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Disclaimer

The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Sunday
Sep042016

A Few Words About Mother Teresa. And Burqas.

Mother Teresa was canonized today, September 4. Officially she is now St. Teresa of Calcutta,* but I suspect she will always retain the name she was known by in her lifetime, Mother Teresa. This sometimes happens -- a few Catholic saints are known by their non-saint names, such as Father Damien, Padre Pio, John-Paul II. So I will call her Mother Teresa, or MT, and I don't think anyone will take offense. So much for names.

Mother Teresa is the most acclaimed religious figure of our time. While most Catholics accept her sainthood without question, there are a few people who have voiced doubts. Was she really as great as people say she was?

Perhaps it is fitting that a woman Father James Martin calls “the saint of doubters” inspires doubt in a few people. I sympathize. Like a lot of people, when acclaim reaches near-unanimity, the contrarian in me sees a sheep stampede. Is she as great as she is cracked up to be? Let's look at a few of the criticisms.

One criticism of Teresa was that she collected millions of dollars for her cause, but has very little to show for it. Almost all the money she collected she turned around and gave to the Vatican. When she started her ministry, all she had was a small building in Calcutta that she used to deliver care to the dying. A hospice. By the time she died, she barely had anything more than that.

She ran a hospice, but from what I can gather, it was not a perfect one. Dying patients were taken care of by nuns who had little or no medical training. There were stories of re-used needles, of people suffering from conditions that might have been better managed in a hospital. Some have asked why, given MTs resources and the amount of money she collected, couldn’t she have built a real medical facility and practiced a bit of real medicine? Wouldn't that be a better use of the cash than turning it obediently over to the Pope?

Being a physician, I can’t fully dismiss this criticism. But I don’t see that I need to. MT was not perfect. Saints are not perfect. On the contrary, Church history is littered with stories of saints doing unsavory things. It is probably true that if you took all the marvelous things saints did and wrote them in one book, and all the bad things they did and wrote it in another, the books would be about the same size.

Sainthood does not mean perfection. It never did. God is perfect. The rest of us struggle. What we are supposed to get from the lives of the saints is not that they are perfect, but that the struggled and sinned just as we did. They just did a better job of struggling.

It can be a hard thing to embrace. But we have to remember that most saints lived before the media age. We don’t have pictures of St. Paul, or video of St. Thomas Aquinas giving a homily. Mother Teresa’s life is well-documented, and that makes her imperfections more clear. Although I seldom would presume to speak for MT, in this case I will. She almost certainly would say, “Look at my imperfections! Learn from them!” She would be fine with her imperfections known as long as they helped another person towards God.

In all likelihood, she did not build a Mayo Clinic because she did not think that medical technology was the path to heaven. She was not a doctor, and did not want to be one. What she wanted was to show compassion for the suffering, and that is what she did. India had hospitals, then as now, and it had doctors, then as now. I know many doctors who were trained in India. There is nothing deficient about Indian medicine. They may lack our money, but they do not lack knowledge and sophistication.

MT wanted to provide what she thought medicine did not — compassion. She thought that the goal of living was to get to heaven. She did not think this world was an end of itself. That is to say, she did not think humans should be striving to make earth a heaven. She was a knowledgeable Catholic, and knew the teaching of Original Sin, that humans are all flawed, and that we are all born into a sinful world and will all sin eventually if given the chance. She thought that trying to perfect the world is a task bound for failure. We cannot perfect ourselves.

Given this, MT thought that the goal of life on earth was to spread love and compassion, nothing more. I don’t think she objected to doctors or thought what they were doing was evil, but she did think that love and compassion were more important than curing. Her hospice was set up that way. It delivered love and compassion first, medical care second.

One can argue with this way of running a hospice. As a doctor I would not run a hospice quite that way. But that does not mean what she was doing was wrong. Her hospice was not a prison. People could go to the hospital if they wanted to. But they chose MT because they preferred to die in love than live in indifference. In that sense, MT was holding the world to a harsh standard. What does it mean that a person would rather be loved than cured? This question has never, to my knowledge, been completely addressed in the medical profession. We just plow on with our new technology and techniques, and fail again and again to wonder if we are leaving humanity behind.

