About 2500 years ago, Charon, the mythological boatman, helped the disembodied Greek soul across the River Styx. He insisted on a small fee for his services, so Greeks were buried with a coin on their tongues, lest their souls languish forever on the banks of that dark river. Today, astounding technologic developments in medicine have devalued that coin to the point of worthlessness, and channeled the Styx through Nursing and Extended Care Facilities. There, often in foul fluorescent air, many Americans wait, imprisoned by well intended but costly and ultimately cruel care.
A brain dead teenage woman survives a head injury. Her mother had died in the same accident. Her father is with her constantly during the first several months, searching for any sign of cognition, pouring into his child every shred of hope, love, strength, and longing he owns. He prays for the miraculous return of sentient life. Many years later he still visits regularly, to hold the hand, touch the face, and speak with the memory of his lovely daughter. For several years her young body retains its youthful promise and beauty. But in time she undergoes a heart rending metamorphosis, with muscle wasting, skin, joint, and tissue changes related to seizure medication and chronic invalidism. Her bodily functions are provided by various catheters, IV ports, and diapers. She is a ‘no code’ but her frequent infections and pressure sores are treated aggressively and expertly. Pneumonia, the ‘old man’s friend’ is not allowed to intervene or invite the ministrations of Charon. Her father waits. The State and taxpayers wait. The child waits. Death waits.
My dear friend and colleague had developed a persistent cough. One night, while on duty in the ER he ordered his own chest XRay. Looking at the ugly Xray film silently and alone he discovered his lungs riddled with cancer. Following pathologic confirmation and a decision to attempt chemotherapy, he and his wife threw an all day swim party for his two families: his nearby blood relations, and those he lived and worked with for eight or ten hours daily. It was a celebration of all he was, all we are. Defiantly, we scheduled another party in a year. But he deteriorated very rapidly, focused on two things: Reaching out to his extensive families, and avoiding hospitalization. We stayed with him as he reached out to his own past, and his own death. In the advanced state of dying, or living, we kept 8 hour shifts so that both a relative and a colleague were with him at all times. He was never hospitalized, or hospiced. It was a transcendent experience for us all.
Carlos Castaneda’s invented Yaqui warrior, Don Juan, usually speaks in metaphorical terms. His own death, for example, is always with him. It takes the form of a black crow, and at times when he turns his head quickly, he sees it flit away. In any crisis, that crow is his best counselor. Yet when asked about old age Don Juan says simply: “Fight like hell!”, despite knowing that in the end he will lose. But not all of us are Yaqui warriors. As physicians we see those who desperately want release from living. They may find comfort in religious sources like Ecclesiastes 4:2-3: ‘There is a time for all things under heaven: a time for birth, a time for death…’, or Revelations 9:6: ‘…they shall seek death, and not find it.’ Or in Aleuts, whose elderly are allowed to walk out into the cold alone when they are ready to die. They may find solace in the eastern religions’ respect for the continuing cycles of interrelated life and death.
Beyond ‘patient directives’ to the medical community to limit interference with dying, they may appeal to a physician to accept their decision to expedite the end of their own life; to be counseled and assisted in considering or acting on their will to die in a way and at a time of their choosing. What is ‘free will’ if such an option is denied people? While the famous oath of Hippocrates denies physician the possibility of assisting dying, it is almost as old as Charon. It’s not that time is unimportant, but that reality does change. Times change.
So I suggest this is the time for a subspecialty of primary care or geriatrics/gerontology, called Charontology. Ethically and legally the involvement of more than one physician should be required, and when possible, family should participate. Charon’s fee might be more than a coin, though low cost fare across the Styx could be provided by insurance of various sorts. People buy funeral services and burial plots, why not include the services of a charontologist?
I suppose some might consider Dr. Kevorkian the ‘father of charontology.’ Or the State of Oregon’s assisted suicide laws the current expression of Kevorkianism. Others might beat the drums about ‘death squads’. Yet there should be a way for a person to choose a clearly expressed and considered wish to end his own life on earth, other than suicide. And for a family to choose to end the legalized torture imposed by society on a loved one who has no hope, no voice, and no mind. Who does the choice of death belong to, and who do the choices of life belong to? The state? Or the professions of medicine or law? I don’t think so. These options belong to the free individual, and to the family of an individual who is imprisoned in a hopeless living death. While opponents can rant about ‘death squads’ and ‘euthanasia’ or ‘mercy killing’, society has only the right to place rational safeguards and limitations on these choices. As in the pursuit of life, liberty, and happiness, the right a ticket on Charon’s little boat is clear.