Thursday, February 21, 2013

Buckeye Eviscerated on KevinMD

The medical social media Godfather Kevin Pho will occasionally cross post some of my work on his hugely popular and successful blog KevinMD.  Earlier this week he chose to include my relatively recent post on an article I had read in the Economist last fall about physician assisted suicide (PAS).  I was in one of those moods when I wrote it.  I suppose I was looking to achieve a certain degree of shock value by writing it as a straight satire of what it could mean to be an actual doctor who participated in PAS.  I mused about how a general surgeon might get involved in such a vocation.  This musing involved several proposals for procedures that a general surgeon would have within his skill set to do if requested, including but not limited bilateral carotid artery ligation, aortic transection, and trachea clamping.  The KevinMD readership did not take kindly to such apparent insouciant treatment of a sensitive issue.

To wit, from the comment section:

-It is apparent that you have never been in 'a situation with another who was suffering horribly with months to live'.

-you come off as cynical, judgemental and ignorant all at once. what kind of parallel are you trying to highlight comparing acne vulgaris to a terminal disease? pointless article.

-Dr. Parks,
You might want to read a medical ethics textbook and learn the difference between physician assisted death and euthanasia. I doubt any doctor (usually the doctor that was taking care of that terminally ill patient) is motivated to assist someone in their death by monetary gain. In terms of economics, the live patient is always worth more to the doctor than the dead one. Maybe instead of vilifying these doctors you should do some more research to hear their stories

-Wow. I'm kind of surprised Kevin accepted this post. Setting aside the offensive nature of it's (sic)jokes, this writer has a very limited view of the role of the physician. It is our job not only to heal the sick but to attend to the dying. I am all for an adult discussion of PAS, but this is not it.

-Doctors like you are a disgrace. You are nothing more than a heartless, drug-dispensing medical-billing machine that is more than happy to prolong someone else's suffering for your own benefit. You can hide behind your oath, but this is the real world and, for the patient and their family, death and dying is as real as it gets. I am thankful that I live in a state where we have passed a Death With Dignity law. We have the ability to take the decision about how we die out of the hands of people like you, Dr Parks.

-Your satire is not satirical. You come across as an arrogant, judgmental know-it-all. I am glad that I will not have you to deal with when I am facing death.  I cannot imagine having to deal with your self-righteous sanctimonious BS on top of dying.

I realize that by blogging, I  take the risk that someone is going to take great offense to something I write, that not everyone will agree with my views, and that sometimes I may even be called out for factual inaccuracy.  Online, you have to have a pretty thick skin.  But in this case I felt I was being attacked, to some extent, unfairly.  It seems most commenters missed the satire and moved on to condemning me as anti-palliative care, an uncaring, money-grubbing pill pusher, someone who hooks dying patients up to machines just for sadistic kicks, and various other personal insults.  Given the exposure that Kevin's blog has, I felt the need to reply in the comments section.  Here's what I wrote:
I think many of the commenters are talking past the content of the post. Why is it monstrous to delve deeper into the actual content of what it means to be an advocate for physician assisted suicide? I think it's important to determine what exactly it is that people are objecting to in the post. Is it the fact that I question the role of a physician in providing the materials/instructions in hastening someone's death? Or is it merely the grotesque examples I have provided? I think that if you want to be an apologist for physician assisted suicide, you should say so. If you think that doctors ought to provide direction on how to end your life, then say so. If you think euthanasia and physician assisted suicide ought to fall under the rubric of palliative care medicine, then say so. Only understand that by doing so you accept the unpleasantness of what it actually means, in real practice, to end someone's life. If the end result is the same, why should it matter what the means are that one chooses to implement such an end. What is truly the difference between overdosing someone on morphine vs. "performing bilateral carotid occlusion surgery"?  
It's an uncomfortable post, I grant you that. I appreciate that Kevin had the balls to put it up (he chooses all my posts, I don't submit anything to this blog). I would just try to reiterate once again that I am not satirizing palliative care or hospice medicine.  This was not a post about palliative care or end of life issues as we face in the United States. This was a post about physicians who volunteer their services for the express purpose of ending some one's life. To me, such an endeavor has nothing to do with the concept of "physician", in the Hippocratic sense. To me, whether you intentionally end some one's life via an IV cocktail or any of the absurd examples I provided is the same thing--- a violation of the very essence of what it means to be a doctor. If, as a society, we want to legalize assisted suicide, then we need to create carve out an entirely new cadre of professionals who will perform these services, apart from the physician fraternity.
Anytime you are challenged so forcefully in public, once the adrenalin of defending yourself wears off, it's natural to retreat somewhat into a posture of reflective contemplation.  It's obvious that we, as a nation, are still quite uncomfortable with end of life issues.  To joke about or satire the dying process is to risk automatic expulsion from acceptable discourse.  And honestly, I don't have a firm enough grasp on death--- how I will handle its encroachment either on those close to me or, hopefully decades from now, when my reckoning comes-- to be able to whimsically shrug off the self righteous objections to my post.  It affected me, I admit.  It made me reconsider whether I ought to have written it.  I hate pissing people off, dammit. 

