November of the Soul

by George Howe Colt

  In 2000, Peggy Sutherland, a sixty-seven-year-old divorced mother of five, was told that fourteen years after smoking her last cigarette, she had lung cancer again. Over the following year, she underwent two surgeries (one lung was removed entirely), intensive chemotherapy and radiation, and seemingly never-ending rounds of CT scans, bone scans, PET scans, and MRIs. Her strength declining, her thick, dark hair gone, she tried to keep up with the opera nights and jazz concerts she loved, to attend the board meetings of her many community interests, to continue with her Friday-morning bridge group, and to visit her nine grandchildren. But as the cancer spread to the bone and ate away a rib, the pain grew so great that she had to be hospitalized several times. In August, her doctors told Sutherland she had less than six months to live. Around that time, one of her sisters was diagnosed with the same kind of cancer, and Sutherland watched her suffer a lingering death. During one of her better periods, the week before Thanksgiving, Sutherland went with her family to their cottage on the Oregon coast, where they had often gone when the children were young and their mother had taught them how to sing their favorite songs in harmony.

  One morning in December, when Sutherland woke, she could hardly sit up, so intense was the pain. Rushed to the hospital, she spent three weeks tethered to tubes, a morphine pump implanted in her spine, her mind so fogged by painkillers she could barely carry on a conversation. She was coughing up blood, losing control of her bowels, and having difficulty breathing without an oxygen tank. She would never walk again. On Christmas Day, with her family around her hospital bed, she gave her grandchildren their gifts. After a desultory New Year’s Eve in the hospital with her family, she was sent home and provided with hospice care. Sutherland, who had herself worked as a hospice volunteer, knew the end was near. “She didn’t see any point to staying alive that way for another six weeks,” said her daughter Kathleen. The day after she came home she told her children that she was ready to die.

  Sutherland’s children talked about her experience, as well as their own, in Compassion in Dying: Stories of Dignity and Choice (a book by Compassion in Dying president Barbara Coombs Lee from which this description is largely drawn). According to them, their mother’s decision was in keeping with her lifelong belief in independence and self-sufficiency, a resolve that had been tested when her husband of four decades had divorced her six years earlier. Indeed, that year, when Oregon’s Death with Dignity Act was first passed, she had talked approvingly about the right to choose one’s own death. A philosophy major in college, she had always valued speaking openly about difficult subjects. Over the previous months, she and her children had talked about life and death in general and about her life and death in particular. Now her children moved quickly to help their mother carry out her wishes. Her longtime internist referred Sutherland and her family to Compassion in Dying, who sent them the paperwork necessary to apply under the Death with Dignity Act and made available their team of palliative-care experts and volunteer counselors. Although her children, two of whom are physicians, supported her decision, they occasionally played devil’s advocate, raising objections just to make sure she had no second thoughts, and that if she did, she’d feel comfortable voicing them. But she remained firm.

  On the morning of January 25, 2001, one year after the return of Sutherland’s cancer, her best friend, her sister, her nephew, her physician, and her five children and their spouses gathered in her apartment in Portland, overlooking the Willamette River. The previous night had been difficult. “She was waking up in these weird morphine states, half-awake and half-asleep, crying out, having bowel movements,” recalled daughter Ellen Baltus, who had slept on the floor next to her mother’s bed. Once her family had assembled, however, she seemed relaxed. “I remember feeling surprised at how clear-minded Mom seemed the morning of her death, lucid and happy,” said Baltus. Downstairs in the kitchen, a Compassion in Dying volunteer opened ninety capsules of secobarbital, a fast-acting barbiturate, and mixed them in water. Upstairs, as Peggy Sutherland had requested, passages from Shakespeare and a poem by Annie Dillard were read. “I watched her take it in, seeming so relaxed and ready,” said Baltus. “I could see in her face the relief she felt in being able to finally end the suffering.” But Sutherland remained her independent self to the end; when her son read the Twenty-third Psalm, she interrupted him partway through to insist on the King James version. Her friends and family held her and said their good-byes. When the glass containing the barbiturate was placed beside her, she drank the liquid and fell asleep. Twenty minutes later, she was dead.

