Wednesday, December 6, 2017

Fatal Choice: Choosing no longer to live

Photo by Alberto Biscalchin, used under Creative Commons Licens

Presented to the Club on Monday evening, Dec. 4, 2017 by William P. Densmore

One day in March, 1981, a short obituary appeared in the Chicago Tribune about a fatal choice — the suicide of Earl Russell Marshall, of Tulsa, Oklahoma. It mentioned that Mr. Marshall was a supervisor at the Tulsa maintenance base of American Airlines.

Colleagues of Mr. Marshall at American Airlines had also made a fatal choice two years earlier, a choice primarily responsible for the deaths of 271 people.

Those 271 people had been passengers May 25, 1979 on an American DC-10 jumbo jet which dropped an engine and crashed on takeoff from Chicago O’Hare International Airport. The engine had been worked on at American’s Tulsa maintenance two months earlier. The day after his death, Mr. Marshall, then 47, was to have been questioned by lawyers for the aircraft maker.
The airline said Marshall had no involvement with the accident aircraft. The Tulsa World newspaper talked to Mr. Marshall’s widow in 2004, 25 years later. “He had very bad guilt feelings, and the accident gave him something to attach his feelings to,” Marilyn Marshall to the daily. ‘He was a casualty of that crash.”

DC-10 maker McDonnell Douglas Corp. and American sued each other after the crash and the National Transportation Safety Board investigated. The companies and the government learned that a maintenance work shift ended on one of the nights the DC-10 was in Tulsa and the crew left a 15,300-pound wing engine and attached pylon hanging overnight partially disconnected from the wing – and supported only by the forklift’s hydraulics. The result – a hidden, 13-inch crack formed in one of the three attachments of the engine to the wing.

During the O’Hare takeoff roll at the start of a Los Angeles flight, normal engine thrust broke the attachment, the engine shot forward, rotated over the top of the wing and separated from the aircraft – severing lines of all three independent hydraulic systems vital to control. The plane rolled to the left and crashed. It remains today the highest death toll of any single U.S. aviation disaster.

It was a fatal choice that American Airlines made, to remove the 13,477-pound GE jet engine and 1,865-pound pylon in a single procedure, because it saved 200-man-hours per aircraft engine overhaul, and reduced to 27 from 79 the number of disconnects of lines and cables.

McDonnell Douglas didn’t recommend it, but it also didn’t tell American not to do it that way.

Another fatal choice

I know all this because I was an editor for Chicago Lawyer magazine in 1980 and 1981 and I covered the lawsuits about the crash – I still have hundreds of pages of moldy legal depositions in our basement that contain detailed testimony about the forklift procedure. And ever since, I’ve been fascinated by the safety decisions we make and do not make, and the consequences, and how we assess or become even aware of those consequences.

As a nation, and species, we make policy decisions that involve fatal choices.

For example, we make the fatal choice to allow global climate change to progress, and already we can see migrations, floods, arctic melt, atmospheric and food-security challenges arising. Each of us can think of more such choices for humankind. It seems as if the more distance the policy from our own personal lives and the more people who are at risk, the more likely a fatal choice is made almost without transparent forethought or balancing of costs and consequences.

Another choice. Predawn on Dec. 2, 2017, the United States Senate cobbled together a 500-page document of tax changes, and some completely unrelated matters, scribbled amendments in illegible page-border handwriting, and approved and sent it to the House on a 51-49 partisan vote. There were little or no committee hearings and no time between amendments and a final bill.

One of the provisions of the bill, if it becomes law, is predicted to result over time in 13 million Americans losing their current health-insurance coverage. That’s clearly another fatal choice. Because some of those 13 million Americans are likely to die, or at least die sooner, as a result of coverage decisions by governments and health insurers. Has the United States Senate just become a “death panel”?

It is here – in the domain of health and medicine – that I want to dwell a bit tonight to consider a fatal choice that will affect us all. Some of us will leave here tonight believing the particular fatal choice I’m thinking of is ours to make. Others may well think it should be – indeed is in fact — up to a higher power. I want to argue that the truth lies somewhere in between, that the truth will be different for each of us, and that the sooner we think about it for us and our loved ones, the better – for us and for society.

I’m talking about how we exercise compassion and care near the end of life – a point we shall all reach, perhaps unexpectedly, but more likely with some warning and time for thought and reflection.

