to administer appropriate or adequate medication to the terminally ill stems from a number of causes. To begin with, physicians are generally undertrained in the area of pain management. (Significantly, research shows that those health-care professionals who perceive themselves to be less competent at managing pain are more likely to endorse assisted suicide or euthanasia.) In addition, many physicians, like many nonphysicians, bring to the use of opioids and sedatives attitudes highly colored by subjective opinions and cultural beliefs, attitudes which often dispose the physician to undertreat even the most severe states of pain, on the grounds, for example, that heavy sedation would reduce the patient to a "vegetative" state. Then, too, despite ethical and legal clarification of these matters, many health-care professionals remain uncertain about that region where the use of symptom-control methods blurs with either voluntary active euthanasia or physician-assisted suicide.

Countless studies reveal a wide range of serious physical and psychological symptoms among the terminally ill. Such symptoms, along with social and existential factors, comprise what physician Cecily Saunders calls "total pain" or what Eric Cassell names "global suffering." Unfortunately, most doctors lack both the range of expertise and the time to address the total pain of the patient. This can be tragic in the case of a cancer patient who is suffering from depression. Studies have shown that antidepressants can be strikingly effective in treating depressions among persons with severe physical illnesses; moreover, they can have a direct effect in reducing the chronic pain that may precipitate such depressions. Physicians may also fail to consider other factors affecting the patient's experience of pain, including relations with his family, religious beliefs, and even beliefs about pain itself. …