PHYSICIAN ASSISTED DEATH ? — How’s “Termination of Suffering”

The debate over physician assisted suicide (PAS) is hampered by its terminology.  For some, suicide is always an evil.  

I personally don’t have a problem with the term but other’s prefer physician assisted death (PAD)_.  There is legal precedence now accepted in four states.  It began in Oregon and is making its way through the NJ legislature. (not sure where at present).  Criteria are extremely strict and the process is highly regulated.  Physicians who sign on to the program can prescribe a lethal dose of  medication.  The patient must be physically and mentally capable of ingesting the drugs.  There must be no clinical evidence of depression.  

The Oregon experience seems to contradict the fears of many who oppose such legislation.  Massive numbers of individuals did NOT sign up for the program.  Only about 10% of those who qualified and received the drugs actually took their own lives with them.  Palliative care and Hospice use actually increased in Oregon (as opposed to opponent’s beliefs) and there was no deterioration in the patient-doctor relationship.

Kevorkian exhibited the right intentions but his efforts were not well thought out.  He was actively challenging the law and forced the country to take notice.  His active euthanasia was too provocative for the population to accept.  He was not particularly careful about screening out those who were severely depressed and not truly terminal.

 Perhaps there would be even more acceptance if our labelling of the program would change.  Termination of Suffering says it all.   Perhaps we should change the term to PATS (physician assisted termination of suffering).  I hope no one truly believes that hopeless suffering servers some higher spiritual purpose?

Who in their right mind would object to that?  How naive of me.   There are those who will.

THE BLACK JEWELRY BOX — Unexplainable Experiences

A devout skeptic, my metaphysical journey was first triggered by hearing first hand the personal experiences of ordinary individuals who had unexplained experiences.

 What was so compelling was the context of these experiences.  They were told to me in deepest confidence.  The experiencers were rather reluctant to share what had occurred for fear of appearing strange or foolish.  Yet I knew many of these individuals for years.  I knew they had nothing to gain by fabricating these stories.  They were compelling yet unexplainable. There was a level of credibility to them that drew me in.

 I still find them compelling and worthy of investigation.  Although they remain unexplainable, they point ever so subtly to a level of reality which transcends every day awareness.  Do they “prove” survial of consciousness after physical death.  Hardly. Yet taken as a whole they cannot be easily dismissed.

 The following was told to me by a patient and acquaintance of many years.  His credibility is without question.  I have altered the names and details of the story but the core of it remains intact.

 I was cleaning out my Mother’s house prior to the official closing.  After she died we tried to empty it of all its objects.      First we held a garage sale.  They we donated what was left to a local church.  Some of it became garbage.  We went through her possessions is great detail, many times, as did the numerous visitors.  We were particularly seeking to find her black jewelry box which she claimed had become lost.  She had suffered from some dementia before she passed.  She cherished the modest jewelry she kept inside and my family had bought it for her.  It was essentially gone and we began to believe it would never be found.  Now I was the last one to visit the home.  I walked through the rooms one last time.  I removed the mezzuzahs from the door posts.  I spoke out loud to my Mother thanking her for all she did for us and that now she was moving on as were we.  There was a deep silence that followed.  For some reason I glanced one last time into the empty living room.  The jewelry box was there!  It was literally impossible for that to be so.  Dozens of people had marched through the home.  Our family checked every square inch of it for that box.  But there is was.  Here’s the photo of it.  We have it securely with us  now.  I thought you would find this interesting.

   To say the least.

 

THE TRIBAL GENE — Our Dark Nature

It goes like this. We are tribal creatures. Deep down in the recesses of our DNA we evolved with the propensity to associate in small groups and to regard them as our kin/family. We immediately perceive outsiders as a threat and are capable of annihilating them without remorse.  We do not see them as ourselves. Although they are like us, exactly like us, we are capable of de-humanizing them. We feel no guilt or remorse regardless of what and how we destroy them.  After all they are a threat to our existence and the existence of our tribe.  How do I know this to be true?  Look at the world today.  Look at the world yesterday, or a thousand years ago or probably since the inception of Homo sapiens sapiens.  And perhaps further back to our primate ancestors who we share with contemporary chimpanzees.  They, too, are capable of ripping apart fellow chimps found within their territory.  They, too, create military-like bands which fight to the death for their tribe.  The tribal gene was necessary for our survival.  Today it threatens the world.  Our tools are powerful, and the subsequent destruction they can inflict can destroy the planet.  But the instinct to use them runs deep within us.  When we teach our children to hate we merely reinforce their inherent tribal instincts to do so.  This is not about religion.  We point to radical Islam today, to Hamas inculcating hatred into their children.  We are shocked when Palestinian mothers dress their children in homicide bomb outfits.  But we should understand why and how this is so.  The tribal gene leads us to sacrifice our own lives for the sake of the tribe.  We see this in the heroism of the battlefield as well. We know that religion alone is not the culprit.  Hitler was successful in his creating of the German myth of tribal supremacy.  The Jews and others were clearly of another tribe and by definition a threat to be dealt with by any and all means. Racism is tribalism  but even within the same race African tribes annihilate each other by virtue of the same tribal impetus.  There is rarely a sense of guilt when members of the other tribe are destroyed.   And so it goes.  Is there any hope to at all?  The answer is yes.  The approach is shockingly simple.  We must recognize our true nature.  We need to be aware of this tribal imperative.  We need to re-define what a tribe is and our relation to it.  We need to recognize our common humanity and teach this to our next generation.  We are ONE tribe.  It is the Golden Rule expanded to recognize the biologic truth.  Our DNA speaks to it.  But we must fight the impulse to break down into small units.  Our tribal gene pushes us to find differences amongst each other.  Our neocortex provides us with the ability to think.  We need it to direct us away from instinctive reactivity.   Is any of this realistic?  Perhaps not.  But we have nothing to lose at this point by trying.

