Alternative to euthanasia: pain management.

• Author: Conolly, Matthew E.

Alternative to Euthanasia: Pain Management

Euthanasia is increasingly being touted as a beguilingly simple solution to the tragedy of a badly managed terminal illness. However, critical examination reveals that, far from being any kind of worthwhile solution, euthanasia turns out to be a Pandora's Box of woes far worse than those which now confront us.

It should be emphasized that opposition to euthanasia does not mean that one is committed to maintaining existence to the last possible gasp, nor that one is obligated to apply every available form of life support to those who are clearly dying. Providing therapy aimed at alleviation rather than cure while a disease runs its inevitable course is not the same as wilfully ending a life. The intention of such palliative care is not to bring about the death of the patient. Consequently, to call such treatment "passive euthanasia" is to brandish an oxymoron of the most unhelpful kind.

The call for euthanasia is often based upon the notion that the terminally ill are bound to suffer horribly, and that this suffering can only be relieved by death itself. Like all lies and half truths, this is in danger of being believed, if for no other reason than because it is so often and so loudly trumpeted by misinformed persons in the proeuthanasia lobby. It cannot be stated firmly enough that this is a false premise.

It is false in the sense that it does not have to be so, for there is already much that can be done which will effectively alleviate suffering. The purpose of this article is to demonstrate that pain management provides the basis for a valid alternative to euthanasia.

The questions that must be addressed are these: What is our duty to persons who are terminally ill? Should all persons who are terminally ill receive pain management? Where can pain management be provided? What is the consequence if pain management is not provided?

What is Our Duty to Persons Who are Terminally Ill?

Considering first our duty to persons who are terminally ill, it is of supreme irony that while terminal care has always been a major concern of physicians through the centuries, the explosive triumph of medical knowledge in this generation has served to focus attention in directions that have largely excluded the dying.(1) Such care as is offered means, in the popular mind, a hospice in the form of a gloomy building hidden behind high walls where hushed attendants wait, impotent and silent, until death releases their charges from further pain and suffering.

The genius of the contribution of Dr. Cicely Saunders has not been the re-creation of the hospice as a less oppressive place for terminal care. The credit for that lies with the nuns of Ireland under the leadership of Mother Mary Aikenhead.(2) Rather it was to reclaim scientific medicine for the care of man, to show that academic excellence, critical research, and teaching all belong to the care of the whole person in his final days every bit as much as they do in any other phase of the fight against disease.(3)

Such has been the magnitude of her contribution that the stage has been reached where care for persons who are terminally ill rests on a solid bedrock of scientific observation, and terminal care is at last resuming its rightful place in mainstream medicine. No longer a field reserved for retired and moribund physicians, it is attracting an ever-increasing flow of young and academically orientated physicians.

In meeting the challenge of care for persons who are terminally ill, it must never be said or even thought that nothing more can be done. Cure or no cure, patients are entitled to the assurance that everything possible continues to be done. A patient dying of cancer may present a constellation of symptoms, and the goal must be to gain control of them all so that the patient and his family can employ to the fullest extent whatever time remains.

Pain looms large in the thoughts of most people at the very mention of cancer, and looms even larger in the arguments of those who would have others adopt euthanasia. However, at least a third of all patients dying of malignant disease suffer no pain at any time.(4) Even though pain is not the most common symptom, this article will consider pain as an illustrative example of what is possible to offer the terminally ill in lieu of euthanasia, and of how much can be done to make the life that remains worth living.

The approach to an incurable patient in pain is no different from the approach to any other person in distress. A physician well trained in this area needs to first take a careful history and to conduct a thorough examination. From the observations of Dr. Saunders,(5) it is clear that pain is more than just a disagreeable physical sensation. "Total pain" is comprised of mental, social, spiritual, and physical pain. Failure to remember this complexity is one of the most common reasons why patients fail to achieve adequate symptomatic relief.(6)

Mental Pain

Mental pain is prevalent when dying, especially in the minds of those who die young and face the distress of leaving behind small children. This distress expresses itself differently at different times, and although few patients follow the sequence described by Elizabeth Kubler-Ross,(7) the elements of denial, anger, bargaining, depression, and acceptance are commonly encountered. When there is little that can be done about the patient's impending death, just standing by them means more than one realizes. At St. Christopher's Hospice, each patient is assured that they will never be alone, and that promise is honored.

Social...