AmyTuteurMD

AmyTuteurMD
Bio
Dr. Amy Tuteur is an obstetrician-gynecologist. She received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine. Dr. Tuteur is a former clinical instructor at Harvard Medical School.

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SEPTEMBER 24, 2009 7:04AM

Suicide: a love story

Rate: 9 Flag

elderly holding hands

There are not many heartwarming stories about death, and even fewer about suicide. That small number is destined to grow with the addition of the true story of Sir Edward and Lady Downes, and elderly couple who chose to end their lives together as she faced imminent death from terminal cancer.

From The New York Times:

...[O]ne of Britain's most distinguished orchestra conductors, Sir Edward Downes, [flew] to Switzerland last week with his wife and joined her in drinking a lethal cocktail of barbiturates provided by an assisted-suicide clinic.

Although friends who spoke to the British news media said Sir Edward was not known to have been terminally ill, they said he wanted to die with his ailing wife, who had been his partner for more than half a century.
According to their children:
Sir Edward, who was described in a statement issued earlier on Tuesday by [their son and daughter] as "almost blind and increasingly deaf," was principal conductor of the BBC Philharmonic Orchestra ... [and] a conductor of the Royal Opera House at Covent Garden in London, where he led 950 performances over more than 50 years.

Lady Downes, who British newspapers said was in the final stages of terminal cancer, was a former ballet dancer, choreographer and television producer who devoted her later years to working as her husband's assistant.

"After 54 happy years together, they decided to end their own lives rather than continue to struggle with serious health problems," the Downes children said in their statement.
What could be more natural or more romantic? An elderly couple who had an unusually long and happy life together faced only debility, decline and life apart. They viewed this prospect as insupportable and chose to take control of their destiny by ending their lives now instead of suffering longer. Their deaths were quiet and peaceful, just as they had planned
...[T]he children said, they watched, weeping, as their parents drank "a small quantity of clear liquid" before lying down on adjacent beds, holding hands.

"Within a couple of minutes they were asleep, and died within 10 minutes," ... the couple’s 41-year-old son, said in the interview after his return to Britain. "They wanted to be next to each other when they died..."
Of course Britain, like the United States, does not permit an elderly couple to control the timing and method of their own deaths, even when those deaths are inevitable. Sir Edward and Lady Downes were forced to leave their home and travel to Switzerland, where the organization Dignitas helped arrange the suicides.

Predictably, the news of the deaths ignited controversy back home. The British Medical Association, in their wisdom, voted recently to deny the terminally ill the option of assisted suicide.

Not surprisingly, though, in a society that forces the terminally ill to live even if they are suffering, it is Sir Edward's death that has sparked the most outrage. He may have been 85 years old, almost blind and losing his hearing, he was not terminally ill. He had lived a long time, longer than most men, and was satisfied with his length of life, but the British, like Americans, believe that death is far too serious a matter to be controlled by the person who is dying.

That's the source of the outrage. It is certainly not about the deaths of this elderly couple for natural deaths at the very same moment would have provoked no concern. The outrage is directed at the temerity of Sir Edward and Lady Downes in arranging the time, place and manner of their deaths instead of taking their chances with cruel fate.

The concern is not for them, of course, but for us. As Rod Dreher writes on Beliefnet:
We shall very soon proceed from the "right" to die to the "duty" to die, when one is seen, or made to see oneself, as a burden on the living.
In other words, Sir Edward and Lady Downes' continued suffering is a regrettable necessity to protect the rest of us. If they are allowed to die, the inevitable next step would be to force others to die. It's the classic slippery slope argument. But as students of logic know, the slippery slope argument is an intellectual fallacy. The slippery slope is a fallacy because it denies the possibility that a middle ground can and does exist.

It does not follow logically that allowing people to control their own deaths will lead to forcing people to die. It is possible, but those who wield the slippery slope argument are obligated to prove a connection, and thus far, no one has done so.

Moreover, the slippery slope argument in this setting is incredibly cynical and selfish in the extreme. The underlying supposition is that any amount of suffering of any number of other people is allowed in order to prevent the chance that one of us may suffer inadvertently in the future. In other words, for Dreher, the Downes' suffering is the price they have to pay to protect Dreher from a theoretical future where he might be forced to die.