Mother Teresa insisted that we never leave humanity behind. Or God. Her insistence stands as the same challenge it did in her lifetime. Build a Mayo Clinic? Sure. But will the gleaming new building be a monument to loving kindness, or to human ambition? MT had her answer. Not in words, but as usual, in her actions.

I will be the first to say that her devotion to low-tech medicine was a fault. But again, saints are not perfect. She provided love for the dying, and that has to overshadow her shortcomings as a medical administrator. Let’s remember that we all have to die someday. No doctor ever saved a man’s life — death can only be postponed. MT would say there is no need to postpone death if you are prepared for it.

This is a very difficult challenge to Western values, especially Western medical ethics. And we are not meeting it on its own terms. We in the West have an idea what heroism is, and it usually involves social change and overcoming barriers or saving fellow soldiers or landing a plane safely in the Hudson river. These may all be examples of heroism, but is this really all it is to be a hero?

Isn’t being a hero loving other people? Isn’t it human concern, basic and quiet, and not necessarily an act that will turn the world on its ear? People can criticize MT or any saint, but MT did not ask to be world famous. A few critics, most notably Christopher Hitchens, considered her a self-serving media star, a charge that is ridiculous. If I wanted to be a global celebrity, there are many ways I might go about it, but none of them involve wandering the slums of India, looking for dying people to take care of.

There is a jealously in accusing her of seeking celebrity, an anger that she got so famous by being so small, which flies in the face of almost everyone else, who seek fame by becoming larger and larger. No wonder such people distrust her -- she short-circuited the entire business of becoming a world leader.

If she had never been world famous, she would have toiled out her entire life in Calcutta, doing what she was famous for anyway. And God might have opened the doors of heaven to her at her death, as He does for many unknowns, and she would have been a saint nonetheless, except we wouldn’t have known it.

If there is a testimony to her greatness, it is this: She probably would have been exactly the same woman, Nobel Prize or not. Fame or not. She was devoted to compassion, your approval and my approval not needed, and whether we approved of her methods or not didn’t matter either. She wanted to please God and save the souls (not the lives) of her patients. She did that, no matter what we think.

Mother Teresa has also been criticized for her wholehearted support of the Catholic Church and the papacy, which is sometimes seen as a male-dominated organization. She was a simple woman who lived in a time when women’s liberation was in full swing. Although she was probably the most revered Catholic of her time, she submitted to the Church in every way. She was never able to say Mass, or even preach a homily. She remained either silent or completely supportive of the Papal position on many women's rights issues of her day, including birth control, divorce, and the role of women in the Church.

Many would argue, what kind of woman leader submits herself completely to a male hierarchy? Didn’t she owe the women in the world more than silence and complicity?

This is not a question I can completely answer. Mother Teresa would have to answer that question herself, but on that subject she was characteristically silent. She was not the kind of person to challenge sacred authority.

This can be discouraging, but it is worth remembering that after her death a series of her letters was published, under the title “Come Be My Light,” in which it was revealed that Teresa profoundly struggled with what theologians sometimes call “spiritual dryness,” or the feeling that God is absent. And while she struggled with this mightily, she remained unwavering in her public commitment to the Church. Some have even argued that this meant she was a fraud, a secret atheist who enjoyed her celebrity and played it for all it was worth.

Poppycock. Mother Theresa was devoted to her work. One must ask — how do you judge someone, by their words or by their actions? Clearly actions tell more about what is in the heart than words. We can all think the right things, and usually do, but acting on our convictions is much more difficult, and much less common. We can be distracted by the day-to-day anxieties in her letters, or we can look at her almost 90 years of devotion to her Church and weigh that more heavily. An easy choice.

