The Man with Stars Inside

The Man with Stars Inside

Deep in this old man's chest

a shadow of pneumonia grows.

I watch Antonio shake

with a cough that traveled here

from the beginning of life.

As he pulls my hand to his lips

and kisses my hand,

Antonio tells me

for a man whose death

is gnawing at his spine,

pneumonia is a welcome friend,

a friend who reaches

deep between his ribs without a sound

and puff! a cloud begins to squeeze

so delicately

the great white image of his heart.

The shadow on his X-ray grows

each time Antonio moves

each time a nurse

smoothes lotion on his back

or puts a fleece between his limbs.

Each time he takes a sip of ice

and moist chest shakes with cough,

the shadow grows.

In that delicate shadow

is a cloud of gas

at the galaxy's center,

a cloud of cold stunned nuclei

beginning to spin,

spinning and shooting

a hundred thousand embryos of stars.

I listen to Antonio's chest

where stars crackle from the past

and hear the boom

of blue giants, newly caught,

and the snap of white dwarfs

coughing, spinning.

The second time

Antonio kisses my hand

I feel his dusky lips

reach out from everywhere in space.

I look at the place

his body was,

and see inside, the stars.

I wrote “The Man with Stars Inside” shortly after Antonio died of lung cancer in 1986. In the poem, Antonio reaches for my hand and kisses it as I stand beside his hospital bed. At the same time, the “I” of the poem reports looking at Antonio's chest x-ray, where he sees the patchy fluffiness of pneumonia and transforms it into “a cloud of gas/at the galaxy's center.” The same “I” also listens with his stethoscope to the old man's chest, “where stars crackle from the past.” Only in poetry could all these things be happening at once. The truth of this poem, however, is deeper than the facts.

Antonio did kiss my hand on the last day of his life, shortly after I had set up his morphine drip. His daughters had brought him to the hospital that morning because he had a terrible racking cough and difficulty breathing. He and I had decided not to use antibiotics to treat the welcome friend whose presence was reflected in his chest x-ray. I don't believe we even discussed the issue of intensive care and mechanical ventilation. After Antonio died that evening, I remember spending a long time in the room with him, talking quietly to his two daughters, both of whom had taken remarkable care of him during the preceding several months. After a few weeks, when the poem came to me, I sent a copy to each of the daughters with a note telling them how grateful I was to have had the opportunity to know Antonio. In return, they sent me notes of thanks.

I am fairly certain that the morphine drip hastened Antonio's death, as did our decision not to embark on the treadmill of intensive care. We treated aggressively, all right-with aggressive comfort care rather than with interventions that would only prolong the painful process of dying. I am not sure that I can explain my intent in starting the morphine drip. Was this a classic case of double effect-did I intend only to relieve Antonio's suffering? Or did I also intend that he die quickly, as well as painlessly? I had no doubt, whatever my motives, that the morphine drip was the most humane and moral course of action available.

Ten years after Antonio's death, a national obsession with professional help in dying appears to be escalating. In retrospect, it seems inevitable that the 1970s' right to refuse treatment would quickly become the 1980s' right to die and then the 1990s' right to determine the time and manner of one's death. Because we are a nation of violent and over-whelming obsessions, physician-assisted suicide and euthanasia are likely to play themselves out over the next few years in splashes of dramatic color. Public opinion polls show that the majority of Americans currently favor the legalization of physician-assisted suicide. Surveyed physicians seem about evenly split on the matter. Recently, the 2nd and 9th federal circuit courts have issued decisions striking down state laws in New York and Washington that forbid physician-assisted suicide near the end of life. It is possible, of course, that the U.S. Supreme Court will overturn the lower courts' decisions. Nonetheless, medical ethicists and lawyers all over the country are already vigorously (albeit somberly) debating proposed rules, regulations, guidelines, and criteria for physician-assisted suicide.