But his fear of theoretical future suffering is not a justification for the very real and ongoing suffering of terminally ill and elderly people who are ready to die but are forced to live. I applaud Sir Edward and Lady Downes for having the strength of character and purpose to make their own most intimate decisions and carry them through. And I have deep respect and admiration for the intense love that makes surviving alone an unbearable prospect. myspace profile counters

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So what are you suggesting that the leading medical ethicists in Britain and North American go back to school to learn critical thinking?

The Slippery Slope is not a "logical fallacy", it's a legitimate ethical situation when a law which is introduced cannot be repealed.

You've told a heart breaking story, but at the same time medical ethicists have to consider the reality of arrogant doctors and GPs who will not acknowledge the possibility of a wrong prognosis and feel a moral authority to encourage people to terminate their lives.

You've done it yourself in a previous post on Alzheimer's in which you argued that it is selfish for the children of Alzheimer's victims to drain social resources by demanding treatment for their parents. No?
"No?"

No.

The issue is choice. If elderly people wish to plan how and when they die, who has the right to stop them.
Of course they have the right to stop them. I don't foresee a law that punishes for preventing someone's death.

What we're discussing here I thought, is if we have the right to assist them.

So have reversed your position then that children of Alzheimer's victims have a duty to withdraw treatment?
"So have reversed your position then that children of Alzheimer's victims have a duty to withdraw treatment?"

No, the only reason to continue treatment is if the person him or herself has expressly requested in an advanced directive.
CONTINUE TREATMENT?! So what you're suggesting, if I understand correctly is that unless an Alzheimer's patient has specifically asked in a directive to CONTINUE TREATMENT, we should terminate.

Because I believe the practice in our society is to discontinue treatment only if there's been an advance directive requesting withdrawal, or there's obvious irreversible brain death.

So unless that was a typo, it tells me nothing about your position.
"if I understand correctly is that unless an Alzheimer's patient has specifically asked in a directive to CONTINUE TREATMENT, we should terminate."

Yes, of course. Alzheimer's is uniformly fatal and no one ever gets better. Once someone no longer knows who is he, what is the point of continued treatment?
"uniformly fatal"

But how and when they die is far from uniform. The medical community is far from hopeless when it comes to treatment for Alzheimer's.

So I think you're oversimplifying this situation.

Once we introduce the legal right to assist people in their deaths, it's a right that cannot be taken back if we don't like how that right is being exploited by the medical community.

If we lived in a society where people trusted the medical and legal community and it was universally believed that health care decisions were really made in the interests of the patient and not according to a debatable belief in scarce resources, then maybe it would be a right we could risk.

But we're far from there, so I think the medical ethicists are a lot brighter and more compassionate that you seem to think.
As romantic as this might sound to some, and as much as I understand the difficulties facing those who are elderly and/or terminally ill, I have difficulty justifying this, or embracing it in the terms described above. I don't condone the taking of a human life, not even one's own, and romanticizing it does it no favors. Death is horrible, regardless. It's messy emotionally for everyone, whether it's quick or it's long. It leaves a lot of victims in its wake. I don't share the enthusiasm for ending one's own life by choice, with or without a partner.
Once so called "right to die" laws are on the books you can bet that they will go in to practice. Next step will be an obligation to die (save resources) next the necessity to terminate because of no resources, no family, no funds, no use to sociaty, and an ongoing list of NOs. Bureaucrats with their usual "humanity" will slowly take over the decision making function and using a check off list they will score an individual. If you don't reach the "live" score you die. If you don't think it will happen this way over the years you have no understanding of how government governs. Also within the next 25 years all these old baby-boomers will be overwhelming the countries medical and elder care facilities. They just can't be allowed to die "naturally" or we will have vast warehouses loaded with hangers on who are beyond use to anyone. I like the Soylent Green method. Voluntary termination. Welcome to Tomorrow Land. Not quite the Disneyland we expected
This is a wonderful, thought provoking article. It is hard to argue with what you have said. Here in the US, where personal autonomy is such a strong value, it seems natural that people should be able to make their own decisions about womething as personal as their own deaths. It is frightening, however, to think about how much this right could be abused or be used as a way to manipulate others. these days, governments don't seem to care much about he welfare of the individual. Our elected officials don't seem to care much about the individual and don't seem to be able to effectively manage feeding and clothing them or providing medical treatment for them. Therefore it feels scary to allow them to grant people the freedoms you write about. I guess I mean that I am not sure I trust them to handle it in such a way that it will be fair, just and really benefit people.
I accept the right to die, the same as I accept a woman's right to choose. It is a choice.