WANT TO HAVE YOUR CHARTS?– Then What?

Access to medical records seems like a perfectly fine idea.  After all they are your records.  I have always been a supporter of that contention.  Problems occur, however, under conditions when medical records are released to patients without explanation.

Patients have had access to their lab work for years. Abnormalities that are noted by these print outs may have no real clinical meaning and yet will induce immediate and unnecessary distress.

 Now patients have access to radiology reports with detailed discussions of findings.  Many of these are “incidental” meaning they have no clinical significance.  But does the patient know that?  No and they should not be expected to know.

What then occurs in the real world is a frantic attempt to read, comprehend and analyze medical terminology by the lay public who do not possess medical knowledge and experience. The inevitable results–internet searches, panic, despair and immediate calls to doctor’s office to make sense of it all. Patients want immediate phone discussions or internet responses.  That sounds just great.  The problem is that communication which is not in person is much more difficult and often leads to more confusion.

 I would prefer to discuss medical records/ radiology documents, pathology reports, endoscopy papers, lab data etc. etc. face to face in front of my patients.  Then I could immediately put their concerns to rest, or offer explanations, or suggest subsequent testing or referrals.

So hurrah for full disclosure. Let’s bring some practical sanity back to the situation.   Now I understand the impracticality of ALL discussions in person.  When a quick call can dispel immediate fear, I all in favor of it.  But when then there is further confusion or significant complexity, the examination room, not the phone or internet is the best place to do so.

WANT YOUR MEDICAL RECORDS ? Now What?

I get it.

It is a consumer’s right to have access to their medical records.  God forbid some physician denies you that right. We are obligated under some vague government penalty to allow you to do so.

 So now what?  What do you do with them?  What happens when you find some abnormality in your lab work?  What is that abnormality on your CT scan?  What is that dark hole on your endoscopy report?  You will panic.  You will search the internet, frantic to understand specific medical terminology, you will make yourself crazy with fear.  You will call me in my office in panic.  What is this? What does that mean?  What is that shadow? Is that a mass on my colonoscopy photo?  And now it is up to me and my office staff to undo what has been done.

 WE need to do this together—in the first place!  This is why I don’t routinely offer photos of my patients colonoscopy/endoscopy reports until I see them in my office……so I can explain what they are looking at!

 And yet I am not following the new guidelines.  I should be handing everything to you without comment.  But then we have the problem of trying to explain it all to you.  

So please.  Let us do this together.  I’ve been doing this a lot longer than you have.

 Thank you for your consideration. Its better for both of us.

MAGIC IN THE MOONLIGHT — Woody Allen, Metaphysician

I have always been an enormous fan of Woody Allen’s films.  Even his less than stellar creations are worth viewing and as a body of work there are few in his league.  I was particularly fascinated by this summer’s Magic in the Moonlight.

 I will not attempted to critique the film as such.  I am strictly an amateur on the subject.  But I am a devotee of metaphysics– the field that seeks to comprehend the nature of reality.  Woody (I feel I can freely refer to him as such) has touched upon such themes as the nature of life, death, the soul, the existence of God, the “unseen world” in many prior films.  But here he addresses it directly through the character played brilliantly by Colin Firth.

 As a magician (Woody as well) he is a master of illusion.  He understands the gullibility of mankind, their need, even desire to believe in more than this physical world.  Yet as the ultimate skeptic he is capable of debunking the fraudulent perpetrators of such scams.  To summarize all too briefly, he becomes the victim of a scam himself and begins to believe in the afterlife and the power of the Emma Stone character to truly communicate with a spirit realm.

 In the end all is exposed and our skepticism renewed and validated.  Woody, the ultimate romantic, seems to feel that love is capable of transcending rank cynicism.  But to me he still wrestles with the metaphysical questions.

