Sir Edward's Choice

It is ironic that while some of us were offering mostly light-hearted comments about how we might choose to die, news circulated  that  Great Britain’s reknowned conductor Sir Edward Downes and his wife had just made that very real decision for themselves.

Sir Edward and his wife Joan, a ballerina before she gave up her own career in support of his and of their family, flew to a Swiss clinic sponsored by the Dignitas organization with their two grown children to end their lives together. He was 85, almost blind and losing his hearing; she was in the final stages of terminal cancer.

I strongly support the right of terminally ill, mentally comptetent adults to hasten their own death. While there is a very distinct line between hastened dying for the terminally ill and “suicide,” it would seem almost cruel to criticize Sir Edward’s choice. And the key word is choice.

What most of us would choose is precisely what Sir Edward and his wife did indeed have: a swift, peaceful end with loved ones at the bedside. Few of us would choose what actually happens too often in the U.S.: prolonged pain and indignity, often a death that follows extended, expensive, frequently futile treatment, in circumstances we would never have chosen for ourselves.

Physician aid in dying, now legal in Oregon and Washington, is one good way to put rational choice back in the hands of mentally competent adults.  The Oregon law has been in effect for over a decade and has proven that such legislation works. It offers comfort and compassion and has not been abused. Efforts to extend this humane law into other states have been vigorously fought by religious groups, but end-of-life choice is just as much a right as is reproductive choice; like other individual rights, it will eventually come.

Given the enormous financial cost of the universal healthcare system most of us want, and the enormous human cost of futile end-of-life treatments and denial of physician aid to terminally ill adults, the time has come for serious dialogue about the right to die.

Sir Edward Downes left a remarkable legacy in his music. A very private man throughout his long life, he nonetheless left another admirable legacy in his poignant death. Maybe those of us over here in the colonies can learn something. Maybe we could at least honor him with a little civilized discourse.

A Novel Idea for Healthcare Reform

Not long ago I attended an event at San Francisco’s Commonwealth Club, featuring a speech by the President’s Council of Economic Advisors Chair Christina Romer. Dr. Romer’s talk, “The Great Credit Freeze and the U.S. Economy,” was all about improving healthcare while slowing down the growth of its cost. We know we can’t reduce costs, she said; what we hope to do is reduce the rate of increase. And one way to contain healthcare costs might be to find out what the patient wants. Imagine.

This observation was not in direct response to a question, but could well have been. Dr. Romer was asked, by more than one audience member, about how to address excessive expenditures at the beginning and end of life. A grossly disproportionate share of costs, she conceded, “are spent on the last six months of life. And one thing we’re not doing enough of is letting patients express what they want.”

If the issue were not so grim and sorrowful it would call for a “Well, duh.”

It would be hard to find many people saying they’d like their last few days on this planet to be spent semi-conscious or in pain and distress, hooked up to a tangle of wires and tubes in a blue-lit hospital room (see Scott Bowen’s post 7/14.) But this is in fact the system we have created: we focus on prolongation of life without regard to quality, we aid and abet doctors who equate death with failure, we never talk about our own mortality as if in silence we can become immortal. Most of us would choose to die at home, properly medicated for pain and surrounded by our loved ones; most of us will die in an institution

Audience members had a wide assortment of questions, and Dr. Romer had plenty more to say. But finding out what the patient wants, and acting accordingly, is surely one excellent path towards better care – and even contained cost growth — and everyone in America could begin that process today.

It is an easy solution, even if only a small, partial solution, to this piece of the muddled medi-puzzle of our healthcare system: talk. Tell your doctors, caregivers, loved ones what you do or don’t want. Write it down. Use the forms universally available (Advance Directives, POLST, others.) You might even wind up with what you actually want in your final days. Christina Romer is on your side.