Life's Ultimate Choice

 

Life and death,

     inextricably linked.

One yields to the other -

     freely, peacefully,

     individually,

     universally.

 

          The desire to live is a general biological trait that promotes survival of the species. It is a manifestation of a built-in survival strategy shared by virtually all living organisms. Yet all animals, and even some unicellular organisms, are programmed to die. Programmed cell death aids development and insures continued exchange of genetic material between members of a species, thus promoting species vigor. Programmed cell death, which underlies organismal death, is the terminal step of a linear developmental program that has been selected for over evolutionary time because of its long-term benefit to the species. Even simple bacteria, yeast, and ciliates possess developmental programs that ultimately end in death.

         Not all cells in the human body are programmed to die. Our germ cells (spermatogonia in men and öogonia in women) are programmed to undergo meiosis, giving rise to haploid sperm and egg cells that have the potential to fuse into a fertilized egg, which in turn develops to produce more germ cells. Life is therefore a continuous cycle. The mortal human organism that we identify with can be thought of as a mere vessel or shell that functions to protect and provide for the immortal germ cells that produce the next generation. Somatic organisms are sloughed off and discarded after their primary function, reproduction, has been fulfilled.

          Biological organisms, like the genes that provide the organismal blueprint, can be selfish by nature. However, in social insects such as ants and bees, many members of the community sacrifice themselves for the good of the colony. Also, during human development, many fetal cells die in order to promote survival of the somatic organism - the germ cell vessel. Even in simple bacteria, during differentiation processes such as sporulation or fruiting body formation, some cells are programmed to die in order to promote the survival of others. The former cells are therefore altruistic in behavior, sacrificing themselves for the welfare of the latter.

         To date, there is no scientific evidence that anyone has ever escaped his or her ultimate, inevitable fate, the constraints of mortality. Sooner or later we all die. Our hereditary desire to live has expressed itself in the Western world by the advent of medicines and medical knowledge that in part aim to prolong life. Our social conventions and religious doctrines also protect human life - any human life - regardless of its physical or mental state. Even suicide is considered a crime in many societies including ours, although it is difficult to punish the successful offender. And in all but one state in the U.S., it is a crime for a physician to assist a terminally ill patient to die, even if death is that patient's express desire.

         Too often, terminally ill patients are entrapped in a situation in which they suffer pain and indignity without hope at devastating emotional and financial cost. One of my former students whose mother had died of cancer related to me the circumstances of her last year. She had been diagnosed with advanced cancer and was immediately put in the hospital where she received a variety of treatments including radiation and chemotherapy. These treatments weakened her immune system and sapped her energy so that for months she could not leave the hospital. At the end of a year's time when she died, the net medical bill was two million dollars. This incredible cost was partly covered by her health insurance, but the cost to the family was nevertheless hundreds of thousands of dollars which they could not afford. My student was forced to abandon his studies.

         The father of one of my friends is dying of cancer. He had had an operation and after coming home complained of intense stomach pain. He was taken back to the hospital where the doctors opened him up to discover that cancer had spread throughout his internal organs. They knew it was terminal and decided not even to sew him up again. They told the family that the end was near. Fear, frustration and pain, accompanied by hallucinations induced by high morphine dosages, caused him to become verbally abusive and rendered the last few weeks a mental and physical nightmare for all concerned. As I write this essay, he is still alive, but he is miserable, in pain, and without hope.

         One of my colleagues endured a similar situation. At the age of 57 he was diagnosed with cancer. He too went through extensive therapy treatments during his last two years, suffering terribly and putting an inexplicable burden on his wife and family, all to no avail. This man had a large dog, a Mastiff named Duke, and the two of them were inseparable. When the man succumbed, the dog went into a stupor, stopped eating, and died a couple of weeks later. He just didn't want to live without his master; he died of a broken heart. When we have an animal that is suffering, we do the responsible thing and take it to a vet so it can be put to sleep. But we can't do the same for our human loved ones.

         One of my musical associates, a sensitive psychologist and excellent violinist, contracted AIDS. This was before treatment was available, and he knew when the end was near. He had experienced the horror of his partner's condition who had died just months earlier, coughing up blood and writhing in pain in an attempt to live to the bitter end. This was not what my friend wanted for himself. When his condition worsened, he quietly took his own life.