 I, too, was the ultimate nonbeliever.  Yet my experiences with mediums and ordinary individuals has led me to understand that there is evidence for a spiritual domain (see my book and various prior postings).

 I do not claim to understand the depth of this world.  I am a total novice, but I do believe an open-minded skeptic can explore this area on their own and eventually come to their own conclusions.

 I’m sure Woody is still in hot pursuit of the ultimate truth.  I’d love to share what I have learned with him and make suggestions for his own exploration.  In either case I wish him well.

MANAGING A CHRONIC DISEASE — Israeli/Palestinian Conflict

I am presenting here the Israeli / Palestinian conflict in terms of a medical analogy.  It is a chronic disease.

In medicine we attempt to cure/resolve/ eradicate disease states.  Our goal is the elimination of the pathological process which has produced the illness.  However, there are diseases which (based on the present state of medical knowledge) may NEVER be cured.

Known as chronic diseases, they are, at best, “managed”.  This often requires significant doses of medication.  It requires frequent re-evaluation.  Sometimes it requires hospitalization to deal with deterioration of conditions. Sometimes there is pain and suffering which must be endured. It can result in a life which is less than ideal but still valuable and meaningful.  And so, life goes on.  

 Just listening to Palestinians being interviewed regarding their attitude towards Israel and Israelis brings little hope of reconciliation.  Raised on hatred, they  are still  willing and ready to sacrifice their children as martyrs to destroy Israelis.  They do not recognize that the State of Israel even exists.  It is all Palestine, and in their eyes, time is on their side.  Only the dissolution of the country of Israel and the death of its Jewish inhabitants will do.

 Now considering the historical fact of continuous Jewish survival in the face of adversity, and the powerful IDF, I will boldly venture out on a limb and state that Israel will not self-destruct.  And furthermore, the Palestinians will continue to pay a disproportionate toll if fighting persists. 

 So we have an incurable process.  Like a chronic disease the only solution is to manage it as best as possible.  And meanwhile Israelis continue to do so with an energy and zest for life which is quite remarkable. They continue to live, to thrive, to have a culture, to do science and business and music and art.  Palestinians have no culture other than hatred.  Do they make art? music? science? medicine?  It is a waste of human potential and that hurts us all. But their hatred blinds them to all else.   Their chronic disease ravages them.

 What Palestinians don’t understand is this– the vast majority of polled Israelis don’t hate them.  They may hate their refusal to face the reality of Israeli existence, their continual harassment of Israelis and their perverted sense of moral outrage and religious fundamentalism. 

 So the Israeli/Palestinian conflict will persist like a chronic disease.  It seems as if it will never be cured because their is no grounds for civilized compromise.  Meanwhile Israel has lived with this chronic disease not only since its inception 66 years ago, but as Jews with the chronic disease of rapid anti-Semitism for more than two millennia. Who will deal with their disease better? 

PULLING BACK FROM ANGER – In the Face of Danger

The recent/ongoing Israel-Palestinian conflict and the world-wide jihadist movement which threatens us in the US as well has engendered a degree of reactivity and anger within me that I recognize as self-defeating.

The tragedy of anger is just that–it produces a self-perpetuating cycle of hatred.  I notice how it makes me feel.  There is a temporary feeling of power, self-congratulatory sense of control then followed by a darkness which brings out the worst in human emotion. And quite frankly, I don’t like it.

Let’s be clear about this.  We are alll capable of hurting others.   It originates in the desire to live, to defend against perceived aggression.  Kill or be killed.  Without this instinct, quite frankly, none of us would be here today.  But we need to recognize that dark side of ourselves.  

 I want to make clear that I am not an apologist for all Israeli decisions regarding settlements, Palestinian rights, etc.  But when Hamas speaks of annihilating Jews (not Israelis)  I react as if personally threatened.  It is in the DNA of every Jew.  That righteous indignation feels powerful, for the moment.  But its dark side can paralyze as well.  It is hard to write poetry, or feel truly at peace.

Just look at what radical Islam has done to Islamic culture.    When all energies are focussed on hatred, revenge, war– there is nothing left for civlized life.

 And on the level of the individual, hatred drives away the ability to recognize beauty in the world around us.  When young children are encouraged to die in martyrdom their potential as human beings is crushed.  It is tragedy of epic proportions. Where are the outcries from the UN, from human rights groups, from the political left?  Only silence.

So how do we balance the ability to remain vigilant against true evil, those who wish our death and destruction, while remaining open to live’s blessings?  We must look to Israel.  In the face of a continuous threat of war and annihilation,  they embrace life in its entirety.  The Jewish  tradition which affirms life, not death.

They have science, technology, business and  culture.  Like a viable culture they contribute to the world beyond themselves.  They are not bunkered down.  They life lilfe to the fullest.  Yet they cannot afford not to be completely prepared and vigilant.