I also believe that the slippery slope is a fallacy, an argument created by people who somehow seek to control people other than themselves.

I am all about choice and this story is really about that. These two people chose to die together and/or he did not want to live without her and she could not tolerate the pain any longer.

Who are any of you to claim a right to make people continue to live in paid or to make people live when they clearly have no further interest in living?
Kathy Riordan:

"I don't share the enthusiasm for ending one's own life by choice, with or without a partner."

That's fine. It is not something that you would choose. Why should you keep other people from choosing it, though?
BudGor:

"Once so called "right to die" laws are on the books you can bet that they will go in to practice. Next step will be an obligation to die"

Where's the evidence for that claim?
"It is frightening, however, to think about how much this right could be abused or be used as a way to manipulate others."

That's why it would need to be regulated by laws. The key point, though, is that elderly people are suffering right now because they are not allowed to end their lives when they see fit.
Oh Amy, you are so right! I think those two dead people should totally be prosecuted! I say dig their dead, cold corpses up and drag their bodies into court! Jail time is too good for them!

snerk. I tried to resist. I swear I did.
John Steiner:

"Who are any of you to claim a right to make people continue to live in pain or to make people live when they clearly have no further interest in living?"

Exactly!
Dear Mr. Choice: Anyone at anytime can end it. When the institutionalization and use of "helpers" will becomes the norm, then the government will intrude and your precious choice chant will become "must", "have to" or "mandated" then you can lament the slippery slope at your leisure.
"just like Romeo & Juliet"
This is a good, thought provoking article and I am rating it. You have received mostly negative ire but I think the whole thing merits a little more consideration. I especially like your thoughts on the "slippery slope" principle, which is applied as ultimate truth to discussions of almost any behavior. Many (but not all) societies, past and present, have sanctions against suicide so to reconsider is to swim against the current. I find it interesting that people cry out for the death penalty for our most heinous criminals and yet their incarceration involves making damn sure they don't kill themselves.
Hi GorBud,

Can you provide any factual information to substantiate your position? As "Mr. Choice" I am not trying to change your choice, but in order to evaluate you positions (and others the same ability) I would need a bit of evidence to evaluate your claim.
Typo...it should be "your" and not "you".
the government will intrude and your precious choice chant will become "must", "have to" or "mandated" then you can lament the slippery slope at your leisure.

Yes, I mean look at what happened with abortion! Once upon a time it was a choice, and now every American woman is required to abort her first 3 pregnancies, whether or not she wants them!

Oh wait, that NEVER HAPPENED.
noah tall:

"I find it interesting that people cry out for the death penalty for our most heinous criminals and yet their incarceration involves making damn sure they don't kill themselves."

Perverse, isn't it?

As regards suicide, I think it is reasonable to do everything possible to keep people from ending their lives because of treatable depression. That's very different, though, from elderly couples wishing to die together.
Well, what?

"Yes, I mean look at what happened with abortion! Once upon a time it was a choice, and now every American woman is required to abort her first 3 pregnancies, whether or not she wants them!

Oh wait, that NEVER HAPPENED."

Excellent!
Amy...you hit this nail dead-smack-dab on its head.

I may think you wrong as hell on lots of other things...but on this one, we are shoulder to shoulder.

Good post.
:-) Thanks. The "inevitable slippery slope" thing just galls me. Most people can't even come up with *one* good example, let alone enough to declare it a universal phenomenon.