Each of us has the opportunity to make a fatal choice about the time and manner our life is to end. Thankfully, life is good enough that most of us don’t choose suicide as did American Airlines supervisor Earl Marshall. But we do make make choices in daily life which could be fatal. We engage in hazardous sports or recreation, unhealthy or excessive eating or drinking. We smoke or become addicted to pain-killing drugs. We own guns.

As we age, there will inevitably be things that will draw us nearer to death. As much as we make decisions as a society, and live as individuals in ways that involve fatal choices, why wouldn’t we do the same as the very real probability of death draws near? At the point where we draw nearer to God, we seem oddly to be more willing than ever to suspend any consideration of whether and on what terms we choose to be alive.

Now, there are people in this group — clergy — who have spent infinitely more time than I thinking about divine intervention and life. So I just have to credit and borrow from a Nov. 7 sermon by The Rev. Sarah Stewart of the First Unitarian Church of Worcester, Mass., whose sermons, by family connection, I receive by email. It helps me to illustrate the fatal-choice nuance I’m driving at.

Rev. Stewart wrote about God’s hand in retelling this joke:
Once upon a time, a man was shipwrecked and flailing around in the sea. He kicked his feet and waved his arms and cried, "O God, save me! I'm going to drown!" And lo and behold, a helicopter spotted the wreckage and flew in low over the man. A ladder uncoiled from the belly of the copter and a rescue worker made his way down. "Grab my hand!" the rescuer shouted.

"No, God will save me!" the man replied. No matter what the rescuer said or did, the man refused to take his hand and be pulled to safety. The rescuer watched in utter dismay as the man slipped beneath the waves. The man came to his senses in Heaven. Dry, warm, and comfortable, he walked toward God, who was hanging out in her favorite chair by the fire. "Hey God!" the man said. "I prayed! I was faithful! Why didn't you rescue me?!"

"Buddy," said God, "who did you think sent the freaking helicopter?"
Here’s why I like Rev. Stewart’s retelling of that story. Because it teaches that God works in many ways, and in ways that you may not even see as divine in the moment. And it teaches that God works in ways that may appear patently secular – the rescue helicopter. And in ways that you have to choose to actively embrace – take hold of the rescuer’s hand.

I think that’s an important aspect of what happens as we age. We may think we will be OK if we just go about our life and assume that God will take care of everything. There will be no pain, no reckoning with family, no diminished quality of life, and if there is, that’s what God intended. That sounds too much to me like the man who just waited in the water until he drowned.

So that’s my little sermon, and I tell it, because the rest of this talk, which is about choice, and a fatal choice at that, is about something still controversial and I want you to know my point of view so you can filter what you hear. My view is that active personal engagement with our fate, whether or not in consultation with God, is appropriate in politics, in life, and in the lead up to death.

A couple of months ago, I wrote an op-ed piece in The Berkshire Eagle. The headline was shortened a bit for space, and it was fine, but the one I had proposed was this: “Right-to-die debate about four words – burden, control, religion and choice – not suicide.” A surprising number of people spoke to me about that piece and how they had been moved to thought by it. It was published Sept. 26, 2017, the same day the Massachusetts Legislature’s Joint Committee on Public Health conducted a hearing on Beacon Hill on Senate Bill 1225 and its twin, House Bill 1194: “An Act Relative to End of Life Options.” Sometime before Feb. 7, 2018, the committee will have to decide if it will refer the bills to the House and Senate for floor votes. It has refused to do so for many years, just letting it lapse.

On Saturday, something happened which may cause the bill to be voted on. At their fall meeting, the Massachusetts Medical Society house of delegates voted 152-56 to end the society’s long-standing opposition to what it has called “physician-assisted suicide” and to adopt a neutral stance. Now, it is calling it “medical aid in dying” and the resolution adopted says that “the act of a physician writing a prescription for a lethal dose of medication to be used by an adult with a terminal illness at such time as the patient sees fit will, if legalized, be recognized as an additional option in the case of the terminally ill.” It says it will train doctors.

The medical society acted after it conducted and reported results of an online survey of a statistical sample of its nearly 25,000 members. A total of 12% responded. Sixty percent of the survey respondents supported “medical aid in dying” . . . the practice of physicians giving terminally-ill adults prescriptions for self-administered lethal medications. The same percentage – 60% — wanted the society to stop opposing physician-assisted dying.