  Some say the Oregon Death with Dignity Act doesn’t go far enough. They point out that even when a physician is involved, assisted suicide is not always foolproof. In Oregon, although most patients die within thirty minutes of swallowing the lethal medication, in a few cases the patient has lasted as long as twenty-four hours; in one instance, a forty-two-year-old man dying of lung cancer consumed the prescribed dose, went into a coma, and woke up nearly three days later. “David said he came back to suffer like Jesus,” said his wife. “And he did.” Two weeks later, he died of natural causes.

  Some also claim that the act discriminates against those people, like Tom Youk, who can’t bring hand to mouth to take the pills or who can’t swallow them or who can’t keep them down. They point to the Oregon man who applied for physician-assisted suicide, received his lethal dose in the mail, but had difficulty downing the medication; his brother-in-law had to prop up his head to enable him to drink all of it through a straw. Discussing the case, the Oregon deputy attorney general suggested that once assisted suicide is accepted, lethal injection may also need to be accepted, because the Death with Dignity Act does not provide equal access to people who cannot swallow—and may thus violate the Americans with Disabilities Act. “To confine legalized physician-assisted death to assisted suicide unfairly discriminates against patients with unrelievable suffering who resolve to end their lives but are physically unable to do so,” wrote a group of six ethicists, lawyers, and physicians, including Timothy Quill, in the New England Journal of Medicine, contending that it should be legal for doctors to bring about death in terminally ill patients, at the patient’s request, using lethal injections. Although the vast majority of doctors reject active euthanasia as a violation of medical ethics and an abuse of the doctor-patient relationship, some ethicists, as we have seen, maintain that there is no real moral distinction between physician-assisted suicide and voluntary euthanasia. They cite the case of Sigmund Freud, who suffered from cancer of the mouth for the last sixteen years of his life. Refusing painkillers so that he could continue to work with an unclouded mind, Freud made a pact with his physician, Max Schur, that when his condition became unbearable, Schur would help him die. In 1939, when the pain became so great that he was unable to read or write, and necrosis of the bone gave off an odor so foul that even his beloved chow kept his distance, Freud asked his physician to keep his promise. Schur gave him two injections of morphine, and Freud died quietly, at the age of eighty-three.

  Voluntary euthanasia—actively causing a person’s death at his or her request—is against the law throughout most of the world (although that has not stopped doctors in various countries from practicing it and, like Jack Kevorkian in the case of Thomas Youk, in some cases admitting it). There is, however, one country in which euthanasia, as well as physician-assisted suicide, has been widely practiced since 1973, when a physician gave her ailing seventy-eight-year-old mother a lethal injection. Although Article 293 of the Dutch criminal code called for twelve years’ imprisonment for anyone who “takes the life of another at his or her explicit and serious request,” a Dutch court found her guilty but gave her a short, suspended sentence. Public opinion strongly supported the physician’s act. Over the following decade, a series of court cases established conditions under which physicians in the Netherlands might perform “aid-in-dying,” as it was called, without fear of prosecution. The patient must be experiencing unbearable suffering th
at cannot be relieved in any other way; the patient must make a voluntary, well-considered, and persistent request; the physician must consult with another physician in making the decision; the case must be reported to the coroner. In 1984, the Royal Dutch Medical Association announced its support for the practice, provided that guidelines were followed. (Physicians opposed to euthanasia split off and formed a separate medical group.) In 1993, a statute explicitly stipulated that a physician following the guidelines would not be prosecuted. In 2001, the Dutch parliament formally legalized physician-assisted suicide and euthanasia. For several decades, Dutch doctors have quietly helped more than five thousand terminally ill patients to end their lives each year—nearly 4 percent of all deaths in the Netherlands—either by providing drugs to be taken orally or, far more often, by lethal injection.

