Academic journal article Issues in Law & Medicine

Dying Safely

Academic journal article Issues in Law & Medicine

Dying Safely

Article excerpt

A rabbinical dictum has it that we should 'place fences around the law.' The idea is that restraints and prohibitions should be in place to prevent us from reaching, or at least impede our progress toward, the point of absolute and damning transgression. There should at least be safety rails around the abyss. Perhaps the best that our culture can provide are signposts warning against the danger ahead.(1)

I wrote the prescription with an uneasy feeling about the boundaries I was exploring--spiritual, legal, professional, and personal.(2)

Tenderness leads to the gas chamber.(3)

Doctors like to tell stories. Sometimes the story is a brief clinical vignette one physician shares with another over coffee in the nurses' station. Sometimes the story is a literary masterpiece by a renowned physician-artist such as William Carlos Williams, Anton Chekhov, or Walker Percy. And sometimes doctors tell stories designed to revolutionize the heart and soul of medical practice. Such a story, "Death and Dignity: A Case of Individualized Decision Making," appeared in the March 7, 1991, issue of The New England Journal of Medicine.(4) Author Timothy E. Quill, M.D., a Rochester, New York, internist, tells us about his patient Diane, who developed acute leukemia, refused treatment for it, and ultimately asked for and got his aid in killing herself.(5) This story is no simple clinical anecdote, however. While never directly saying so, Dr. Quill offers it as evidence that under certain circumstances, like those in which he and Diane found themselves, physician-assisted suicide can be clinically and ethically "right," and our laws should be changed to permit it.(6)

This text invites examination precisely because of its revolutionary agenda. Yet this story is so disarmingly simple and moving, and its surface so smooth and opaque, that our inquiry seems to be barred. The euthanasia project is hidden here behind the mask of plain narrative and attractive metaphor. How can we get up close for a clear look at this encounter between Diane and Dr. Quill?

Any text speaks to us on many levels. Astute readers note how the author writes as well as what he writes about. Close attention is paid to such formal elements as language, tone of voice, point of view, genre, plot, and figures of speech. We note patterns in the narrative action. Who says or does what to whom, when? In addition to reading on the lines, readers should attend to the white space between the lines. What is not being said? Are there paradoxes or gaps in a seemingly unified text that, once explicated, can lead us to a more complete understanding of the story? What is the author trying to persuade us about? Are there contradictions in such authorial claims on us that might qualify our assent? In what social and cultural context does the text appear? What audience is it designed to reach? Who publishes it, and why? No work of art is ever simply the product of its time and place; nonetheless, attention to these more external factors provides another perspective for apprehending the text in its fullness.

Patients also tell physicians stories, to which physicians listen, although not always as patiently as they should. The patient's account of a developing illness is still the threshold at which the physician enters the patient's life. One group of specialists who are particularly likely to hear such stories are psychodynamically oriented psychiatrists. They use some of the same techniques to understand their patients' stories that a reader uses to understand a novel or a short story. Of course, no live patient is equivalent to a written text, or vice versa. Nonetheless, similar techniques of listening do characterize these two human activities. Let me first describe how the psychiatrist listens. Then, let us "listen" to Dr. Quill's story in the same way, and perhaps find a way into its interior.

At the beginning, the psychiatrist will hear the patient's story as it is told but, equally important, will note how the patient tells his story. …

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