Glad you've taken the side you have on this--the topic needs good contrarian defenders who're willing to talk about unpleasant truths, and force logic into the swirl of emotions, and you fit that bill.
I mostly agree with the post's argument, and the couple's story is touching. I wonder, though, what the call would be when a say 40 year old wanted to die alongside their terminally ill spouse?
I too find it ironic that the people who are claim to be desperate to protect against government intrusion into our lives, are also opposed to a woman's right to govern her own body or someone's right to die with dignity.
Man I hate it when I've written something grammatically offense and I can't delete it. Have mercy on me and delete my last comment Amy MD!
We are more humane to our pets than we are to our grandparent or other sick loved ones. Until you watch someone close to you die a horriblely painful death you will not understand this issue. A very close friend of mine battled cervical cancer. But she was losing the battle and weighted just 80 pounds and was in horrible continuous pain. She told me she was ready to die and asked for help to die. She understood what whe was asking us to do but we could not help her. They could not increase the pain medication any more because, believe it or not, it might kill her! She lived another 3 horrific weeks.
Artist at Heart:

"We are more humane to our pets than we are to our grandparent or other sick loved ones."

How true. We understand mercy, yet we don't show it to people who are dying.
For a very long time now I have thought that in the not too distant future, the #1 cause of death will be suicide. I had not heard of assisted suicide clinics in Europe but am not the least bit surprised and imagine this trend will spread. It makes perfect sense to me. I have the deepest respect for life and also for the right to choose one's end to life. We can choose whether or not to bring a viable fetus into the world, we can choose to pull the plug/DNR, we can choose whether or not to take our doctor's advice or to have life saving surgery or not, so why not be able to choose how long we live and how to end it? It surprises me to hear myself express this out loud. I have always kept this inside. I understand this couple more than I care to. And it is the perfect ending to a long time love story.
I live in Oregon where we've had the Death With Dignity Act for about ten years. There is no slippery slope. If someone is diagnosed with a terminal illness, has less than six months to live, and that diagnosis is confirmed by a second physician, they may request a lethal dose of medication from their physician, get it legally filled at a pharmacy, and die in their own home at the time of their choosing.

Honestly, it's No Big Deal. The stats are available online here:

http://www.oregon.gov/DHS/ph/pas/index.shtml

In the ten years since the law was enacted, we've had a maximum of 60 deaths in a year. We've had ten years to see the famed slippery slope... it's just not there. No one is pressured to do this. Very few people actually choose it (60 per year with a state population of 3.7 million). But the option is there, and honestly I find it comforting. Should I ever need it, it's there.

I still maintain that we are kinder to our pets at the end of life than we are to our fellow humans.

I still maintain that we
Mostly I agree.

However, it can be argued that a person who is physically healthy and who would like to die is not mentally healthy, otherwise they would not want to die. And so, because of their mental instability, they are not competent to make that sort of medical decision.
Doctors helping people die in this country goes on every day.

My mother had bladder cancer. When her "end time" came the doctor, as directed my her in advance, snowed her. Yes her death certificate said bladder cancer but the real reason...............

Dr. Amy, how many people are snowed in hospitals in a year? Hopefully, if needed, I will be one of them.
Catnlion:

"Dr. Amy, how many people are snowed in hospitals in a year?"

Not nearly as many as request it. Doctors and nurses have to very careful about the amount of medication they order in case a family member decides to sue them.
We seem to be more progessive here,in Australia.
Last week,the Supreme Court,ruled that a terminally ill patient in a
nursing home,had the right to refuse nourishment,and medical aid.
On another level, this issue is about the transfer of wealth.

Old people used to die and leave money to their kids, but now doctors, hospitals and long-term care facilities, prolong their lives long enough to take that money for themselves, leaving the kids nothing.

Call me crazy, but I would actually like to pass a little wealth on to my kids, but I see a medical conspiracy (cloaked in "morality") that wants to prevent me from doing that.
Also, if medical technology continues to advance to the point where people can be kept alive indefinitely in a near-vegetative state, does that mean that we will NEVER be allowed to die?

For heaven's sake, let's bring some common sense to this whole issue. If our beloved cat or dog is suffering and we know that their health and quality of life are only going to go downhill, we don't FORCE them to endure a long, painful decline. We MERCIFULLY end their lives. Why must humans be made to suffer to the last painful twitch?

And from a biological perspective, animals are SUPPOSED to die when they are no longer productive, and they have passed on their genes. How many old people on life support can we afford? 10% of the population? 20%, 50%, 80%? At some point there will be too many people on oxygen tanks and not enough actually WORKING.