  “Every patient, every human being, has the right to see his suffering as unbearable and has the right to ask a doctor for euthanasia,” says Pieter Admiraal, a Dutch anesthesiologist and author of Justifiable Euthanasia: A Manual for the Medical Profession. “Every doctor has the right to do euthanasia. And every doctor has the right to refuse to do euthanasia.” At a 1986 conference sponsored by the Hemlock Society in Washington, D.C., I heard Admiraal, a portly, bearded man who was, and is, the most well-known practitioner of euthanasia in the Netherlands, describe one of the hundreds of patients he had helped to die at his hospital in Delft. “She was twenty-four years old and she was in a nursing home,” he said. “I had a phone call from her doctor that she wanted to speak to me about euthanasia. I said that she wanted to speak to me. That’s not true. She couldn’t. She hadn’t been able to speak for a long time because she had cancer of the tongue. She couldn’t swallow, and they had put a tube in her stomach, through her skin, to feed her. That also means that she couldn’t swallow her saliva. People produce between one and two liters of saliva each day. She was a very, very nice and handsome girl, and she was sitting there, in one hand a tissue to remove continuously her saliva, and with her other hand to write down what she wanted to say to me. But I knew already what her problem was because that tumor was growing, very slowly but growing. The next step was a tracheotomy to open her trachea, to enable her to breathe if it closed. And that’s what she refused. So she wrote down that she refused this kind of tube. And she asked me to assure her that I would give her euthanasia just before she should suffocate. And I agreed, of course.

  “After a few weeks she came to our hospital because the tumor was bleeding. We all thought that she would bleed to death, but she didn’t. She remained in our hospital for the next two days, and we discussed when we should do the euthanasia. It was, of course, always a group decision, never a decision on my own. We talked long with the priest, nurse, and doctor on the case. And she was writing to us or knocking her head when it was time to do it. And we agreed we should wait until the last moment because we were all there so we could do it immediately if something went wrong.

  “And then two days later it proved that it was necessary to do so. First she saw her parents. Although usually the family are in the room at the moment of giving euthanasia, they refused to be there. In this case, then, the nurse, the priest, her doctor, and myself were there.

  “She wrote on her paper a farewell. I kissed her and said, ‘Have a very good journey.’ And I gave her an injection and she died.

  “I have two simple questions for you. I am always with my patients when they are dying, whatever the cause of their death, and if they have tongue cancer or cancer of that sort, then should not the doctor be there available to assist?

  “And the second question is, if a doctor is there and he’s standing in the back of the room with his hand on his bag and watches this patient suffocate, should not this doctor be liable to prosecution?”

  II

  “YOUR GOOD END IN LIFE IS OUR CONCERN!”

  DESPITE POPULAR BELIEF to the contrary, unless one lives in Oregon, the Netherlands, or Belgium, suicide is not easy—particularly if one is old, infirm, or terminally ill. Under current laws, those without access to lethal drugs are often driven by desperation to more secretive, violent, and lonely deaths, deaths that can be horrifically traumatic for friends and family left behind, like that of the terminally ill cancer patient, immobilized in a Stryker frame and partially paralyzed, who doused his chest with lighter fluid and set himself on fire. Furthermore, when knowledge of proper dosages and methods is lacking, suicide attempts often fail, and bad situations are replaced with even worse ones. Many intended suicides by gunshot leave the person alive but brain-damaged; drug overdoses that are not fatal may have the same effect. One eighty-three-year-old woman obtained an insufficient number of pills and lost consciousness but did not die; her daughter ended up smothering her with a plastic bag.

