Monday, August 24, 2009

"The Woman Who Decided to Die"

Ronald Munson is a bioethicist who has worked for such esteemed organizations as the National Institutes of Health and the National Cancer Institute. He has also authored several non fiction books, as well as one of the most widely used medical ethics texts in the United States. His newest book "The Woman Who Decided to Die: Challenges and Choices at the Edges of Medicine" was published in 2009 by Oxford University Press.

When I read the prologue, describing that the flow of the book would be ten scenarios of real world moral dilemmas faced by Munson himself, I was pretty eager to jump in.

While the stories themselves were extremely well written and even page turning in their narrative form I was surprised with how common place I found them. I was expecting moral and ethical dilemmas that would spur hours of discussions amongst my colleagues. What I found were stories more geared to a non medical audience. For those of us in the trenches, these are a part of our daily experiences.

For instance, there was a 31 year old woman who opted to not pursue further chemo. Now it was a little edgy that she decided not to bring her husband into that decision, but I'm pretty used to people not wanting to pursue chemo, even if doctors know it will help or even with a chance of cure.

Another woman with a schizophrenic break, was a suicide risk and was committed against her will into a psych unit. Yep, pretty standard.

I'm probably sounding too critical. It is a very well written book, I just think it is my career in palliative medicine that skews the "wow" factor.

Probably the most interesting story I found was about an inmate who had been convicted of murder (that of a woman and her child), who was admitted from prison in need of a heart transplant. I did find myself wondering what the outcome would be, as different states have actually taken different approaches to this exact scenario. California has transplanted an inmate to the tune of an estimated cost of 2 million to the state, while as Arkansas denied a transplant to a inmate, who then died of liver failure. You'll have to read the book to see what Munson suggested at an emergency ethics meeting regarding this case.

This review would not be complete without mentioning the narrative I had the most trouble with. The story was of a man with throat cancer, who had communicated with family and friends that he wouldn't want to be kept alive if his quality of life was not an acceptable one. Things progressed, he had a final surgery which removed most of his tongue and half of his face (both upper and lower parts of his jaw) and was on life support after surgery. He was dying anyway of cancer, and his wife stepped up to advocate his wishes.

What happened next is what troubled me. In this situation I would expect a palliative care consult, a review with medical staff and nurses for a planned extubation with family at bedside for the switch to comfort measures. Instead something clandestine occurred. We aren't quite sure, but the doctor was in the room alone, and then comes out saying his bleeding had worsened, blood pressure dropped and he died. WHAT? The implications was that this doctor actually did something to hasten death. Even more alarming were these last sentences in this chapter;

"Patients are given large doses of morphine to reduce their pain. The drug also slows respiration, so an amount effective in controlling pain can, in a weakened patient, hasten death"

I nearly jumped from my chair. Morphine used as an amount to effectively control pain does not hasten death! When will such fallacies quit embedding themselves into literature and the media. I expect such things from a non-medical author, but clearly Ronald Munson,while not a clinician, is experienced in the medical world.

Perhaps these were stories from the edges of medicine, but I'd almost guess that like the galaxy expanding, the edges he knew are now just generally accepted principles. It is the new edges we deal with now that I hope to someday see in print.

4 Responses to “"The Woman Who Decided to Die"”

Sean Marks said...
August 25, 2009 at 9:23 AM

I like your review and from the sounds of things, you certainly are NOT being too critical. I'd like to take aim at the title of the book, "The Woman Who Decided to Die." Not to sound too glib, but it's not as if one can just close their eyes, sigh and say "aahhh, I'm going to die now." Just tried it myself, didn't work.

To me this misconception gets at the heart of this issue in regards to the big public debate about end-of-life care. Certainly, there's already been many more excellent and thoughtful entries on this web site about the debate, and I hate to morph your book review on this tangent. But these cases aren't about people choosing to die, they're about people honestly facing the life-limiting nature of their disease and then choosing care that helps them individually account for it.


Christian Sinclair, MD said...
August 25, 2009 at 9:03 PM

Wow that is really surprising to hear from an esteemed bio-ethicist.

I agree that sometimes seeing the tough ethical challenges every week as is common in palliative care does make some ethical challenges look more trivial to us where others would see a very difficult decision in front of them.

But then again it is really a matter of perspective. To someone else the story of the prisoner may seem very obvious as to the outcome. They may wonder where the ethical conflict is based on their background and life experiences.

It is something I have to remind myself more often that 'common' end of life ethical challenges to me may be fresh, new, and challenging to others (patient, family, staff) and I must temper any cavalier approach to finding 'obvious' answers with a touch of humility and graciousness to those who do not have my same experiences. Only then can I stop and listen and help make a decision based on multiple views and not just my own.

Great piece! Thanks.


Christian Sinclair, MD said...
August 25, 2009 at 9:03 PM

And Sean,

I am glad your thought experiment didn't work!


Sean Marks said...
August 26, 2009 at 7:43 AM

I'm glad it didn't work too! Again, excellent posts. I love this art section on your blog. Great idea and execution.