To return to my own experience: What would I have done if Antonio had come to me a week or a month earlier and asked for instructions on committing suicide? My answer in 1986 may have been different than my answer today, but I'm not sure. As a person who believes strongly in the underlying connectedness of persons, I consider assisting death an extraordinarily difficult moral problem, regardless of its legal status. I've found that many traditional moral arguments about end-of-life decisions are not as useful as I once believed them to be. For example, although the clear-cut discontinuity between active and passive euthanasia still carries intuitive weight, I now respect the logical power of arguments that challenge the distinction. Similarly, the gap between the intent to relieve suffering and the intent to kill is not nearly as clear as the text-books claim. In the case of Antonio's morphine drip, yes, I did intend to relieve his air-hunger, but just as surely I embraced (not simply recognized) the fact that his life would more quickly be over.

I experience the moral problems of assisted suicide and euthanasia as being much like a “cloud of gas at the galaxy's center.” What underlying truth does the cloud obscure? How can I find a way to penetrate it? The current public discourse on assisted death doesn't help me very much. A discourse based solely on population surveys and abstract principles of ethics and law fails to penetrate to, much less illuminate, the core of the problem. What's missing? My intuition as a poet is to cherish each case, each story, individually, while attempting at the same time to see its connection with others. The great 20th century physician-poet William Carlos Williams used the aphorism “no ideas but in things” to summarize his belief that poetry arises from concrete experiences rather than abstract ideas. Similarly, I believe that the human work of wrestling with physician aid in dying has to begin with specific life narratives and relationships rather than with abstractions like rights, autonomy, and beneficence.

Contemporary discussion about assisted suicide and euthanasia also seems to lack introspection about why and how this particular public controversy began. What energy drives us to experience these as pressing societal issues? As we embark on an effort to regularize assisted death, I believe that we need to step back and pay attention to the bigger picture. We need to ask ourselves, Why now? Is U.S. society today more morally sensitive and more enlightened in 1996 than it was 10, or 25, or 200 years ago? Are we more compassionate and just? Have today's pluralism and multiculturalism illuminated an important expression of human dignity heretofore ignored?

I don't know the answers, but I do know we need to stop and pay attention to the questions.

As I look around me, I am angry about the social and medical climate in which we are developing an obsession with palliation-by-death. We do very poorly in meeting the needs of terminally ill and dying patients. Although the hospice movement has grown dramatically since I cared for Antonio in 1986, the large majority of patients who die in the United States, even those who perish from lingering illness, do not receive hospice-type care. More disturbing yet, there is good reason to believe that the majority still do not receive adequate control of pain and other symptoms. Granted, it is not possible to relieve symptoms for every patient, but we could do so much better if we simply paid attention to our patients' suffering rather than distancing ourselves and justifying our neglect with false fears of addiction, respiratory depression, and the consequences of “taking hope away.”

Moreover, the cultural emphasis on life-sustaining technology has accelerated to the point where many more patients nowadays are swept along into advanced chemotherapy and artificial life support without realizing that the treatment will almost certainly not benefit them, that it will be very uncomfortable, and that they have every right to decline such interventions. Thus, we seem to have created a peculiarly American way of death, a syndrome characterized by poor communication, lack of emotional support, increasing vulnerability, and a prolonged phase of diminishing quality of life. This image of dying is understandably frightening, and so the public has begun to demand palliation-by-death-and to request it from the very profession that has created (or at least enhanced) the syndrome they wish to avoid.

Over the last generation, the imperative in medicine, as in our society as a whole, has been to expand: more specialization, greater intervention, an increasing array of options. In the last couple of years, however, the pendulum has begun to swing in the “less is more” direction: fewer procedures, less intervention, fewer choices. In this context, perhaps, legalization of assisted death is a well-timed moral advance, presenting us with the opportunity to affirm ever more aggressive patient self-determination while at the same time offering a novel way of substantially reducing the costs of dying. The proponents of assisted death will, of course, argue vehemently that physician aid in death constitutes an additional option and not a limitation of choice. Nonetheless, if (as I believe) the current culture of U.S. medicine promotes excessive and unnecessary use of technology despite a widespread consensus that patients can choose to reject it, then it seems likely that a new culture that is tolerant of physician-assisted suicide and euthanasia will have similar power to manipulate the use of those procedures. It may transform them into desirable (and perhaps preferred) medical choices despite the continued availability of life-prolonging treatments. In an age of scarcity, palliation-by-death will provide a quick professional solution.