You notice I just said physician-assisted dying, not suicide. Much as in the history of the abortion debate, that one-word shift in terminology is at the center of polarized views. Massachusetts Citizens for Life and the Catholic Church use “suicide.” The Denver-based Compassion & Choices group (formerly the Hemlock Society) and Portland, Oregon-based Death With Dignity National Center -- the two advocacy nonprofits in favor of letting physicians prescribe fatal medication to a willing and competent patient with six months or less to live — both avoid the word suicide.

That’s worth a digression. What do we mean by suicide? That’s simple, you might say. It’s the willful taking of your own life by some overt means. There is no other single English word for that act. “Took her own life,” perhaps. What if you willfully do something very dangerous and it results in your death – driving way too fast as an example? Would your death be deemed a suicide, or an accident? Does intent matter?

If it matters, then we need a new word, or a new understanding of suicide that is without judgment, spiritual or otherwise. Because as our society ages, there will be many people for whom active management of their end of life trajectory could seem appealing. We choose medical procedures, or not, as the man in the joke chooses to reach for the rescuer’s hand, or not.

Did the man in the water commit suicide by not reaching for the rescuer’s hand? He must not have thought so. Interestingly, on Oct. 30, the American Association of Suicidology, whose membership includes mental health and public-health professionals, came out with a policy statement saying that medical aid in dying “is distinct from the behavior that has been traditionally and ordinary described as suicide.”

Colleen Creighton, the suicide-prevention group’s executive director had this to say: “The American Association of Suicidology is dedicated to preventing suicide, but this has no bearing on the reflective, anticipated death a physician may legally help a dying patient facilitate.” She added: “We believe that the term ‘physician-assisted suicide’ constitutes a critical reason why these distinct death categories are so often conflated, and [the term] should be deleted from use . . . in suicide, a life that could have continued indefinitely is cut short. PAD is not a matter of life or death; it is a matter of a foreseeable death occurring a little sooner but in an easier way, in accord with the patient’s wishes and values vs. death later in a potentially more painful and protracted manner. In PAD, the person with a terminal illness does not necessarily want to die; he or she typically wants desperately to live but cannot do so; the disease will take its course.”

Use of the word “suicide” implies an ethical or spiritual judgment of intent by the speaker. I say: “Judge not that ye be not judged.”

The judgment varies around the world. Of 28 developed countries, seven permit some sort of assisted dying and three – Belgium, The Netherlands and Columbia, do not forbid euthanasia – the medical killing of a patient suffering from an incurable and painful disease or in an irreversible coma. The District of Columbia and five states, California, Oregon, Washington, Colorado and Vermont – have enacted laws making doctor-assisted dying by prescription legal. (SEE MAP) Montana did so by court decision. Some 34 other states are considering it. In Massachusetts, governments in Amherst and Northampton last month adopted assisted-dying resolutions. Cambridge and Provincetown did so last year.

Two U.S. Supreme Court actions are relevant here. In 1997, in Vacco vs. Quill, the court ruled 9-0 – with six separate opinions. It upheld a New York state law making doctor-assisted death illegal, distinguishing it from palliative care to alleviate pain that has the ancillary effect of hastening death. The 1997 opinion did not rule on the opposite – a state affirmatively permitting doctor-assisted dying. In the second action, the U.S. Supreme Court this fall declined without comment to review a state appeals court ruling in a Minnesota case which fined Final Exit Network Inc. $30,000 for violating a state statute. The action let stand a lower-court interpretation of the Minnesota law to prohibit the giving of written information to 57-year-old Doreen Dunn that she allegedly used to learn how to take her own life using a helium hood. Final Exit is a nonprofit that for decades has been providing information and support to people who wish to end their own life. By not taking the case, no legal precedent is established. Says Final Exit’s attorney Robert Rivas, who provided a copy of his organization’s Supreme Court appeal: “Until our case in Minnesota, every case on point has held that pure speech cannot sustain a conviction for assisting in a suicide.”

The Mass. Medical Society change in position is similar to what happened in California before that state enacted, and Gov. Jerry Brown signed in 2015, the California End of Life Option Act, making California the fifth state to legalize doctor-assisted death. The California law took effect June 6, 2016, and in its first six months, 258 individuals started the end-of-life option process — 191 were prescribed life-ending drugs and 111 used them. That’s out of 183,265 deaths in California during the same period. That 0.0006 of total deaths – or six-one-hundredths of one percent.

This year, Oregon marked the 20th anniversary of its law taking effect. Over the 20-year period, only about 2,000 Oregonians have requested a prescription. One of them was Brittany Maynard, a 29-year-old California educator who moved to Oregon to take advantage of the law when she was diagnosed with inoperable brain cancer. She was very public about her fatal choice, which drew international attention. Her mother is now on the Death with Dignity board, and her widower husband testified on Beacon Hill in September.