  “There is only one prospect worse than being chained to an intolerable existence: the nightmare of a botched attempt to end it,” observed Arthur Koestler. In 1983, two years after writing these words, the seventy-seven-year-old author, suffering from Parkinson’s disease and leukemia, made sure he did not botch it: he took a fatal overdose of barbiturates. His wife of eighteen years, Cynthia, although in good health at the age of fifty-five, decided she could not endure life without him and took an overdose at the same time. Their maid arrived one morning to find a note pinned to the door: “Please do not go upstairs. Ring the police and tell them to come to the house.” Police found Koestler sitting in his armchair, his wife on a nearby sofa. On the coffee table in front of them were a glass of whiskey and two wineglasses with a residue of white powder. Koestler’s suicide note, written ten months earlier and addressed “To Whom It May Concern,” said, among other things, “After a more or less steady physical decline over the last years, the process has now reached an acute state with added complications which make it advisable to seek self-deliverance now, before I become incapable of making the necessary arrangements.” In a footnote appended to her husband’s farewell, Cynthia concluded, “I cannot live without Arthur, despite certain inner resources.”

  Over the years, a number of organizations have gone to great—and often legally dubious—lengths to ensure their members a death more like that of Arthur Koestler than that of the cancer patient who set himself on fire. Although right-to-die groups date back to 1935, with the founding of Britain’s Voluntary Euthanasia Society, they came to wide public attention in the 1980s when an English journalist helped his wife to die and wrote a book about it.

  Like many who become involved in right-to-die activism, Derek Humphry was drawn by personal experience. In 1972, while they were living in London during Humphry’s years as home affairs correspondent for the Sunday Times, his forty-year-old wife, Jean, discovered a lump in her left breast. Tests proved it to be malignant. Despite a mastectomy, chemotherapy, and radiation treatments, the cancer spread to her lymph glands, spine, and bones. In May of 1974 the doctors predicted she would die before the end of the year. Although Jean struggled to maintain a semblance of normal life, she was often in pain so excruciating that she had to be rushed to the hospital. After a particularly harrowing episode she asked her husband to make her a promise: when the pain became too great and she decided that she had had enough, he would supply her with the means to end her life. Humphry promised.

  Although Jean’s wits were as sharp as ever, her physical condition steadily deteriorated. Eventually, she was forced to stay in bed, drugged into semiconsciousness and using a wheelchair to get around the house on the rare occasions she was up to it. A physician told Derek that the bones in Jean’s legs were so brittle that they might snap if she tried to walk. One morning she broke a rib when she bent over too rapidly. When there was another outbreak of cancer at the top of her spine, the doctors at the hospital admitted that little could be done beyond making Jean comfortable. She would probably die within a few weeks. The morning after she returned from the hospital, when her husband brought her medication and her breakfast, Jean asked him if he had been able to procure a drug. De
rek, who had obtained a lethal dose of Seconal and codeine from a sympathetic physician, said that he had. She told him that she would die at one o’clock.

  Humphry and his wife spent their remaining hours talking about their twenty-two years of married life. Shortly before one o’clock he prepared a cup of coffee for Jean, into which he stirred the lethal mixture. Returning to her room, he placed the mug on the nightstand. They hugged each other and said good-bye. Jean drank the contents, leaned back on the pillow, closed her eyes, and fell into a deep sleep. Derek sat by her side until, fifty minutes later, she died.

  Humphry let few people beyond the immediate family know the circumstances of Jean’s death. One of those he eventually told was his second wife, Ann Wickett, an American Ph.D. candidate in English literature who was twelve years his junior. She encouraged Humphry to write about his experience. Three years later, in 1978, Jean’s Way, an account of his wife’s last years and how Humphry had helped her die, was published. The book’s first printing sold out within a week. Humphry received scores of letters from all over the world, some from terminally ill people asking for help in killing themselves, others from people who wanted to be prepared in case they ever became hopelessly ill. Some revealed that, like Humphry, they had helped someone die but had never told anyone. Others wrote that a terminally ill loved one had begged for assistance with a suicide but that, fearing prosecution and stigma, they had been unable to carry out what Humphry called “an act of love.”