People used to just die in their own homes.  Families would gather round for a vigil and when the event occurred, it was without drama or fanfare.  Death was a shared process.  Dad was just upstairs dying.  Death as a facet of life.  Too often nowadays it is sealed off from anything remotely resembling life in semi-sterile, ventilation-controlled, institutionalized ICU rooms with wires and tubes everywhere and strange beeping mechanical noises and never knowing if it's day or night and families collapsed like fallen toy soldiers on stiff, too-small couches in the waiting area with strangers.  We don't want to "pull the plug"  because we can't stand the thought of having our loved one die in that damn ICU bed.  Stay alive long enough to get him home, is what we think.  But Dad has already been sucked into the vortex of the system.  He's already marionetted in a cold white sheeted mechanical bed and it doesn't seem possible to cut him loose.  And so we look for alternatives.  Maybe the kind pain management physician who adjusts his morphine every evening could help.  Maybe the patient oncologist who has been with you and Dad all along could provide an out.  Anything to end the seemingly endless pain, torture, and futility. 

And this is where I draw the line.  In general I am not some sort of unyielding ideologue, making grand pronouncements on acceptable human behavior.  But I do try to adhere to "first, do no harm".  In my line of work, more than others, we sometimes unintentionally implement strategies, perform operations that lead to a worse outcome than if we had done nothing at all.  And the idea of intentionally acting to end some one's life, no matter the circumstances, strikes me as a gross violation of the physician calling.  I'm not talking about withdrawal of care or simply providing comfort measures for the terminally ill.  I am speaking specifically of active intervention, the hastening of some one's demise. 

In time, we may find the rise of a new cadre of heath care professionals who offer their services to specific subsets of dying Americans who have had enough, who don't want to simply "wait it out" in stylized hospices.  They may come from a background of anesthesiology or palliative care medicine.  But it ought to be very clear that they have broken off from these ancestries and speciated into something else entirely.  It will be absurd to even think about calling them doctors, to the same extent that we perceive police officers as different entities from military personnel.  But I think we're a long way from this happening.

We don't even know how to start talking about it without a rational discourse being submersed under a torrent of fear, anger, and prejudice.  But we have to start talking.  The status quo is untenable.  Every disease and infirmary may well have newer and more potent treatments, but the body and soul housing that disease grows weary with time.  And a time comes when it just wants to rest. 


Anonymous said...

My grandmother(GOD bless her soul) used to say to me "don't get old" and "nobody gets out of here alive, you know". It seems to me that past generations were more able to cope with the reality of death. Life is a death sentence. Keep it simple and do as much good as possible. These are words of wisdom from the smartest man alive.

Eric Blair aka Captain Short bus

Joseph Sucher, MD FACS said...

Dr. Parks,

Those individuals who made those comments have not read the entirety of your blog and therefore do not know the extent of you passion and compassion. While, I do not know you personally, I do know the content of your blog. It proves, without a doubt, that you are a professional with the highest morales and ethics of our profession.


Anonymous said...

The public doesn't and cannot know what all goes on in our lives. The things we ponder about are not what they ponder about. Lots of non-clinical people choose to read medical blogs. Maybe they should not do so.

The general public will never understand any part of "us". They read at their own risk - or maybe, should stick with Dr. Oz aka Disney.


Anonymous said...

You are way out of touch or your religious mores are blinding you to reality. What do you think opiod comfort care is? Do you not want to provide people with pain relief if that shortens their life? We're helping people die, just like we help them at every stage of life. If you want to stick your head in the sand and not engage in real life, then fine. But you have to keep your childish beliefs to youself and on some level realize that the rest of us do a hard part of being a doctor for you so that you can live in a fantasy moral bubble.

Jeffrey Parks MD FACS said...

This is a strawman argument: "Do you not want to provide people with pain relief if that shortens their life?"

In no way can you infer from what I have written that I seek to prevent the terminally ill from obtaining pain relief. That's unfair and inflammatory. Comfort care measures and palliative care are enitrely different entities. If you would like to advocate for the idea of palliative care specialists providing specific instructions on how to end life, then please do so.

I live in no bubbles, man. I'm out there seeing these people every single day.

Anonymous said...

Longtime reader buckeye - not sure if the post in question was your first on Kevin MD but it is not representative of your blog as a whole. Rather, one quick peek at your overall picture. Though, I do have to say this post was a little more gloomy than usual. I would still let you operate on me or a loved one! Please keep up the blogging as I love it! - Midwest EM doc (new graduate, in fact I almost went into GNS because your blog was so interesting)

Anonymous said...

I appreciate your blogging. I agree with your OP and the response, but I do want to say once thing-- I don't think that romanticizing death as a "shared vigil" is accurate. Some people die grizzly deaths, some people die in their sleep, some people "die too young". My ICU attending used to talk about the "good death". I think a person is lucky if they have one, and I hope for one, but for others it is the dying. Still, I agree, I think if assisted death is to be considered, I do not think physicians should play a role, it is indeed a separate role. The knowledge to kill or end life is not unique to physicians- Ghengis Khan and suicide vicitims know how. We are not needed for this-- a private rheum