The Third Act

November 30, 2001

Someone once said that life was the ability to be irritated. According to Dorothy Parker life was "[A] glorious cycle of song, a medley of extemporanea..." at least when her tongue was embedded in her cheek; whereas life to Elbert Hubbard is "just one damned thing after another." This is important because the answer to the question "How far should doctors go to prolong life?" is entirely dependent on life's definition, whatever that is.

Indeed, many of the great ethical and political debates of our time hinge, if not on the definition of life, on its beginning and/or its end. These issues, including euthanasia, assisted suicide, stem-cell research and, of course, abortion force society to set guidelines around this impossible subject, one with innumerable personal, cultural, not to mention religious dimensions. And it is at the margins of those guidelines that one finds the agonizing physician. At times when the patient has no desires, or perhaps never possessed or no longer possesses the requisite physiology to generate them, the physician, in the absence of an adequate proxy, must often take the life of a sick patient into his own hands. At this time many feel obligated, even in the face of unthinkable suffering, to reduce the definition of life to metabolism and brainstem activity and to employ the full force of modern medical technology to their maximal prolongation. Often this is done to avoid the charge of or the feeling that one is guilty of "Playing God." This charge is not only a contradiction, but often leads only to more suffering.

By its nature our trade is to provide a path other than that which Nature had intended. This statement, while simplistic (Nature apparently intended us), suggests that we "play God" each time we administer an antibiotic, or for that matter every time we don't. Once we choose that "unnatural" path, however, we should understand that we have wrested control from nature and thus have an obligation to "keep our hands on the wheel," as it were, even when the antibiotic graduates to artificial life support. This is to say that since we turned the machine on, based on our own value system, so may we turn the machine off. Far from playing God, what we must do is play doctor, and let our humanity be our guide.

Most of us are hard-wired to abhor suffering, and it is generally accepted that death per se is neither good nor bad whereas suffering per se can only be bad (perhaps uniquely so). Indeed, it is difficult to imagine the field of medicine evolving from anything other than the initial desire of the first self-aware primate, pondering the use of his hands, to relieve the suffering of a loved one. In addition, we are all alive and have experienced, to varying degrees, the "Human Experience." We need no instruction on the utility of having our lives, or those of our loved ones, prolonged. And it is not merely to continue the consumption of oxygen. We may not be able to strictly define life, but we certainly know it when we experience it. If we apply these same human qualities to our voiceless sick patients: common sense, disdain for suffering and the recognition of the qualities of life that we ourselves appreciate and enjoy, then we as physicians, or as a society, are properly oriented to decide how far to go in prolonging life. If, out of fear, we abandon our own common sense and humanity for the autopilot of blind adherence to theory, technicality, and relativism (i.e. the lazy and clichéd "who are you to..." argument), then we dehumanize our patients. That's not playing God, that's playing the Devil.

Life for the sick and voiceless doesn't have to be, in the words of Truman Capote, "a moderately good play with a badly written third act." As physicians with a share of the authorship of that "third act," we have an obligation to make it more human, even if shorter. And perhaps we find the definition of life by asking: "Why prolong it?"