Confronting physician-assisted suicide and euthanasia: My father's death

Duty: An act ... required of one by position, social custom, law, or religion.... Moral obligation. --American Heritage Dictionary of the English Language, 4th ed. My father's death forced me to rethink all I had written over two decades opposing legalization of physician-assisted suicide and euthanasia. (1) That should not have surprised me. Years ago, when I started working on end-of-life care, he challenged my views on advance directives by insisting that he would want "everything," even in a persistent vegetative state. "I made the money, so I can spend it." More deeply, he argued that the Holocaust was incompatible with the existence of God. There is no afterlife, he claimed. This is it, and he wanted every last bit of "it" on any terms. My father was a smart, savvy lawyer, the family patriarch. He was forceful, even intimidating at times. We had fought over the years, especially as I neared college. That was probably necessary--my separating and our disengaging. When I was a child, it was a family joke how often he and I said the same thing at the same time. We were alike in many ways. My father was diagnosed with a metastatic head and neck cancer in 2002. His predictable view was "spare no effort." A top head and neck surgeon worked through conflicting pathology reports to locate the primary tumor in the thyroid and excise the gland. Metastases would crop up from time to time, but radiation and then CyberKnife radiosurgery kept them in check. For five years he did well. Things changed in June of 2007. The last CyberKnife treatment was billed as the worst, with significant pain likely to follow. Sure enough, ten days later, my father's pain on swallowing became severe. He began losing weight--a lot of it. He weakened. He fell twice in his apartment. His regular internist was out of town, so he went to the emergency room of a local hospital. Doctors did little for this seventy-nine-year-old man with a five-year history of metastatic thyroid cancer plus emphysema and chronic obstructive pulmonary disease. He was briefly discharged to home but finally made it to the head and neck surgeon who had found the primary tumor in 2002. One look at my father and the surgeon admitted him, ordering a gastrostomy tube to deliver nutrition. Now my father was in an excellent hospital, with the head and neck, pulmonology, and gastroenterology services working him up. The mood brightened and the family gathered around him. I spent days in his sunny hospital room reminiscing, plowing through the New York Times with him, singing the college fight songs he offered as lullabies when I was little. With multiple services focusing on my father's condition, I hoped the picture would soon come clear. I waited for a single physician to put the pieces together. And the medical picture was becoming worse. A surgical procedure revealed cancer in the liver. Pulmonology added pneumonia to the roster of lung ailments. Meanwhile, dipping oxygen saturation numbers drove a trip to the intensive care unit. Attempted endoscopy revealed a tumor between the esophagus and trachea, narrowing the esophagus. But no physician was putting the whole picture together. What treatment and palliative options remained, if any? What pathways should he--and we-be considering at this point? He Said He Wanted to Stop My father was becoming increasingly weak. He was finding it difficult to "focus," as he put it. He could not read, do the New York Times crossword puzzles he used to knock off in an hour, or even watch TV. Fortunately, he could talk, and we spent hours on trips he had taken around the world, family history, his adventures as a litigator. But he was confined to bed and did little when he was alone. Then one morning he said he wanted to stop. No more tube feeding. No one was prepared for this switch from a lifetime of "spare no effort." He told me he feared he was now a terrible burden. …