The palatable death bed

UNDER THE MICROSCOPE

Death is currently one of the most fashionable fields in cell biology. It had long been known that programmed cell death played a very important role in the development of the embryo. For example, the fact that our digits are separated from one another is due to cell death in the regions between them during the development of the limb. This process is now called apoptosis. An enormous number of nerve cells die by apoptosis during the development of the nervous system; about one half of all the neurons that migrate into our limbs from the spinal cord to connect to our muscles die. Over the last few years it has become clear, to everyone's astonishment, that all our cells carry an apoptotic suicide package within them and it will lead to self-destruction unless they receive the right signals not to.

I find it rather attractive that it might thus be possible to initiate, by some simple action, this suicide programme when we no longer wish to continue to live. Indeed while we are making very good progress in understanding and dealing with death at the cellular level we are much less good at dealing with death at the human level. Very often doctors do not know, for example, why a particular tumour of the liver has caused death, while a much larger one has had much less effect. Also doctors have real difficulty dealing with death. Dying is something patients are not allowed to do. It is an affront to so go against the doctors' efforts and advice.

I obtained quite new insights on these issues when I met Bert Keizer from Holland, who was in London to promote his book Dancing with Doctor D. What is so special about Dr Keizer is how much attention he has given to the needs of the dying, and his experience of euthanasia. He has chosen to work in a nursing home where many of the patients are chronically ill from a variety of causes. His aim with his dying patients is not to try and cure them, but to turn the death bed into something palatable. He disapproves of those doctors who continue to diagnose and test when it has become irrelevant, probably because they cannot accept that they may, as doctors, have failed. To create reasonable death, to allow the patients to die, is, in his view, a neglected art.

Patients often ask to be allowed to die and his response is to find out what precisely they are afraid of and to enter into a bargain that he will help them. Euthanasia, a physician assisted death, is illegal in Holland. However, provided certain very strict guidelines are followed, there is no prosecution. First there must be a proper diagnosis, then a persistent wish by the patient to die that should last at least several weeks. There must also be written consent by the patient, and all this must be confirmed by another doctor who is not a colleague. And, finally, the most difficult condition of all - there must be unbearable suffering. It is also a great strain on the doctor who inevitably questions whether the right decision is being made, but in the end, when done in the right way, Keizer finds it rewarding. It is also a rare event. Over the last 14 years of the 1,000 deaths at his nursing home, only 13 have been assisted.

I wish the biomoralists, sorry, the bioethicists, would give more attention to this issue instead of concentrating on reproduction. For it is not extraordinary that anyone, no matter how potentially irresponsible a parent they may be, has the right to create life, to have a child, but we do not have the right to choose our own death. If I am not wiped out suddenly, probably on my bike, I hope someone like Keizer will be at my bedside at my end.

Lewis Wolpert is Professor of Biology as Applied to Medecine at University College London.