For some people death is REALLY scary (ironically, a lot of those evangelical sorts fall into this category) and they project their fears onto this issue. But alas, death is INEVITABLE. But prolonged suffering doesn't have to be.
In nursing school I was taught to give the ordered pain medication to a dying patient, regardless of potential consequences. If the patient has respirations of 8, is terminal, is in pain and requests pain medication, you give it if it is ordered. Of course how that translates to practice, I've never been in that situation.
I disagree with assisted suicide and this story is utterly heartbreaking and sickening.
We are ALL terminal. If we accept that a 12 year old, an 18 year old, a 36 year old who attempts suicide may be hospitalized against their will for psychiatric evaluation and treatment, then the same should be applied for those who are elderly and/or suffer from a fatal illness.
The alternative to assisted suicide is hospice and palliative care. We have the means to provide comfort and relief from pain and we should do that while letting death happen at its natural pace.
...letting death happen at its natural pace!?

It seems to me that that's exactly what DOESN'T happen in medical facilities these days. Patients are given oxygen, procedures, and medication that prolong their lives.

My aunt, long after being diagnosed with terminal cancer - and when she had less than a month to live, was given a FLU SHOT of all things. She died a few weeks later without having contracted the flu, but the hospital WAS able to extract a few extra bucks out of her insurance company I guess.

Her husband's health declined shortly after he had lost his partner of 60 years! He sold their home and after a short stint in a retirement-type setup, spent his last couple of years in a hospital room, in a wheel chair, attached to an oxygen tank, with few visitors and almost zero personal possessions around him, until he died due to .... well, being 90 years old!

I remember once when we took our kids to visit him, a really old and confused lady in a wheel chair thought we were HER relatives. She obviously didn't know who we were or even who SHE was.

Is THAT any way to spend your last years? Seeing those folks it drives home the point to me that we're warehousing those people for two reasons; first, so that we can avoid maintain a sense of morality, without having to watch the suffering firsthand and second, (as I mentioned before) so that corporations can shake all of the change out of their pockets before they die.

It's to our shame that we don't allow a dignified way out for these folks, should they choose it.
Amy, laws in general exist to try to benefit society as a whole. They might be flawed, and in some cases, over time, have to be modified. The difficulty with prosecuting suicide is that it leaves the scene of the crime with no living criminal, except in the cases of assisted suicide. It carries its own penalty. Anyone is essentially free to leave this world of their own choosing, and many do. Many, in the face of terminal illness, old age or debilitation, choose to carry on. I watched my own father wrestle with this at the age of 48, in a fast course of malignant melanoma. It would have been the easy way out to overdose on his own pills, and leave behind a young widow and six children. I wouldn't have blamed him if he had. I don't believe people should assist others in committing suicide, however, and I don't believe the law should permit it, for reasons that are entirely my own.
Bummer. I thought it would be about Tom Cruise and Katie Holmes.
My father had lung cancer and was dying. I sat at his bedside for the longest 6 hours of my life while he gasped his life away in horrible pain. I begged the nurse to give him more pain meds to ease his passing and was told that they couldn't because it might kill him, He was dying, he was in the process of dying and did die, 6 hours later and they were worried about killing him. Up here in Washington State we passed a right to die law last year, (just like the one in Oregon) I voted for it and I for one am glad that if I get a terminal disease like my father's it will be my choice and mine alone. Not some stranger's who has a problem with it or thinks that I should go natural. There is nothing natural about dying of cancer, I can assure you of that.

Good post.
"Yes, of course. Alzheimer's is uniformly fatal and no one ever gets better. Once someone no longer knows who is he, what is the point of continued treatment?"

If someone doesn't remember who they are does that mean that they are incapable of enjoying a piece of music, or a random, fleeting thought, or a warm breeze?

When you say stopping treatment, are we talking life-support or any kind of treatment, such as blood pressure medicine or breakfast?
fins2theleft:

"Call me crazy, but I would actually like to pass a little wealth on to my kids, but I see a medical conspiracy (cloaked in "morality") that wants to prevent me from doing that."