The truth about her spiritual struggles is that she believed in God, but for long stretches she didn’t “feel” God’s presence. She said so, quite literally, several times in her letters. She didn't say God didn't exist, she said she did not feel His presence. This is not the same thing. Floating in water, I can say that I don't feel the force of gravity. This cannot be taken to mean I am denying gravity. When MT said she didn't feel God's presence, she meant precisely that. She didn't feel Him there, but that didn't mean she didn't believe He was there. To ignore this distinction is to ignore everything that she ever said, and more importantly, everything she ever did, her life's work. Which one can do. But then one is taking issue with an imaginary Teresa, not the real one.

But back to the letters: The letters tell us something else interesting about Mother Teresa. Her inner spiritual life was very different from her public persona. We tend to forget that about famous people. We tend to forget that about practically everyone. What goes on inside people is not necessarily what we think is going on. So how can we know or judge what Mother thought about the Church? Can we really know that she had no qualms, ever, about the role of women in it? Not really. To say that we do is to be unjust to her. We know she supported the Church wholeheartedly. But that does not mean there was no nuance in her thinking.

Sometimes when I think of MT and her fidelity to the Church I think about Muslim women and the burqa. There are many Muslim women who would not wear a headscarf if given the choice. They are forced by circumstance to do so. But there are many who wear because they want to, it out of reverence to God. As a Westerner I have some problems with that, as many Westerners do, but I need to hold my tongue.

Why is it that when a woman stands up to the limitations of society, when she bucks the system and fights back against sexism, we see her as a hero, but when she decides, completely of her own volition, to conform to a religious or social requirement (by wearing a burqa or staying at home with the kids), we see this as weakness? It isn’t fair. Part of the outcome of social freedom is that some people will choose traditional roles for themselves. This is no more or less an act of feminism than any other, provided the woman does so freely.

This applies to MT as well. She chose to adopt a very traditional role in the Church. That she did so freely is beyond question. She moved thousands of miles from her birthplace in Albania to serve as a nun, leaving her family life and traditions behind. She moved to India and started her religious order all alone, her own choice, and did so despite some resistance from her bishop. There is no question she chose to be what she was. In that sense, she is as much a feminist as anyone ever was. We have to honor her decision, and set aside our expectations of what a feminist is or should be. She chose her life and did so with an informed and free conscience. Our right to say she was not the feminist leader she ought to have been is extremely limited here. She chose her burqa. Which in her case, was a nun's habit.

* The official spelling now Kolkata, which was changed in 2001 by the city to closer approximate the Bengali language. Since Teresa died in 1997 and was known her entire life as Mother Teresa of Calcutta, the Catholic Church has retained the old spelling when attached to Teresa. Seems reasonable to me.

Monday
Aug292016

Katrina: Eleven Years

Katrina.

One thing I learned: what is really important. I lost virtually everything, from every childhood picture I ever had, down to my socks. All my clothes, all my books, every letter I ever received, all my furniture.

Today, in my house, everything in sight I have acquired since August 29, 2005.

And yet I am surprised to find that I lost nothing. I got out with my wife and children, that's what mattered, and the rest of it -- who cares?

Although I have replaced much since that day, my relationship with everything I own is profoundly changed. I see that don't own anything, really -- my possessions amount to a handful, a small pile of junk that makes up my personal empire -- things that have passed into my caretaking for awhile.

And one day, one way or another, they will pass out of my care.

What I have besides that -- myself, those I love, hope, faith, purpose -- those are the things I cannot lose.

So let the winds blow. Let the waters come. All they do is enable me to distinguish what is truly mine, and what will never be mine.

What is truly mine can never be washed away.

Thursday
Aug252016

The Great Louisiana Flood of 2016

Two things emerged last week as South Louisiana dealt with with a deluge of over 20 inches of rain in 72 hours: the scope of the damage was much worse than originally thought, and the American media proved ill-equipped to cover it.

The raw statistics of the terrible downpour is enough to give anyone pause. Forty thousand homes flooded, 20,000 people rescued from their homes by boat or special flood vehicles, 7,000 people in shelters, 70,000 registered for emergency federal insurance, 13 dead.

Some people have the misconception that, as with Hurricane Katrina, the flooding occurred because the victims were living in low lying areas. This is not so. Baton Rouge is 53 feet above sea level. Not mile-high, to be sure, but high enough for flooding to be rare in that part of the state.