         Recently I learned that for the average American, medical costs for the last year of life are about equal to the costs of all medical treatment prior to that time, an amazing statistic. It means that we could reduce total medical costs in the U.S. by 50% AND avoid suffering, excessive personal expenses and unpleasant family dependencies if we could just recognize the point at which our lives are no longer rewarding and comfortably end them. I certainly would want to; wouldn't you?

         These experiences remind me of my mother's frustration and intense desire to end her life when she realized that her mental state was deteriorating due to progressive Alzheimer's disease. Every day she would express her death wish. "I just want to die," she would say over and over. I remember my sister, who, considerably distressed by her condition and mental attitude, told me: "I wish she could just die." It is amazing that in our society we can only stand around helplessly although we give the members of our families the support they want in every other way.

         My parents were pragmatists and they brought me up with the belief that we can best solve our problems through a rational decision making process. Death was to them a part of life, and they planned in advance for their fateful day. They let us know they did not want to be kept alive artificially. They made prior arrangements for the cremation of their bodies themselves, and instructed us that they did not want us to conduct funeral or memorial services in their honor. They wanted to die unobtrusively as they had lived.

         I, for one, know that I don't want to go through the torment that I've experienced with my dying friends, colleagues and family members. As an avid swimmer, I've decided that when I'm ready, I'll just go out for a long swim in the ocean and keep on going. But most importantly, I want to have the choice when, where and under what circumstances I'll die. If suffering or incapacitated, I hope to face my final moment bravely and be able to end my life with dignity.

         I had known of the Hemlock Society USA (recently renamed "The End-of-Life Choices Society) since I was a child, but recently I became a member. My respected colleague at the University of California in Santa Barbara, Professor Garret Hardin, and his wife had been longstanding members of the Society. It was therefore no surprise to anyone when they, in their late 80s and in poor health, quietly took their own lives in the surroundings of their own home. How wonderful that neither of them had to suffer the pain, insult, humiliation and expense of a drawn out death. And how wonderful they could go together so neither had to suffer the loss of the other and the subsequent loneliness that would follow.

         What are the principles and beliefs of members of the End-of-Life Choices Society? Like my parents and many of us, these conscientious Americans don't like to think about death, but they feel that a head-in-the-sand approach to difficult end-of-life issues may not be the best course to take. They believe instead that each of us has the right to choose the way we die, just as we've had the right to choose how we've lived. The right to choose the conditions of one's death is one of our most important civil rights, an intimate and universal right, as basic as the right to life, liberty and property.

         Dying in this country is often the worst part of life, but it doesn't have to be. No one should be forced to endure a prolonged, painful death, or to be kept alive unwillingly. Terminally ill patients should have the choice to die with dignity - in partnership with their loved ones and doctor. This right is as basic as the right to other personal decisions, such as marriage, sexual preference and practice, and having children. According to a recent survey, 68% of American citizens support the legalization of physician-aided end-of-life choice. Yet only one of the 50 states, Oregon, allows this practice. And the Bush administration is trying to overturn Oregon's "Death and Dignity Act." Their archaic religious beliefs convince them that doctors who are willing to help their patients achieve a gentle, peaceful, pain-free death should be punished, an ironic view for a regime that feels no remorse over starting an illegal war and murdering over 100,000 innocent people.

         The End-of-Life Choice Society is not a suicide organization; it doesn't give out poison pills. It offers a "Caring Friends Program" that provides personal information and support for terminally ill patients. Additionally, it seeks to expand the legal options for a dignified death. This includes voluntary physician aid in dying for mentally competent, terminally ill adults who request this service. The primary goal is to change the law so that everyone has the right to die with dignity. The time will undoubtedly come when everyone will be able to choose a gentle death, under careful safeguards, with medical assistance. Let's hope that time will not be in the very distant future.

 

 

 

 

For further information about the End-of-Life Choices Society, including guides to relevant books, magazines, pamphlets, and tapes, please visit the Society's website at www.endoflifechoices.org.

 

 

Saier, M.H. and Jacobson, G.R. (1984). The Molecular Basis of Sex and Differentiation. A Comparative Study of Evolution, Mechanism, and Control in Microorganisms (Chapter 13), Springer-Verlag, New York, pp. 187-207.