Because of the importance of empathy, continuity, and good communication in palliative care, the poor and disenfranchised suffer more in dying than do those who are fortunate enough to have both a generalist physician and good medical insurance. Moreover, the United States has an enormous population of persons, now estimated to be nearly 40 million, who have no medical insurance at all and are therefore at the mercy of the “invisible hand” of capitalism. The invisible hand provides little care for those whom it has swatted to the sidelines. Those fortunate enough to qualify for Medicaid often have access to high-quality technical services because medical teaching hospitals are their prime source of treatment; private physicians are frequently unwilling to care for them. Such services, however, do not in themselves constitute care. Care requires respect, understanding, solidarity, and empathy. High-tech intervention, if not provided through the medium of a compassionate clinician-patient relationship, is usually the worst thing that can happen to a dying patient.

The frail elderly, especially those with impaired decision-making capacity, also suffer disproportionately in dying. They are often the target of prolonged, aggressive intervention in the hospital. Outside of the hospital, they encounter inadequate economic support for long-term care facilities and home health services. What impact will palliation-by-death have on the lives of this rapidly growing part of our population? Take, for example, a mildly demented man whom I took care of not long ago. He suffered from metastatic prostate cancer. His family had agreed on a plan, consistent with the patient's wishes, of maximizing comfort care but not seeking further treatment to prolong life. Strong doses of narcotics alleviated his pain, but they also made him more confused. The patient had lived with his daughter for 3 years, during which time he had become progressively disabled. His care involved enormous emotional, physical, and financial expense for the daughter and her family, but they bore it gladly because they loved him.

How would the legalization of assisted death affect the care of patients like this one? The present public policy proposals are based on the right of competent adults to decide for themselves; they envision assisted suicide and euthanasia as options available only to those who explicitly and autonomously request them. Thus, patients like the man with prostate cancer would be ineligible. Yet, it is difficult to imagine legally sanctioned palliation-by-death without a mechanism to allow this suffering old man the same relief that patients with decision-making capacity have available to them. A legal remedy would have to be developed to “protect” the liberty interests of demented and developmentally disabled persons. In my mind, this would further compromise the care of these vulnerable patients, replacing the current too-aggressive use of intervention and lack of long-term services with a culturally approved method of putting these patients out of their suffering.

Antonio never asked me to hasten his death. In fact, patients have rarely raised the question of suicide or euthanasia with me. My generalist colleagues report similar experiences. These (admittedly anecdotal) impressions run contrary to a major (equally anecdotal) claim of palliation-by-death proponents, which is that a great many physicians illegally assist suicide and perform euthanasia. I suspect that these actions are infrequent. Interestingly, I imagine a curious inverse relation between good physician–patient relationships and requests for physician-assisted suicide. Patients who feel comfortable enough with their physicians to discuss assisted death usually do not need to do so because they are receiving good palliative care: skill in empathic communication is apt to be correlated with skill in meeting patients' needs. Conversely, patients with greater perceived need for assisted death-as a result of ill-advised aggressive treatment, poor communication, and lack of palliative care-are apt to feel estranged from their physicians and, therefore, are unlikely to ask them for assistance in dying. Medical and legal guidelines for assisted death would provide a more stable framework for such discussions but would not address deficiencies in palliative care. The major moral problem in the care of the dying, in my opinion, is the lack of compassionate care, not the lack of legally approved palliation-by-death.

Poor communication between physicians and patients (and their families) is a theme that underlies our aggressive treatment of dying patients, our inadequate palliative care, and the special vulnerabilities of poor and elderly persons. In turn, failed communication results from lack of empathy and respect. No wonder the public is disillusioned with medicine and angry and frightened about end-of-life horror stories! We should devote our attention to developing more compassionate medicine and a public policy that encourages more equitable care, rather than embarking precipitously on a policy of palliation-by-death. Dying patients do have a right to high-quality care and to a caring society that embraces its suffering members rather than discarding them. Although I appreciate the arguments supporting professionally assisted death, I want to cry out, “Stop! Stop and pay attention to what is going on here.” The movement toward state-regulated physician-assisted suicide and euthanasia will surely move us somewhere, but not closer to each other.