The phrase “I want to help people” was prominent on my application to medical school, and primum non nocere was a mantra during clinical training. Near the midpoint of my third year, I still believed in these ideas and was proud to be a part of saving lives. The principles of beneficence and nonmaleficence complemented one another and were the foundation upon which I built my approach to patient care. However, this foundation was shaken one morning when I was forced to ponder the responsibility of a physician to a patient who is suffering and dying.
I was the first member of our palliative care team to enter the room and to behold a world-weary woman with multiple tubes going in and out of her anasarcous body. Her tracheostomy made it difficult for her to speak, so she communicated by writing on a small white board with a green marker. Our attending introduced himself, our nurse, and me, then inquired about her wishes. Mrs. S. scribbled on the white board and handed it to me. It read, “One pill, one shot, just make it quick, that’s all I ask.” I gulped and quickly surrendered the board to my attending. He digested the message much more stoically than I had and asked Mrs. S. why she wrote it. She implied that she had suffered for too long, and she requested a swift end. We explained to her that we would do everything possible to make her comfortable but that we could not cross that line. We could continue life support or discontinue life support and provide comfort care through pharmacotherapy, but we could not assist her death. After all, physician-assisted death is wrong morally and ethically, and, in most states, it is illegal. A short time later, we turned off the intravenous machines and administered narcotics, and she passed away.
Mrs. S. was the first person I watched die. Although the staff said hers would be a peaceful death, I thought it was gruesome. It wasn’t like in the movies when an elderly relative peacefully goes to sleep and simply never wakes up. Instead, I witnessed a 35- to 40-minute process of intermittent jerking motions and agonal gasps every 20 seconds. During the interminable time it took her to die, I was screaming in my mind to the nurse: “Just end this. You can end this right now.” I understood that the narcotic was quashing her air hunger, but I remembered clearly that she explicitly stated her fervent last wish right there in green and white. Wouldn’t an extra dose—even one more push on the syringe—be more ethical than strangers watching the life slowly wrenched from her body?
Mrs. S. had aortic stenosis, respiratory failure, and renal failure but no friends or family. However, she still had her dignity, decision-making capacity, and especially her right to autonomy. Despite my preliminary horror upon reading her words that conjured images of murder, I knew that nonmaleficence trumps autonomy. Yet, what about beneficence? We tried to be beneficent, but a slow, ghastly, death in front of strangers in white coats doesn’t seem to be good for anybody, including me. Interestingly, the tensions between these bioethical principles seemed to transcend her situation and engage me on a personal level. I’m not sure where I stand now, but I am certainly less adamant and recognize that there is no clear right answer. As a third-year medical student, I wore scrubs, looked in patients’ bodies, inquired about intimate details of their lives, and was forced to reflect on existential questions that I thought were already answered. It was a terrifying time but also an honor. Thank you, Mrs. S., for your beneficence.
Carlos A. Sandfoss and Andrew R.
Hoellein, MD, MS
Mr. Sandfoss is a fourth-year medical student, University of Kentucky College of Medicine, Lexington, Kentucky.
Dr. Hoellein is an associate professor of medicine, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, Kentucky; e-mail: firstname.lastname@example.org.