Assisted Suicide: A Footnote on the Relief of the Dying 

Previously unpubd. paper, 19 December 1973

    This day last week I was talking to an extremely eminent American physician.  He told me that not so long since his wife had died in hospital with general carcinomatosis. Her father was a doctor he said; her brother is a doctor, and she had a doctor husband. But despite all her bro­ther and he himself could do, she spent the last weeks of her life in terri­fying distress and suffering, while the hospital staff strove with might and main to prolong her life to the last possible day and the last possible hour. Could he not have influenced the staff to let her die more easily? The im­pression I gained from him was of the total domination of the situation by a great impersonal technological machine. The staff are organized into highly integrated teams, indoctrinated and trained to act as one man in fighting for survival; for whom any other purpose in patientcare would be unthinkable. Such is the discipline of that and many other American hospitals; and relatives can only contend against it if they are so perverse as to do so ‑ at the cost of alienating the entire caring personnel, and leaving themselves and the patient without support and without a friend.

    My American colleague told me that it is very difficult indeed to get an American doctor to prescribe morphia. For some years he had been subject to attacks of tic douloureax, a very painful form of facial neuralgia, and only once had been given an injection of morphia, on that occasion with immediate relief. In Britain our most effective drug against unbearable pain is heroin; and it is relied on, for‑instance, in the care of the dying at St. Christopher's Hospice. In America heroin is absolutely forbidden to doctors, and is only available on the black market. Great reliance is placed on narcotics which, while not relieving pain, so stupefy the patient that his moans are not heard.

    This is the picture which has been painted for us in a systematic survey reported by Marks and Sachar in a recent issue of the Annals of Internal Medicine. [1] In their review of various inpatient services of New York's Montefiore Hospital they found that in virtually every case the patient received inadequate amounts of drugs and the house staff was reluctant to pre­scribe more. Even when prescribed in a potentially adequate amount, a narcotic analgesic, such as morphine or meperidine, was administered errat­ically, minimally or inadequately. A patient with terminal malignancy in severe distress because of pain was denied adequate drugs because the house staff were afraid of 'possible addiction'. A patient with severe pain in an amputation stump was given only minimal doses because the staff believed him tu be “an addictive personality” ‑ until a large abscess was evacuated. 37 patients, 17 men and 20 women, consecutive admissions, were followed through systematically, and 102 house staff physicians in two New York teaching hospitals answered a questionnaire. “The results were astonishing." “There was clearly a pattern of undertreatest of pin with narcotic analgesics leading to widespread and significant patient distress." Twelve of those 37 patients were in severe distress; 15 in moderate distress; 10 in minimal distress. Drugs were prescribed on a four‑hour schedule although

three hours was the average duration of action. The average dose of meperidine for an adult is according to the manufacturer, 100 mgm, say then 800 mgm for full cover for 24 hours. The average amount prescribed was less than half of that, 360 mgm; the average amount actually received was less than a third of that prescribed, i.e. 100 mgm, or enough for a three‑hour effect for the whole day. Low doses were prescribed for patients with myocardial ischaemia, in which complete pain relief is considered a vital part of treatment. Low doses were also given in metastatic malignancy, renal colic, and other notoriously painful conditions.

    This could all be put down to very curious ideas entertained by the hospital doctors. 21% of them said they would choose not to increase the dose of meperidine in a patient with terminal cancer, if he was already re­ceiving 100 mgm every four hours. In fact if the cancer patient complained of increasing pain, 14% of the doctors would either decrease the dose or initiate a trial of placebos. I repeat, placebos.

    Britain is not America, but tends always to follow in her footsteps. The extreme forms of organization and mechanization that we have in intensive care units have been copied from America. With the increasing mechanization of a service we face its progressive dehumanization. In Britain we do pre­scribe the opium‑derived analgesics, but always with caution. Dr. Lamerton writes: "The whole secret with pain is not to treat it, after it has arisen, but to anticipate it, before it comes." This is admirable; but I do not believe that as many as one per cent of patients in pain get treated in this way. I think it is fair to say that, by and large, doctors and nurses do not try to relieve the patient of all pain, but rather to ake off the worst edge of it. It is not customary to give a second dose of an analgesic until the effect of the first has fully passed off. I speak subject to correction. With patients who are going through their last illnesses in their own homes it is just not possible to give immediate relief as called for, or to anti­cipate pain, as can be done in properly oriented specialized clinics for the dying. And pain is probably not the worst of the distresses of the dying. As Dr. Rees reported in the BMJ in 1972, a high proportion of them also have to go through breathlessness, impairment of consciousness, depression, anxiety, vomiting, bedsores and incontinence.

     What this amounts to is an immense area of human suffering. Of the hundreds of thousands of people dying every year in this country of cardiovascular disease, respiratory diseases, cancer, and so forth, a substantial proportion suffer real, sometimes terrible distress. Those who do not suffer outright distress still in the great majority of cases have to go through weeks or months of anxiety, depression, weakness, incapacity and general misery. Death for very few comes quickly and easily. There is no point or purpose to this suffering; and, as a matter of practice, most of it could be easily avoided. But it will not be avoided until we change our attitudes.

    The dying are people with a particular problem, which is not the problem of getting better. We should try to understand their position, but we don't even try. The man who is well sees the man who is dying as already a stranger, divided from their common humanity, He is not really somebody's father or husband; he is not a man but a piece of faulty failing mechanism, the proper object of a soulless instrumentalist technology, a thing, which it is necess­ary to stuff full of tubes and monitor electronically.

     The dying cannot resist. They are completely defenceless, completely helpless. Whatever is done to them, in the end they will not complain. What is done to them is done out of fear. Perhaps in an age to come we shall lose this overmastering fear, and not deny to the dying the elementary kind­ness one human being owes to another. We may perhaps treat them with the tenderness that their plight deserves.

[1] see abbreviated report given by:

     WYKERT, John: Pain undertreatment reported because doctors fear addiction, Psychiatric News Official Newspaper of the American Psychiatric Association) vol. viii, No. 20, October 17, 1973, pp. 8‑11.