The area needs help, and a lot of it, but from all reports the federal response has been adequate. Unlike Katrina, where standing water persisted for weeks, in the Baton Rouge area the floods have receded, which means getting emergency help to those who need it has not been as difficult a task as it was in 2005.

The Red Cross has called it the greatest American disaster since Hurricane Sandy, four years ago. The devastation is serious, and it deserves serious national attention.

But here is the problem: It has not gotten serious national attention. The flood waters started rising on Friday, August 12th and there was little or no media attention until the following Monday. And even then, it was anemic.

The Flood of 2016 had the misfortune of occurring during the Olympics, the Donald Trump campaign, and wildfires in California. It had much to compete with.

This exposes a serious problem in the American media, which at times seems so vast, but in reality is very limited. The media concerns itself mainly with personalities, conflict, and photo-ops, not to natural disasters that don't feature the face of Ryan Lochte or the Donald himself. The media is conditioned like Pavlov's dogs to respond to certain stimuli, but not to others. Since Baton Rouge didn't provide the right kind of story, the necessary sound bites, it was not paid attention to.

When a police officer shot a black man in Baton Rouge a month ago, the media roared into town. When the city was hit with a all-time record rainfall, it couldn't be bothered to get up in the morning.

I wonder how we go forward as a country when our media has to have ice water poured on its head to pay attention to truly important events, instead of ones that merely titillate. It won't be easy. Our current choice of presidential candidates is proof that the media can't focus on the important things. Otherwise we wouldn't have the candidate with the most donor money and the greatest ability to buy attention on one side, and the candidate with the biggest and foulest mouth on the other.

Friday
Aug052016

Winston and Hillary

On a recent vacation trip to London, I had the pleasure of visiting the Churchill War Rooms, a complex of underground offices in central London that Winston Churchill and his cabinet used during World War II to direct the British war effort.

The War Rooms are extraordinary, one of the best historical sites I have ever visited. In 1945, a week after V-J day, the War Rooms were sealed, hardly disturbed again for 40 years, until Margaret Thatcher authorized their opening to the public. After several years of preparation the War Rooms were opened in the late 1990s, and since then have been one of London's great tourist sights. And they are a treasure: Rarely have I seen such a well-preserved historical site, and one that casts such a clear light on an important moment in world history.

One of the many things I learned about Churchill during my visit to the War Rooms is that, besides being a great political leader, he was a terrible security risk. This surprising discovery changed my perspective on Hillary Clinton's current email scandal. Hear me out.

Sir Winston Churchill was an tenacious and brilliant leader who formed the backbone of British resistance to the Nazis throughout World War II, but especially during the Battle of Britain, the period when Britain stood almost alone against the power of the Axis. For a short time after the fall of France, the Nazis planned to cross the English Channel and invade southern England directly; however, the German Navy was mostly composed of U-boats and was limited in troop carrying capacity. Britain, while reeling from defeats in France, still had more surface ships. The Nazis decided not to risk a Channel crossing, and instead focussed on intensive bombing of London and industrial cities in England such as Coventry and Birmingham.

The British called this time the Blitz, and it was during the Blitz that Churchill and his cabinet were driven underground into the War Rooms.

Churchill was a reluctant resident of the War Rooms. He felt that to hide from the Germans was to admit to a kind of defeat. He was dragged kicking and screaming underground, and his reluctance to stay down there made him a major intelligence risk. One that makes Hillary Clinton's email scandal pale in comparison.

Churchill said that living underground in the War Rooms made him feel "cooped up." He refused to concede anything to Hitler, and therefore, even after war operations were transferred underground, he insisted on continuing to work on occasion at his above ground address at 10 Downing Street.

One evening while he was enjoying his tea and cigar at 10 Downing, the sirens went off, signaling an air raid. Stubbornly, Sir Winston refused to go underground, but he did eventually permit his kitchen staff to evacuate. Not long after the evacuation a bomb landed nearby, destroying the kitchen. Although the blast left the Prime Minister unhurt, it almost certainly would have killed his cooks.

