The Dutch Cousin – Peter S. Kibbe, MD, FHM

Now and again I see in the press a report regarding physician-assisted suicide or legislation proposed to enable the same.  The arguments for and against stir little passion in me, but they do provoke memories.

In a North Carolina hospital where I practiced some years ago there was a native Carolinian obstetrician, experienced, bright and very grey and gangly.  He had the North Carolinian capacity to tell a good story, to “hold forth,” to capture a group of doctors in the doctors’ lounge with a story, often humorous.  I loved to listen as, draping his thin frame of close to seven feet across an arm chair, he entertained us.

One day he rambled in as some of us were drinking coffee or pecking away at the computers, threw himself into a chair, and told us about his recent phone call with a friend in Holland.

He was of Dutch extraction (although you could not tell from his drawl), spoke the language and maintained family connections in Holland.  “I just got off the phone with a friend in Holland who told me about a cousin of mine.  Told me they were going to have a wake for him this Saturday. He said he knew I probably couldn’t make it, but he just wanted me to know.  Well, I said, ‘Hell, I didn’t even know he was dead yet.’ And he told me that he isn’t dead yet, but he is going to die on Friday.”

Then he explained that his cousin had a very advanced, painful and untreatable malignancy and was taking advantage of the Dutch laws which permit patients such as his cousin to employ physician-assisted suicide.  A discussion followed regarding how practical the Dutch were, how they respected human rights and that this man was exercising a right to exit the world of pain in which he was living at a time of his choosing.  There is much to be said in respect to that argument.

I have other memories, although not many, of certain patients living in such horrible pain, untreatable pain, whose lives I might have assisted them to end without a shred of remorse.  I recall a man whom I cared for in a nursing facility who had the most painful form of dementia I have ever encountered.  He was completely unaware of his external environment, fed through a PEG tube, bed-bound and unable to speak coherently.  Worse than any of those impairments, his dementia had rendered his psychic or cerebral environment into some kind of never ending hell.  He screamed and wailed whenever awake, as though some harpy were pulling at his entrails or as though he were on some psychic rack which was tearing apart his cerebral bones and joints. I could find no source of physical pain.  I treated him with a psychiatrist and our only recourse was to keep him so sedated that he was barely ever truly awake.  When he broke through the sedation the howling would renew itself, his tormentors would return, the fires of his psychic hell would flare.

Opportunities presented themselves for him to exit the earth with some dignity—a pneumonia or some other infection, and I advised his wife that we should treat him only with whatever comfort measures he appeared to need.  She was adamant that he be kept alive and be bundled off to the hospital.  I felt that I had become a conspirator in torture and battery. I wondered if he had beaten and abused her.  Was this her vengeance?  In fact, I stopped attending to patients in nursing facilities because of this and similar cases.

Regarding physician-assisted suicide, the line is thin between the admitted and controlled fact of how the Dutch do it, and the de facto fashion in which we often employ palliative morphine to prevent discomfort in the dying patient.  We all know that when someone is dying and is uncomfortable it is often best to exit the earth in the arms of Morpheus, oblivious to suffering.  Yet are we helping the dying soul by permitting Morpheus to slide the patient off into the netherworld? At times I do not know.  It does not rise, for me, to the level of a moral argument.  It is a more viscerally or perhaps soulfully determined act.  As my father-in-law, an eminent physician would say of certain cases, “It is time to bring out the morphine.” Most of us know when that time comes.

As to whether we in the United States could enact legislation to permit physician-assisted suicide, I doubt we could do it. Some states have passed laws that permit what they call medical aid in dying, but a national consensus is probably not possible. We lack the practicality of the Dutch. We cannot do the work to save and preserve New Orleans or Houston from the storms we know will strike them, while the Dutch have been preserving their land from crippling water catastrophes for centuries.  If some part of their landscape is likely to flood, they won’t allow buildings there.  They turn those areas into a space, such as a park, which could capture flood water and still have human use when dry.  We build again and again on landscapes predictably endangered.

Could Americans fashion a way for people such as the Dutch cousin to make their exodus reasonably?  As in the way we attend to New Orleans we would probably muck it up. In the end, Americans in general would rather go to Disney Land.

Peter S. Kibbe, MD, FHM