By Jean Boyd 

I was supervising some student nurses, caring for Joseph, an old man in his eighties, when the doctors stopped by on their rounds. We had to keep the head of Joseph’s bed upright so he could breathe and stick a tube down his throat to suction out copious amounts of brown liquid from his lungs so he wouldn’t drown in his own secretions.  Joseph’s eyes were full of dread, his face tight with fear.  The doctors looked at his urine bag, which was hanging from his bed frame; his urine was also brown.  “We better get a urology consult,” one of them murmured as they left.
 
This experience was the last straw for me. In my career as a medical-surgical nurse I have cared for many patients like Joseph, who suffer while their dying is prolonged by medical procedures and good nursing care.   My objection was ethical: no one had asked Joseph, or his family, what they wanted.  “I’m no different from the Nazis who excused their behavior by saying, ‘I was just following orders,’ ”I thought. In my case, I was following doctor’s orders.  Shortly thereafter, I left medical-surgical nursing for good and entered the mental health field where dying patients were rare.  That day, before I left Joseph’s bedside, I did something we nurses sometimes do in such circumstances. I held his hand and silently, in my mind, I gave him permission to die: “Joseph, it’s all right to let go now.” He died the next day.

The present angry debate over health care reform has brought the issue of end-of-life-care into the mainstream media. Although it’s a lie, opponents of President Obama claim that one of the proposed changes would require people on Medicare to receive counseling that told them how to end their lives sooner. In an Aug. 7 Facebook quote, Sarah Palin, would-be president, coined the term, “death panels,” which would decide who lives.  The truth is that the House bill, which increases Medicare coverage to include counseling about procedures such as ventilation, feeding tubes and other measures, is nothing more than informed consent, something surgeons do routinely before they can operate.

 Looking at how our attitudes toward birth/death have evolved over the years gives us insight into why there is such resistance to changing a medical care system that has been failing for some time. 

During the Middle Ages, Europe was a theocracy. Because the Bible said, “with pain will you give birth to children,” if a woman did not have sufficient pain, she could be tortured for a “confession” and burned alive as a witch, along with the midwife who attended her.  Death by suicide was considered such a great sin that those who killed others could be buried in the church yard cemetery, but not those who killed themselves.

Slow forward to the 19th century.  When male doctors began to deliver babies in hospitals, they paid no heed to evidence that more women died in hospitals from childbed fever than poor women who gave birth in the streets or their slum dwellings. One contributing factor was that to pass the time while the mothers-to-be were in labor, doctors would dissect cadavers and then, without washing their hands first, go directly to deliver the baby. In 1847, when Doctor Ignaz Semmelweis postulated that if doctors were to wash their hands they could cut the maternal death rate from as high as 35% to 1%, he was ignored. Hand washing was not widely accepted until twenty years later, when the medical establishment accepted Louis Pasteur’s germ theory of disease.

At the same time, in addition to suicide being a sin, it became a crime and those whose attempts failed were jailed.
 
Next came the medicalization of birth and death. Having accepted the germ theory, doctors turned childbirth into a “knock–em-out, drag-em-out “   surgical procedure.  Family was barred from the delivery room, women were strapped down with leather restraints  on narrow gurneys and doctors,  gowned and masked, pulled the infant out of the women’s body using sterile forceps – oftentimes causing the infant to emerge with a pointed head. The mother was given drugs that caused a mental fog, which prevented her from being an active participant in the process. Similarly, death moved from home to hospital, as doctors developed medical procedures to prolong life.
 
Suicide, meanwhile, was also medicalized and became a mental illness.
While our views on dying stayed in the medicalization phase, in the late 20th century our views on birthing progressed to what we know today as “natural childbirth.” Although mothers still gave birth in hospitals, it was no longer viewed as a surgical procedure. Child birth classes prepared the expectant mothers to participate and, supported by family and friends, she gave birth in a cheerful room, in a comfortable bed, music playing.  Fathers could cut the cord and various pain relieving medications were available, as well as emergency care for complications.
 
The Semmelweis effect explains why it took so long for us to create a medically safe, humane way of helping women give birth. It describes human behavior that is characterized by automatic rejection of new knowledge because it contradicts entrenched norms, beliefs and paradigms.  Believing in their own world view, people twist the facts, ignore the obvious, focus on the irrelevant details and create a fabric of self deception to justify their preconceived ideas, no matter how false. While doctors will eventually respond to scientific studies, religious beliefs are immune to scientific evidence, reason, compassion or the notion of individual rights.
 
Sarah Palin and her ilk no doubt believe in the untruths they propagate, that the government will create death panels, ration services and intrude on the doctor patient relationship. They don’t notice that the insurance companies have panels that deny treatment to sick people all the time – and people die.  Medical care is already rationed; those who can’t afford insurance,or lose their insurance with their jobs, do without – and people die.  Concerning the doctor-patient relationship, what your insurance covers influences the treatments your doctor orders.

Whom do you want to make your end-of-life decisions: politicians, doctors – or you and your family?  Do you want the choice to die sooner, rather than later, because you have suffered enough? Would you prefer not to end your life diapered, bed ridden and dependent on the kindness of strangers, nurses and also doctors, who have an appalling history of allowing people to die in agony?
 
The historical view that suicide is a sin, a crime and a mental illness make it hard for some people, especially religious people, to view self-termination, physician-assisted suicide and euthanasia as humane, moral choices, which have long been practiced – in secret.  Above all, these are individual choices – nobody else’s business.
 
Physicians, family and friends ease our way into this world; why not allow physicians, family and friends to ease our way out of it?