The ‘good death’ dilemma

BABY BOOMERS FACING THEIR OWN mortality have pushed issues of aging and dying into the public eye. As with so many boomer issues, there’s a certain self-centeredness to attempts at control of the most uncontrollable human event, but at least issues of infirmity and the end of life are no longer whispered, as “the C-word” -- cancer -- used to be. Among the demands being raised is better control of pain, which has caught doctors between a desire to alleviate suffering and the U.S. war on drugs.

A corollary and less-visible policy struggle goes on very close to death, when the opiates that relieve suffering are also likely to hasten dying. A doctor in Redlands who used a very high dose of morphine on a dying patient and may now lose his medical license is merely the latest example.

Most such cases fall in a gray area, involving doctors who may have crossed a legal or ethical line, whether out of compassion or greed. The larger problem is the message that all doctors receive from aggressive efforts to curb opiate abuse, and their resulting reluctance to sufficiently treat severe pain and other suffering.

In Redlands, Dr. Harold Luke’s terminally ill 76-year-old patient died soon after getting a very high dose of morphine in 2002. The state medical board last month voted to strip Luke of his license, and his final appeal is likely to be decided today. The patient’s family still stands strongly by the doctor, as does a patient advocacy group that is supporting his appeal.

Luke’s case hinges on whether he deliberately shortened the patient’s life in an act of euthanasia. If he did, which he strongly denies, he would not be the only doctor to have done so. A 1998 mail survey of U.S. doctors in specialties in which patients would be most likely to request euthanasia found 11% willing to provide it. A 1997 survey found similar numbers among critical-care nurses. A report on a similar survey in Australia aptly described the more usual situation: “Doctors sometimes give large doses of potentially lethal drugs to terminally ill patients to treat symptoms, foreseeing but not necessarily intending a medically hastened death.”

Federal criminal prosecutions have usually involved a different issue -- charging pain management specialists, who often handle very tough cases, with overprescription or outright sale of controlled drugs, including the widely abused OxyContin. Again, most such cases are far from clear-cut, except perhaps in the eyes of federal prosecutors.

The debate over what constitutes a “good death” is ever more public. What hasn’t kept pace is government drug policy and honesty about the blurred line between compassionate treatment and medical euthanasia.