At that point, Churchill conceded that even if he had no concern for his own safety, he ought to spend more time underground for the sake of the people who were working for him.

Even still, after that near-death experience, Churchill continued to risk his life (and thus all of British national security) by sleeping aboveground in a facility known as the 10 Downing Street Annex. Although he had a bed in the bomb shelter, he only slept there three times during the entire war. Sir Winston seems to have preferred running water and fresh air, as well as the defiant boldness of facing direct bombing, to the relative safety of life in hiding in the War Rooms.

Perhaps even worse than the risk he was taking for his own person, Churchill was, by being above ground, allowing himself to be seen. The War Rooms location was classified, and if the Nazis had known where it was, they certainly would have attempted to bomb it. Churchill's regular appearances on the surface in the immediate vicinity of the War Rooms could have tipped anyone off who was paying close enough attention. Luckily, in five years, no one seems to have put two and two together.

It gets worse. Churchill had a notoriously loose tongue, often spilling classified information on his numerous phone calls. Since there was no trans-Atlantic cable available at the time, all of the PM's phone calls to the U.S. were by radio, and vulnerable to interception. Churchill's team pleaded with him to be more careful about what he said on the phone, and finally got him to concede to using the name "Mr. Martin" as some semblance of cover when he made his calls.

Unfortunately, the "Mr. Martin" ruse only lasted two weeks. After that, British Intelligence arrested one of Churchill's personal assistants, a man named Mr. Martin, for revealing classified information on phone calls traced to the War Rooms. Embarrassed, Churchill had to explain to Intelligence that Martin was innocent, and that it was the Prime Minister himself who was making the calls in his friend's name, and breaking classified protocol.

Here is the best story of all. The Prime Minister hated not knowing what was going on during air raids, and often left the War Rooms by himself to inspect the damage from attacks. One day during an air raid, the War Rooms started to fill up with smoke. Fearing the building had been hit, security ordered the facility evacuated. But no one could find Sir Winston. As the smoke built up, someone remembered that the PM had a habit of going up to the roof to watch the bombing, and so an officer was sent up there to check. Churchill was found, as expected, on the roof of the building, during an air raid, cigar in hand. And sitting on one of the chimneys.

As it turned out, there was no fire at all. The smoke in the War Rooms was caused by the Prime Minister's bum, which blocked its escape through the vents.

All of these behaviors represented an uncomfortable disregard for safety and security. In today's America, it would have been grounds for impeachment, to listen to critics of Hillary Clinton. If you think using emails on an unsecured server for State Department business is reckless, imagine the entire classified staff of a war department standing on a London sidewalk because the boss needed a place to sit while he watched a bombing.

If Churchill were alive today, I think he would say this about his recklessness: He was in no way trying to damage the war effort. No one wanted to win the war more than Winston Churchill. But winning the war was such an all-consuming effort that the PM did not have the energy left over to worry about protocol. Sometimes, when you are obsessed with something, you forget about everything else, including your personal safety and the safety of those around you.

Winston Churchill was one of the greatest leaders of the twentieth century. No one would argue that Hillary Clinton measures up to the great British Prime Minister. That isn't the point.

The point is that if a man as great as Churchill can make mistakes like this, anyone can. This isn't to forgive what Clinton did, or what Churchill did, but only to point out that even titans make mistakes. In fact, titans tend to make titanic mistakes. Churchill certainly did. If you want to know what a titanic mistake by a titanic leader looks like, Google "Gallipoli," and learn how Churchill was significantly responsible for 140,000 Allied casualties during one of the most disastrous failures in Britain's incredibly long military history.

The point is that people make mistakes. Even big ones. Sometimes very big ones. What counts in a mistake is two things. The ability to learn from error, and the ability to bounce back from it. Churchill had both.

As for Clinton, she has admitted her mistake with the email scandal. While I wish she would be more forthcoming and direct about the error instead of talking out both sides of her mouth, she did nevertheless admit to wrongdoing. While she did make a mistake, her error was almost certainly the same error Churchill committed 60 years earlier. She was so concerned with the complexities of her job that she ignored security protocol.

