The Million Dollar Question
http://www.100md.com
《新英格兰医药杂志》
If you haven't seen Million Dollar Baby and plan to do so, stop reading. There is much to like about the film. As a father of athletic young women, I loved the physicality of the young female fighter's boxing scenes, though I live in dread of the sucker punch that can change everything. As someone who had to decide about withdrawing life support for my brother who was severely injured in a bicycling accident, I could identify with the agony felt by Clint Eastwood's trainer character as he contemplated the unthinkable — helping the now-quadriplegic former boxer to die. As a physician devoted to palliative care, which tries to maximize quality of life sometimes in the face of seemingly intolerable suffering, I have helped many patients like the boxer to find ways to keep going and find meaning in their lives again. But as an advocate for greater patient choice about end-of-life matters, I believe that such patients have a right to choose to die. In my 25 years of practice, I have helped a few patients to end their lives, sometimes secretly and sometimes openly.
So what's not to like? The movie perpetuates many misconceptions that have confounded the debate about how much choice patients and their families should be given toward the end of life. I appreciated the moral agony that Eastwood's character went through and his decision that his obligation lay with his friend who could not act on her own. But the experience didn't have to be so isolating. In all 50 states, competent patients have the legal right to stop life support. All such patients should be carefully evaluated to make sure they are thinking clearly, but we in palliative care are used to having these discussions, and we can consult our psychiatrist colleagues if necessary.
What most patients need is someone with whom to share their dilemma, someone who can empathize with their struggle and maintain a relationship with them while they seek ways to keep going. Many patients who have recently had a high cervical injury want to die — and later are appreciative that their caregivers were not too quick to respond to their wishes, since they subsequently adjusted to their new life. Perhaps the boxer would have found a new way to fight if she had been given a different kind of coaching at this stage. Perhaps the knowledge that she could end her life if she so desired would have made her feel less trapped — and therefore freer to keep going. Of course, a few such patients want to die despite our best efforts, and after careful medical and psychological evaluation, they are allowed to do so, humanely and out in the open, in the presence of family and health care providers — provided that they are receiving life-sustaining therapy that can be stopped.
Which leads to what is probably the most important issue raised by this film: the danger of secrecy. The choice of death was carried out secretly because of ignorance about existing end-of-life options. The harm caused by her unsuccessful attempt to end her own life and the guilt, shame, and isolation that will haunt the trainer could have been avoided — or at least lessened — if knowledgeable physicians and nurses had worked with them as they faced their agonizing question. The absence of health care providers in the film should be as morally disturbing as the actions of Eastwood's character.
Such considerations raise the question of how we handle mentally capable, terminally ill patients who want to die because of unacceptable suffering but who do not have life support to withdraw. In Oregon, where physician-assisted suicide is legal, such cases are handled openly, with mandatory waiting periods, second opinions, and clear documentation. Physician-assisted suicide accounts for only 1 in 1000 deaths, but 1 in 50 terminally ill patients talk to their doctors about it, and 1 in 6 discuss it with their families.1 Eighty-five percent of these patients are simultaneously enrolled in hospice programs.2 In the rest of the country, the process is handled underground, with patients and families acting on their own — sometimes unsuccessfully, other times violently, often in isolation with, at best, covert assistance from a single physician. If patients are "successful," their families are isolated with an unspeakable secret to compound their loss — much like Eastwood's character, who disappeared from his former life.
Which leads to a final question: are legally regulated, open practices for these morally challenging problems safer and more predictable for patients and families than the current secret systems filled with myth and misconception? Million Dollar Baby demonstrates that secrecy around end-of-life questions has an enormous price.
References
Tolle SW, Tilden VR, Drach LL, Fromme EK, Perrin NA, Hedberg K. Characteristics and proportion of dying Oregonians who personally consider physician-assisted suicide. J Clin Ethics 2004;15:111-118.
Oregon Department of Human Services. Physician-assisted suicide. (Accessed April 5, 2005, at http://egov.oregon.gov/DHS/ph/pas/index.shtml.)(Timothy E. Quill, M.D.)
So what's not to like? The movie perpetuates many misconceptions that have confounded the debate about how much choice patients and their families should be given toward the end of life. I appreciated the moral agony that Eastwood's character went through and his decision that his obligation lay with his friend who could not act on her own. But the experience didn't have to be so isolating. In all 50 states, competent patients have the legal right to stop life support. All such patients should be carefully evaluated to make sure they are thinking clearly, but we in palliative care are used to having these discussions, and we can consult our psychiatrist colleagues if necessary.
What most patients need is someone with whom to share their dilemma, someone who can empathize with their struggle and maintain a relationship with them while they seek ways to keep going. Many patients who have recently had a high cervical injury want to die — and later are appreciative that their caregivers were not too quick to respond to their wishes, since they subsequently adjusted to their new life. Perhaps the boxer would have found a new way to fight if she had been given a different kind of coaching at this stage. Perhaps the knowledge that she could end her life if she so desired would have made her feel less trapped — and therefore freer to keep going. Of course, a few such patients want to die despite our best efforts, and after careful medical and psychological evaluation, they are allowed to do so, humanely and out in the open, in the presence of family and health care providers — provided that they are receiving life-sustaining therapy that can be stopped.
Which leads to what is probably the most important issue raised by this film: the danger of secrecy. The choice of death was carried out secretly because of ignorance about existing end-of-life options. The harm caused by her unsuccessful attempt to end her own life and the guilt, shame, and isolation that will haunt the trainer could have been avoided — or at least lessened — if knowledgeable physicians and nurses had worked with them as they faced their agonizing question. The absence of health care providers in the film should be as morally disturbing as the actions of Eastwood's character.
Such considerations raise the question of how we handle mentally capable, terminally ill patients who want to die because of unacceptable suffering but who do not have life support to withdraw. In Oregon, where physician-assisted suicide is legal, such cases are handled openly, with mandatory waiting periods, second opinions, and clear documentation. Physician-assisted suicide accounts for only 1 in 1000 deaths, but 1 in 50 terminally ill patients talk to their doctors about it, and 1 in 6 discuss it with their families.1 Eighty-five percent of these patients are simultaneously enrolled in hospice programs.2 In the rest of the country, the process is handled underground, with patients and families acting on their own — sometimes unsuccessfully, other times violently, often in isolation with, at best, covert assistance from a single physician. If patients are "successful," their families are isolated with an unspeakable secret to compound their loss — much like Eastwood's character, who disappeared from his former life.
Which leads to a final question: are legally regulated, open practices for these morally challenging problems safer and more predictable for patients and families than the current secret systems filled with myth and misconception? Million Dollar Baby demonstrates that secrecy around end-of-life questions has an enormous price.
References
Tolle SW, Tilden VR, Drach LL, Fromme EK, Perrin NA, Hedberg K. Characteristics and proportion of dying Oregonians who personally consider physician-assisted suicide. J Clin Ethics 2004;15:111-118.
Oregon Department of Human Services. Physician-assisted suicide. (Accessed April 5, 2005, at http://egov.oregon.gov/DHS/ph/pas/index.shtml.)(Timothy E. Quill, M.D.)