In the name of Hippocrates, doctors have invented the most exquisite form of torture ever known to man: survival.
— Luis Buñuel, My Last Sigh, January 1982
I recently lost someone dear to me and watched as they died in almost unrelenting agony over a period of three weeks. As American health care is dominated by sociopaths and a pathological corporate culture antithetical to bioethics, it became apparent to me that we would have to fight for the patient, which meant in this case, fight for their right to die with a modicum of comfort and dignity.
As these unsavory events were playing out, I ruminated on the macabre absurdity of what was unfolding: here was a man in his 80s dying from multiple metastatic cancers, who had battled these illnesses bravely for about a decade but was clearly reaching the end as he had become bedbound and could no longer feed himself, but whose oncologist was champing at the bit to charge once more into battle with toxic drugs, while simultaneously a US-backed genocide in Gaza and a US-orchestrated war in Ukraine were bringing about the slaughter of enormous numbers of mostly young healthy people.
According to a recent report by Euro-Med Human Rights Monitor, over 41,000 Palestinians have been killed in Gaza by the US-backed Zionist war machine, over 15,000 of which have been children, with two million rendered internally displaced. (The Euro-Med Human Rights Monitor number of dead includes those buried under the rubble and assumed deceased). Regarding the cataclysmic conflict in Eastern Europe, former chief of the Polish General Staff, Rajmund Andrzejczak, said “I believe that [Ukraine’s actual] losses should be counted in the millions, not the hundreds of thousands;” while former Ukrainian prosecutor general Yuriy Lutsenko has stated that Ukraine is incurring a staggering 30,000 casualties a month.
This depraved ideation underscores the logic of capitalism, where the fit are sent to the abattoir while those in the throes of terrible suffering from the latter stages of terminal illness regularly have their misery drawn out for as long as possible to fuel the egos of narcissistic physicians and to feed the medical-industrial complex’s insatiable lust for profits.
In chess the term zugzwang (from the German, meaning “compulsion to move”) refers to a point in the game where it is one’s turn and yet all options bring the player closer to checkmate. I watched this process unfold recently at an elite Manhattan teaching hospital. Keeping the patient alive and making them comfortable had come into conflict and could no longer coexist. The patient, their family, and their physician had arrived at a fateful crossroads.
Most rational people would argue that it is preferable to choose hospice at this stage, as keeping the patient alive has become synonymous with imposing growing forms of biomedical torture, which begs the following question: once this tipping point has been reached, is it possible to prolong “life” or is it merely possible to prolong the process of dying?
American doctors are often trained to drag out a person’s demise without regard for the ethical implications, and this is because their training is profoundly influenced by for-profit hospitals, private health insurance companies, and the pharmaceutical industry which care about one thing and one thing only: money. It is relatively easy for the medical-industrial complex to drag out a person’s passing due to the interconnectedness of a fateful pentagon: powerful corporate entities that exist for no other reason than to maximize the greatest possible profit, ambitious and myopic doctors who have neither autonomy nor an understanding of the bioethical ramifications of their actions, a technocracy which demands obeisance and blind obedience to “the experts,” a culture which has deified science and inculcated people with the notion that science can achieve anything – even immortality; and a dying, frightened, and increasingly malleable patient whose lucidity and ability to give informed consent are waning.
Consequently, there is no “wave the white flag class” in American medical schools. Why let someone die without being poked and prodded every ten minutes, when wretchedness can be protracted – and with this more profit-making? This sordid reality underscores the fact that a privatized health care system doesn’t regard patients as human beings but as commodities such as oil, wheat, or cattle which offer opportunities for extraction and ruthless exploitation.
In a system that prioritized empathy and compassion medical students and residents would receive a significant amount of training in helping them to identify situations where further medical interventions are likely to be harmful. It is also critical that patients be asked when coherent and not in pain what their wishes are regarding end-of-life care. Only a minuscule fraction will instruct their physician to continue to keep them alive once zugzwang has been reached, even if this means ending up on a ventilator or incapacitated for a prolonged period of time. Regrettably, many oncologists are not interested in obtaining their patients’ views on the subject.
Just as the Banderite junta and its Western owners are incessantly prattling on about how some new Wunderwaffe will magically turn the tide of the war, oncologists invariably have some new drug up their sleeve, even as death is clearly hovering inexorably. No veterinarian would continue to keep a horse or a dog alive if the animal were in terrible pain and there were no means available to alleviate that pain, and yet this is par for the course in American medicine.
It is the oncologist’s duty to discuss the pros and cons of hospice versus continuing to hammer away with powerful cancer medicines when death is encroaching and defeat inevitable. Failure to do so constitutes a violation of bodily autonomy and the oath to do no harm. Going once more unto the breach one time too many can have devastating consequences and trap the patient in a purgatorial state where, like Prometheus in Aeschylus’ Prometheus Bound, suffering is dragged on interminably – a nightmare without end.
Following John of Gaunt’s blistering chastisement of Richard in act 2, scene 1 of Shakespeare’s Richard II (“Landlord of England art thou now, not king”), noble Gaunt asks his attendants to “Convey me to my bed, then to my grave.” Scarcely a minute later Northumberland emerges to inform the king that Gaunt is no more. If Gaunt died in America today, months or even years would likely pass before Northumberland would have emerged saying “His tongue is now a stringless instrument,” together with a fistful of medical bills totaling hundreds of thousands or even millions of dollars. The scientific prowess inherent in this capability is undoubtedly impressive, but does that make it ethical?
Common sense dictates that it is preferable to die over a period of weeks rather than months, and that it is preferable to pass away in a relatively demedicalized setting. Every cancer journey ends in remission or death. Once it is clear that the former is unattainable, the question arises as to what kind of death the patient will have.
Long regarded as one of the great generals of the 19th century, Robert E. Lee battled until he realized that the Confederate military had been degraded to the point where further resistance would only lead to needless suffering and death. He surrendered. Pushing a vulnerable patient to fight till one’s dying breath denies a human being the right to a tranquil resolution of their life, and as transpired with Germany and Japan at the end of the Second World War can lead to apocalyptic destruction. Writing in Being Mortal: Medicine and What Matters in the End, Atul Gawande warns of the deplorable state of end-of-life care in America:
The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine’s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet—and this is the painful paradox—we have decided that they should be the ones who largely define how we live in our waning days.
Understanding when a cancer patient is in a zugzwang that can only be resolved by comfort care allows a human being to die surrounded by loved ones rather than under relentless medical bombardment by strangers in an ICU or pre-ICU — a lonely, harrowing, and terrifying death.
Good doctors know that prolonging dying is seldom a victory just as surrendering to death when the patient has reached a severely debilitated state is seldom defeat. Not all medical problems can be solved through aggressive medical interventions, just as not all geopolitical problems can be solved through war and aggressive foreign policy meddling. Indeed, the wise oncologist knows that the most difficult battles can only be fought and won by sheathing one’s blade and letting the patient drift peacefully, silently, and restfully out to sea.