As individuals we need to become  Israeli in our attitudes and approach to life.   Be aware.  Be prepared. But refuse to live with hatred and anger.  In trying to live with this dynamic tension, we will remain alive to the beauty and splendor of life itself.

  

THE PARADOX OF JEWISH SURVIVAL — Anti-Semitism Guarantees It

If Jew-haters understood history they would have discovered the best way to rid the world of Jews…..be very tolerant of them.

Throughout the 3500 or so history of the Jewish people, it was during times of extreme acceptance and tolerance that assimilation was at its highest.  American Jews intermarriage rate among nonOrthodox is over 70% !  It won’t take many more generations in this country before the only Jews left are Orthodox.  It you want to rid the world of Jews just be really kind and accepting of them.

 Ironically, anti-Semitism arouses a very deep reflex among Jews.  Even those who barely identify with their Jewish culture or heritage begin to feel a primal sympathy with other Jews.  The present Israeli-Gaza conflict has generated such pure anti-Jewish venomous  sentiment in the world that is clearly NOT a reaction to the policies and politics of Israel the sovereign nation.

 Many young liberal and leftist Jews who routinely criticize Israel and their policies have been deeply hurt and troubled by this world reaction.  When they discover that Hamas has used millions of dollars to build elaborate tunnels to attack and destroy Israel rather than help their fellow Palestinians, they begin to question the conventional wisdom about who are the bad players.  When they see Hamas openly proclaim that Jews  make matzah from the blood of children (blood-libel) they begin to understand who their enemy truly is.

When Islamic fundamentalists openly proclaim that their only objective is NOT STATEHOOD but the annihilation of Israel and its Jewish population, they begin to re-think what is going on.

 They had all read about the Holocaust, pogroms, Inquisitions etc. etc.  They had never expected to actually feel such hatred expressed towards Jews, NOT JUST ISRAELI POLICIES. This is the kind of experience that has actually kept Jews connected to their heritage.

Now this still doesn’t lead to blind acceptance of Israeli policies.  Nor should it.  Jews criticize Jews routinely.  The tradition is one that encourages debate and free expression of opinions.

But….push me and I’ll push back.  Tell me that I shouldn’t exist and I will hold tighter to my tradition.  It is a paradox of Jewish survival.

 Just don’t tell the anti-Semites–not that they will get it anyway.

BEWARE THE CAREGIVER’S SYNDROME

A recent NY Times article by Catherine Saint Louis revisited a topic I have written about previously–the Caregiver’s Syndrome.   Just yesterday one of my patients described her own efforts to step away from that role, for just a while, while her husband was recovering from a serious injury.  I applauded her efforts and tried to relieve her guilt for doing so.  Intuitively she knew she had to do it.  She felt herself breaking down, emotionally first, then physically.

The truth is simply this– the caregiver suffers tremendously from the role of providing care to a loved-one.  Now this is painfully obvious to most, but the extent of the suffering may not be.  I see this in my patients, their own mental and physical suffering often follows their intense focussed care of a loved-one.

From a personal perspective I saw it take place in my own family.  Both my parents are deceased.  But in her last years my mother suffered from dementia.  She recognized everyone but gradually and insidiously her short-term memory failed.  My father was the product of depression/ WWII stoicism.  It was not in his DNA to burden his children with his problem.  As his children, we were in denial as well.  Perhaps we didn’t want to see the inevitable.  We (my sister and I) still viewed my father as an iconic pillar of strength.  How foolish we ALL were.  As my mother lay in bed with Hospice care present, anticipating imminent death, my father crashed.  I saw him earlier that morning.  Our family were at their home to be present for my mother’s passing.  I off-handedly asked him how he was doing.  “Just a head cold” he replied.  Kissing my mother goodbye, I left their home to play golf.  Later that day my wife and sister stopped by, once again to see my mother for perhaps the last time.  But there had been a radical change in my dad.  He was dying from sepsis.  Five weeks in ICUs with pneumonia, congestive heart failure, sepsis, blood clots, pleural effusions……he survived.  But he was never the same. 

He crashed for one reason.  It was clearly the intense emotional stress of seeing the love of his life slipping into oblivion that annihilated his own immune system.  Had we all been more aware, we could have intervened.  As adult children, we should have stepped forward and assumed more responsibility, regardless of his refusals.  We could have insisted that he step back from the daily horror of dealing with someone who asked the same question, over and over again.  He could have been relieved of some of the burden–not only of the actual work involved but of the guilt that enveloped him as he gave in to anger, time and again.

The analogy with airflight is powerfully applicable.  When the flight attendant tells you to put your oxygen on before attempting to help another…..listen carefully.  It will eventually it will apply to us all– if not in the present than assuredly in the future.