December 2000
Volume 64 |
Number 12
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| Letters
To The Editor |
No Merciful End to This Controversy
I very much appreciated your report on the end-of-life care for
your patient "Charles" in the August issue of the NEWSLETTER.
Not too surprisingly, there are many questions.
I am confused whether you are in favor of mercy killing or opposed
to it. Obviously, you stopped Charles from suffering from his
unremitting pain and answered the prayers of patient, family,
oncologists and nurses. Charles died as a result, and you were
quite sure that he would. Your intention was to comfort Charles,
not kill him. I think you were wonderful to do that.
But you write that you had deep remorse for this work. My guess
is that your remorse lies in your flirting with "mercy killing"
but not "euthanasia." This is very confusing for me.
My dictionary defines euthanasia as mercy killing, and everything
you have written clearly points to your motives as being merciful.
Then you write that your relieving of the pain and suffering of
a terminally ill person produces a double effect where the adverse
actions may even outweigh their benefits, thus adding to my confusion.
Given the "givens" in Charles' case, what adverse effect
are you referring to? He was terminal. He was expected to die
and he did. You did nothing to prolong or shorten his living a
reasonably decent life.
Another point: You write that the ambivalence that we physicians
feel is the "culmination of decades of playing the healer's
role." As an anesthesiologist, I have always thought of my
work as a comforter. The surgeon is hopefully the healer. We are
a team, but I do the comforting. Therefore, I like the logic that
we anesthesiologists consider this as part of our work.
Again, thanks for your contribution.
Lawrence D. Egbert, M.D.
Baltimore, Maryland
Editor's Note: The editorial was written
to highlight the ambivalencies and contradictions dealing with
end-of-life care. You succinctly selected the more problematic
areas and embellished the controversies. While I personally do
not support mercy killing, euthanasia (voluntary or involuntary)
or physician-assisted suicide, there are times when what we believe
and what we do are linked only by our intent. Finally, I believe
that mercy killing occurs when death is imminent (hours) while
euthanasia's time frame is more fuzzy (days to months).
– M.J.L.
Will Anesthesiology Suffer Latin's Fate?
Your editorial comments in the June 2000 "Ventilations"
about the future of our specialty and manpower needs are overly
optimistic and may be far from reality.
Our specialty today is taking a multidirectional course of labyrinthine
complexity. Our leaders consent to such evolutionary process without
asking the Quo Vadis or, unlike the ancient writers, without planning
our Deus ex Machina. Political pressures, economic realities,
public misinformation and restrictive regulations, in tandem with
our striving for clinical excellence, lead us to a stressful and
frequently unhappy life.
Any evolutionary process that is based mostly on economics has
the potential to degrade the quality of service and manpower.
Office-based anesthesia, with its officially reported 12 mortalities,
is an example that warrants serious and critical evaluation.
Our professional organizations manipulated by shrewd politicians
and bureaucrats behave like government regulators. ASA presently
has over 115 committees, subcommittees and representations to
various organizations - approximately one for every 312 members.
I was wondering how many committees Intel, IBM, GE or Microsoft
has?
Teaching has become a function of articles read times the articles
written or published. Clinical competence, the backbone of successful
practice, is downgraded to the strict adherence on certain guidelines
and parameters. Often, young teaching lieutenants spoon-feed the
neophytes with knowledge acquired during their refuge in libraries
and computers frequently one half-hour prior to such didactic
meetings.
The future manpower need for anesthesia requires a more realistic
assessment. With the cost of medical education being about $250,000
to $300,000, the consecutive decline of medical student applications
for the last three years and the prospect of being regulated like
a public utility will make medicine as a career choice somewhat
unrealistic.
The adequacy of manpower depends on productivity, not on the
number of physicians. With the likelihood of part-time practice
by 45.8 percent of female students, the productivity gap will
increase, further forcing existing full-time practitioners to
work even harder. Considering the available first-year residencies
for all specialties (about 22,000) and the number of graduates
(about 16,000), anesthesiology has to compete very hard.
Promotional efforts focusing strictly on the intellectual aspects
of anesthesia may influence young graduates. It will, however,
be a disservice and may be negligence on our part if we fail to
disclose the whole picture of anesthesia today.
My writings may classify me as a lounge-lizard naysayer or even
as a doomsday prophet. However, while our organizations may start
planning our Deus ex Machina as individuals, we should consider
our Carpe Diem. Equally, we should keep alive the principle passed
onto us years ago by our teachers: Sedare Dolorem Opus Divinus
Artem (It is a divine act to sooth suffering).
Istrati Kupeli, M.D.
Wellesley Hills, Massachusetts
Helping or Harming? Opinions Changing on Assisted Suicide
Congratulations on a very insightful and courageous editorial
in August's "Ventilations." You have succinctly described
the conflict and anguish of the several parties that determine
when we (primarily the physician but also the family) transition
from the beneficial task of maintaining human life to the harmful
task of prolonging the act of dying. Maine has a referendum on
physician-assisted suicide (Death with Dignity) this November.
I think that it is exactly this scenario, prolonging a process
that is clearly terminal in the immediate future and involves
a significant element of suffering, that concerns the public rather
than a wish for suicide. A recent opinion poll shows that Maine
citizens support the measure by about 60 percent. A similar referendum
a few years back only generated about 35-40 percent support. There
appears to be increasing concern over what we can do as opposed
to what we should do. The medical community has expressed a lot
of concern about some of the ramifications of such legislation
but does not appear to be as vigorously opposed as before. However,
the final language will need careful drafting.
Richard M. Flowerdew, M.B.
Falmouth, Maine
Art and Aphorisms
Thank you for incorporating my modest painting in the report
by Bernard V. Wetchler, M.D., in the September issue of the ASA
NEWSLETTER. By the way, I enjoyed your words of wisdom.
Aphorisms do not grow on trees. They are the product of long experience,
keen observations and good genes. Wisdom is valuable, true and
ageless. It is bestowed on a few lucky ones. Thank you for sharing.
Ezzat Abouleish, M.D.
Houston, Texas
Editor's Note:
Many readers have responded to me with their own favorite
aphorisms, some of which will be featured in an upcoming "Ventilations"
column. – M.J.L.
The views and opinions expressed in the "Letters
to the Editor" are those of the authors and do not necessarily
reflect the views of ASA or the NEWSLETTER Editorial Board.
Letters submitted for consideration should not exceed 300 words
in length. The Editor has the authority to accept or reject any
letter submitted for publication. Personal correspondence to the
Editor by letter or e-mail must be clearly indicated as "Not
for Publication" by the sender. Letters must be signed (although
name may be withheld on request) and are subject to editing and
abridgment.
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