Oregon annually surveys the use of its law and over 20 years it has determined that of four end-of-life issues, pain control was the fourth-most cited reason for choosing medical aid in dying (25.2%). The other concerns were losing autonomy (91.6%), loss of dignity (78.8%), and less ability to engage in activities making life enjoyable (89.7%).

Unless you believe that suicide is an eternal sin, and that hastening your certain death with a pill is in fact suicide, as judged by others, you may have a fatal choice to make. Death and dying are profoundly personal challenges and one needs to appreciate the love and compassion expressed by those with many views, including our families. But we certainly can plan our options for time and manner of death.

It is no longer a taboo subject. In 2014, the state of Massachusetts adopted regulations requiring doctors, nurses, nursing homes other health-care providers to be equipped to provide end-of-life counseling. The Department of Public Health published the seven-page: “Know Your Choices: A Guide for Patients with Serious Advancing Illness.”

Blue Cross & Blue Shield of Massachusetts is a key backer of a nonprofit initiative called the Massachusetts Coalition for Serious Illness Care (, which meets annually. And longtime Boston Globe columnist Ellen Goodman, a Pulitzer Prize-winner, was among founders of The Conversation Project, dedicated to helping people talk about their wishes for end-of-life care. Doctors, hospitals and estate lawyers can help with advanced-care planning concerning the timing of palliative care, hospice care and life-sustaining treatment options. 

For physicians, the fatal choice is not so simple professionally, even assuming that prescribing death-inducing medication is legalized in Massachusetts. The oldest versions of the Hippocratic Oath say, in common translation from Greek, “Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course.” However, the vast majority of U.S. medical schools do not ask their graduates to subscribe to a version with words anything like that. And some ethicists argue even the little-used version is mis-understood. Ethicists note that heavy, constant doses of morphine to reduce severe pain – often prescribed for patients with terminal illnesses -- is justified because the main purpose is to relieve pain, with the deadly effects of morphine an ancillary result.

For physicians personally, the fatal choice appears easier. Surveys and reports find that physicians, faced with intrusive, death-prolonging care with no hope of beating a terminal illness, opt out of such care for themselves. This inclination was summarized in a 2011 essay by a University of Southern California family-medicine professor, Ken Murray, MD, who wrote: “[D]octors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little . . . I cannot count the number of times fellow physicians have told me, in words that vary only slightly, ‘Promise me if you find me like this that you’ll kill me.’ ”

In the Berkshire Eagle op-ed, I spoke of four words – burden, control, religion and choice. I wrote about my father’s 2013 death, and his wish to not become a burden on his family. That’s something that weighs heavily on the elderly.

Concerning control -- the author and research physician Atul Gawande, in his PBS Frontline[1] documentary aired in 2015 — and in his book, "Being Mortal" — talks about the fears we all face as we confront the possibility of our own death. One of the greatest is the fear of losing control – your body or mind gives out and you can no longer do the things in life that give you pleasure. Is it OK to make the fatal choice if you feel you are burdening others and you don’t want to be? Should you decision be intertwined with faith and religion?

The fourth word I talked about in The Eagle was choice.

On Oct. 5, 2015, when Gov. Edmund G. Brown Jr., a former Catholic seminarian, signed the California law, he wrote at the end of his signing statement these words:

In the end, I was left to reflect on what I would want in the face of my own death. I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn't deny that right to others."
More than 15 years ago, I visited a dear elderly friend – the wife of a former co-worker who had been a widow for many years. She was bedridden in a local nursing home. She could no longer live home alone, had been a vigorous, independent walker and couldn’t any longer. I had been encouraged by her daughter to stop in. As we talked, an aide brought her a plate of food and my friend actively waived her off. It was obvious to me that she did not want to eat. She was cheerful and peaceful. I spoke with her daughter, who spoke with the nursing home. A few weeks later, she died. Voluntary stopping eating and drinking – VSED – is one way to go which doesn’t require drugs or anyone’s permission.

While our corporations, our government, our society, make choices in war, health care, aircraft maintenance, the environment . . . without the best consideration of the fatal consequences, at the end of life, let’s all resolve to equip ourselves with the knowledge and support of our loved ones, and our own information resolve, to each make our own . . . fatal choice – with or without divine intervention.

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