There is no reason to think that Clinton was intentionally giving anything away to our enemies. That is conspiracy thinking, and conspiracy thinking rarely has any relation to fact. The Secretary was, like Churchill, completely absorbed in the complexities of her job, and wasn't paying attention. Although this is not a good thing, it is also not something that should disqualify her from being president.

Imagine if the leaders of Great Britain had thought Winston Churchill's actions disqualified him from being the Prime Minister of Britain? Where would Britain be today?

Saturday
Jun252016

California's Right-to-Die Law

If I tried to write everything I could about California’s new right-to-die law, and, by extension, about euthanasia, I would have to write a book. But I will strain to be brief.

There seems to be a movement, at least among liberal states, to legalize physician-assisted suicide. Five states — Washington, Oregon, Montana, Vermont, and now most recently California -- have some type of legal provision that allows doctors to write prescriptions for lethal doses of medication, for the purpose of facilitating the suicide of patients.

And I understand the reasoning behind these laws. The miracles of modern medicine, while remarkable indeed, sometimes enable people to live long beyond their time. Patients can be brought back from the brink of death again and again, up to the point where extreme pain and suffering make death a considered alternative to fighting on.

No one wants to live on indefinitely in misery. No one wants to suffer. Modern people, who enjoy so many comforts courtesy of technology, are unused to hardship and seem to fear physical pain especially. We are used to anxiety, depression, stress, divorce, loneliness — but are terrified of the dentist.

I can understand the fear of dying of a dread disease (usually cancer), the fear of having no way out and nothing but a long path of pain — physical pain — to look forward to until the end. This very thought often leads people to also desire the power to end it.

But one thing is never discussed when the right-to-die comes up: Right-to-die laws have little to do with the right to die. From a practical standpoint, everyone already has the right to die. In most states, suicide is technically illegal. But has anyone ever been prosecuted for it? If someone attempts suicide and succeeds, that person is beyond the reach of the law; if he attempts suicide and fails, he goes into psychiatric treatment. No one is ever prosecuted for attempting suicide. So strictly speaking, the "right to die" is not the issue here. People who want to kill themselves can do so if they choose.

Right to die laws are really about authorizing certain people to help others commit suicide. And who is permitted — even mandated — to help? Doctors. That’s the long and short of it — the right to die isn’t about the right of suicide, it is about making it legal for doctors to kill their patients.

Oh sure, the laws pussyfoot around. They are larded with regulations, such as that the patient has to be terminally ill, and that the doctor is supposed to provide the means of suicide, but not to actually administer it. And that, I guess, is supposed to absolve the doctor. As a physician, I am expected to explain to the patient that he is terminal, that he will die a horrible death, that I am going to write him a prescription that could allow him to end it, and then turn him loose, to do whatever his conscience allows.

That isn’t absolution, legal or otherwise. And I don’t see why a physician should be forced to do it.

Forced, you say? No way -- no one is forcing anyone to do anything. The doctor can refer the patient to another doctor. Right? But while that is technically true, the reality complicated. The very existence of physician-assisted suicide has the potential to sabotage the doctor-patient relationship. As a doctor, I may take care of a patient for years, but then, when the patient is diagnosed with a terminal illness, because of my objections to euthanasia I am forced into a very difficult situation when the final days begin. And the patient slips in to a difficult situation as well.

I have to tell my patient I am personally opposed to euthanasia and must require that they agree never to ask me to do such a thing, and if they wish to pursue this option they must seek another doctor. What this means in practice is that the majority of doctors who have objections to euthanasia will refer all of their terminal patients to the few doctors who will assist with suicide. In other words, the medical community will divide itself the same way it has over abortion, with a large majority who won’t do it and a rare few who will, thus leaving all abortions to a handful of full-time abortion doctors.

But the circumstances with the terminally ill are not the same as they are with abortion. In the case of abortion, most doctors can avoid the problem by choosing not to take care of pregnant patients on a regular basis. They simply go into internal medicine, or cardiology, or dermatology, and avoid the problem altogether.

