The Quality of Mercy
Effective pain treatments already exist. Why aren't doctors using them?
IT TOOK DAVID BOGAN A DECADE TO BUILD A GOOD LIFE AND ONLY A FEW SECONDS to have it destroyed. A financial adviser in Deptford, N.J., Bogan owned a sailboat, a Porsche, and his own home. But one morning in 1995, as he was driving to his mother's memorial service, a car plowed into him from behind and changed all that. A back injury from the accident led to surgery. He woke from the anesthesia with the sensation that his right leg was burning up.
The face of Bogan, now 35, bears the marks of two years of constant pain from nerve damage in his back. "I can't shower because the water feels like molten lava," he says. "Every time someone turns on a ceiling fan, it feels like razor blades are cutting through my legs." He has been to 20 doctors in search of relief. He has drained his savings and sold his possessions to pay medical bills, and his friends, weary of trying to coax him out to dinner or a movie, are gone. Last December, when he began fantasizing about jumping off the Benjamin Franklin Bridge over the Delaware River, Bogan checked himself into Mensana Clinic, near Baltimore, which specializes in diagnosing and treating pain. By night, he watches old movies to distract himself. By day, he fights off suicidal thoughts as his current doctor searches for ways to stop the pain. Bogan says, "I'm dying."
To his doctor, Nelson Hendler, treating a patient like Bogan is humbling. Bogan is intelligent, articulate, profoundly depressed, and prepared to kill himself if no one can release him from his suffering. In the eyes of right-to-die proponents, cases like Bogan's serve as powerful arguments for legalizing physician-assisted suicide.
Indeed, pain is one of the principal reasons the sick ask for their doctors' help in dying. And the fear of an agonizing death underlies the support of more than 50 percent of Americans for legalizing physician-assisted suicide. Pain, says Dr. Mitchell Max, director of the Pain Research Clinic at the National Institute of Dental Research, "is the reason Jack Kevorkian has been so successful."
Pain specialists like Max might agree that legalized suicide is the answer--except that they know better. The best antidote to Kevorkian's appeal, in their opinion, is better treatment for pain. And that treatment already is available. Medicine at this very moment has the means to relieve the agonies of the majority of dying patients. It could ameliorate the suffering of many people enchained by chronic pain. Even more effective treatments are on the way. Scientists have traced pain's path from the site of disease and injury to the brain. This knowledge is beginning to yield experimental drugs that eventually will relieve suffering even better than current therapies, with fewer side effects.
What is lacking is not the way to treat pain effectively but the will to do it. For a quarter of a century, pain specialists have been warning with increasing stridency that pain is undertreated in America. But a wide array of social forces continue to thwart efforts to improve treatment. Narcotics are the most powerful painkillers available, but doctors are afraid to prescribe them out of fear they will be prosecuted by overzealous law enforcers, or that they will turn their patients into addicts. Patients, too, are leary of the drugs. And living with pain in stoic silence still is seen as a sign of moral strength, while taking drugs to relieve it is often viewed as weak or evil. "We are pharmacological Calvinists," says Dr. Steven Hyman, director of the National Institute of Mental Health.
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