The problem with that argument is that the bulk of the cost is borne by the taxpayers, through Medicare, not by the individuals and their families.
JenniferC:

"letting death happen at its natural pace."

Why?
RicTresa:

"He was dying, he was in the process of dying and did die, 6 hours later and they were worried about killing him."

The sad fact is that there is an appalling amount of suffering going on for bizarre reasons like fear of hastening a dying patient's impending death. That should not be happening.
"If someone doesn't remember who they are does that mean that they are incapable of enjoying a piece of music, or a random, fleeting thought, or a warm breeze?"

Yes, of course.

The issue is not what you think people might be "enjoying," it's what those individuals want for themselves. The vast majority of people do not want to be kept alive after they no longer know who they are.
I understand that concept, but what kind of treatment are we ending... in theory? Life support? Food? Should we just smother someone once they no longer know who they are? This is a serious question that may not sound like that. I'd like to understand your definition of a patient who should have treatment ended. Thanks.

ps

On my earlier question did you mean "of course" they can enjoy things or "of course" they can't?
I'd like to have a personal visit with anyone who advocates withdrawing supportive measures in a hospital setting from someone whose situation appears dire, and tell them a real love story, a story of sitting in a hospital for several months, three of them in ICU, next to a husband hooked up to a respirator, who couldn't even be tube fed the first three months, missing half his internal organs, tubes running everywhere, five big bleeds, multiple infections, pneumonia, and an open wound. I'd like to show them that man today, who is alive and well because someone chose not to terminate supportive measures. I'd like to tell them the story of the patient down the hall with amazingly similar circumstances, whose family stopped going in the room, and who finally chose to end their father's/husband's life by terminating treatment.
Kathy Riordan:

"next to a husband hooked up to a respirator, who couldn't even be tube fed the first three months, missing half his internal organs, tubes running everywhere, five big bleeds, multiple infections, pneumonia, and an open wound."

I'm not sure what this has to with my post. Was the man terminally ill? Was he elderly? Was he asking to die? Had he made an advanced directive that rejected the care he was receiving?
I'm sorry but if someone wants to ends their live, that is THEIR business. It is their life, not yours, to decide. If my husband was 85, losing his sight and hearing, and I was dying of terminal disease, and he wanted to die with me, then ok. That is HIS decision, not mine or anyone else's. If he were the one dying and I were that old, what more do I have to live for? LIFE is a terminal disease, contracted at birth. We are ALL going to die at some point. I for one would like to have a say as to when.
Amy, it has everything to do with your post. "The man" (my husband) went into the hospital perfectly healthy. A series of post-surgical complications lead to him becoming the most critically ill patient on the surgical ICU, for three months, and fighting for his life for several more. He arrested on day two. He was a full resuscitate. He received very aggressive medicine in order to return him to his life, but return him to his life we did. Not fighting for that life would have been morally suspect. My point is that even some who are trained in medicine, yourself included, can fall into the habit of saying it's too difficult, too cost prohibitive, can't be done.

"The man" didn't know who he was for months, but is now fully rehabilitated. You seem to suggest that people in those situations should have treatment withheld. I can find several physicians at Mayo Clinic involved in my husband's care who would disagree with you.

Too often family members, unaware or uninformed, are influenced by physicians and other health care workers that their family member's situation is hopeless. While that can be true in some situations (brain death being a notable one), there are many cases where patients are very much able to be treated, saved and rehabilitated, but families are convinced to withhold treatment.
ghanyma:

"LIFE is a terminal disease, contracted at birth. We are ALL going to die at some point. I for one would like to have a say as to when."

Amen!
Kathy,

You are talking about a situation that has absolutely nothing to do with the discussion at hand. I was writing about people who are near the end of their natural life and wish to end it.

You are talking about someone nowhere near the end of life who has not expressed any intention to end his life. See the difference?

I am talking about people who wish to control when their life ends. you are talking about someone who didn't want to die.
You clearly know more about it than I do. How close do you imagine my husband was to the end of his natural life during his prolonged hospitalization?

Amy, I followed the discussion on this thread very closely. It's entirely relevant; I wouldn't have mentioned it otherwise.
We are more humane to our pets than we are to our grandparents