This cannot be the case with the right to die. Since the dying process is a natural endpoint in almost every area of medicine, there are very few doctors who can avoid caring for the terminally ill. A small number — the pediatrician, the dermatologist, the psychiatrist — can largely evade dying patients because of their patient population, but none have the ability to run a death-free practice. Eventually every doctor will be faced with counseling a dying patient. And it is wrong that a doctor who has treated a patient for years should be forced to send a dying patient away simply because he has moral reservations about assisted suicide.

If you are one of those people who wants suicide as an option when facing a terminal illness, fine. But understand that if you want to die in the face of terminal illness, that decision should be yours. It is not fair to ask another person, let alone a medical professional, for a seal of approval.

Because that is what assisted suicide is. To qualify for the right to die in California, you have to have the opinion of two physicians that you are in a terminal condition and have less than 6 months to live, and that you are mentally competent. These are all medical decisions. Thus, the ball sits in the court of the doctor. Not a lawyer, not a judge, not a counselor, not a clergyman. Lawyers and politicians carefully wrote themselves out of this law because they are smart, and don’t want people coming to them from the street asking for permission to kill themselves. So they dumped the responsibility on doctors.

As a doctor, I don’t have the ability to make decisions like this either. I never, ever tell my patients they have 6 months to live. I don’t own a crystal ball. I have seen patients I thought had six months last 2 years. I have seen patients I thought had 6 hours last a month. Any doctor will tell you -- there is no magic book in our libraries that we can consult to look up the patient’s diagnosis and physical findings and get a lifespan estimate. Everything is a guess, and any doctor who says differently is not telling the truth.

The matter of patient competence is even more difficult. If a patient comes to me who has a terminal illness, this is a person who is likely to be depressed and very anxious. Is such a person fully competent? Would you, under most circumstances, think a person who is depressed is in a place to decide if he or she wants to die or not?

Standard medical practice says otherwise. Psychiatrists are authorized to lock up a suicidal patient against his will precisely because the medical community does not believe a severely depressed person is mentally competent.

And there is more. People with terminal diseases are profoundly ill. They may be taking chemotherapy, they may have cancer metastases in the brain. They may be on painkilling drugs. Again, how do you judge competence in such cases? While I would agree that many of them are competent, not all of them are, and as a doctor I certainly would not be comfortable standing as judge in such difficult circumstances.

In my medical career, I have never had a patient or a patient’s family approach me and ask to euthanize a patient. And as a physician who specializes in hospital medicine, I have seen many, many terminal patients. Perhaps this is a function of the community I live in. Mississippi culture is different from the culture of California and Oregon in many ways.

But also, I think it is a function of life. The number of people who are actively dying and want to be euthanized is vanishingly small. In a state like Oregon, who has legalized assisted suicide for quite some time, the practice is rare. I am sure that most Oregon doctors, like me, more often have the opposite problem. The most common problem I run into with dying patients is not that they want to die, but that they continue to struggle against death when death is inevitable. I see patients suffer mightily from this. I see family members who think their 80 pound grandmother will one day walk again, or that a patient whose brain is riddled with metastatic cancer will be cured if he just gets one more chemo treatment.

We are all born to die. It is the great human equalizer. There is nothing any of us, including us doctors, can do about it. Many patients cannot accept this, and I watch with sadness as they struggle against an invincible opponent. Instead of making the best of the time they have left, they spend their time extending their suffering to no good end.

Death simply is. You don’t get out of it by fighting until the end. And you don’t get out of it by committing suicide before your time. While some people think those who seek physician assisted suicide are bravely facing death, I do not. I think people who want their doctors to help them die are mostly looking to the doctor, one of the few authority figures modern society has not discredited, to agree with them that they are justified in seeking suicide.

As a doctor, I am not willing to extend my seal of approval to anyone’s suicide. If a patient wants to die, he can do so without my help. And it is not right that state governments, frightened to accept responsibility for the right to die themselves, are now writing laws to absolve themselves of responsibility in the matter, and turn it over to the people whose jobs are to heal, relieve suffering, and comfort in the hour of death.

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