LILIPOH: How can one manage pain?

DR. SZEKELY: We always have sensations that we are more or less aware of. They can be exaggerated or minimized depending on their context. When fear surrounds pain it can become magnified. When a person is living with cancer, it is often the fear of the unknown that s/he has to come to grips with. If s/he can get a handle on it, then the actual pain is not quite so overwhelming. If we can contain the pain and create boundaries, it is not as amorphous and all-consuming.

LILIPOH: Why do we always hear "fighting cancer" as in a waged battle?

DR. SZEKELY: Fighting is a reaction to fear, and fear is what we don't understand. That is where understanding cancer can begin, if we don't let it take us over. There is a difference between lashing out when fighting the unknown and coming to grips with it. Conquering the illness through love and understanding, and coming to know its role in our destiny, requires tremendous courage and strength on our part.

LILIPOH: Would you equate suicidal feelings with cancer?

DR. SZEKELY: These are two very different situations. Cancer is more a picture of long term destiny, something that is part of one's long plan, putting life into a new, broad context. Suicide is much more short term; an acute reaction to overwhelming circumstances. There may be long-standing depression, but I don't think it is the same destiny question as cancer. Suicide is on the increase among teens and young adults. In many situations it is a reaction to emptiness in life, a lack of meaning, and so in that sense more of a reaction to current conditions, with a shortage of a spiritual connection.

LILIPOH: Yet pain or abandonment in serious illness could lead to the desire for euthanasia (assisted suicide)...

DR. SZEKELY: Young suicides abandon themselves. Seriously ill people at the end of life may feel abandoned by others and want to take their own life. When faced with "terminal" disease, they would hurry a process seen as inevitable. But then in some ways they would not be dealing with the transformative experience of illness, fast-forwarding to death while bypassing the whole process of dying.

LILIPOH: Why would someone want to bypass the process?

DR. SZEKELY: It is natural to think that people are afraid of pain or suffering, but most of the time they are overly sensitive to themselves as personal or financial burdens on someone else. Also, when people cannot care for themselves, or lose control of bodily functions, they perceive it painfully as a loss of dignity. We completely take for granted changing a baby's diaper, but adults feel this to be extremely demeaning. They have a hard time allowing others to participate in their fundamental care. They're guessing at what other people feel about the effort they are causing, and we know that we're usually wrong when we try to do that... People today are often estranged from others and can't develop a community around themselves. They don't have support when they're terminally ill or, through their behavior, they push people away when they need them most. This causes the feeling of abandonment (crying out for help that is not forthcoming) which probably parallels the emotions of young teens who feel life is irredeemably empty, Indeed, that is the only place where I see a close parallel between suicide and the desire for euthanasia in severe illness.

TO A SUICIDE

May the truth in you
Dear Friend
Rise
Beyond the threshold
In spite of the debris
Of your self-destroyed  house,
And we
Who follow your destiny
Want to reflect upon ourselves
So that you reflect on yourself
And stand up,
Looking back on the debris
Deciding to rebuild it
Into a new solid house.

- R. STEINER

LILIPOH: Do you think euthanasia is ever justified?

DR. SZEKELY: It was tolerated in Holland for some years and just recently been made legal, with the intention of allowing it throughout the European Union. The original intent was to help people in the utmost pain and suffering, but it is immediately a slippery slope because other considerations arise, such as convenience or cost. Here we have a paradox. On the one hand people want at all costs to extend life, to employ extreme heroic measures to hold on to what is slipping away (Ahriman says, "I am so bound to the physical that letting go is overwhelming!"). On the other hand there is the wish to push away too quickly (Lucifer says: "I don't want to be a burden, I just want to let go, to fly away'). What is needed here is an understanding of the right progression, which involves everyone, from medical professionals to family, in order to balance those two archetypal extremes.

LILIPOH: How is this to be achieved in a hospital setting?

DR. SZEKELY: In large part the care that is rendered there reflects the fear or the courage of the caregivers. That is why discussions with caregivers are so important—to allow them to see and recognize their own fears. Some cancer specialists have such a fear that they drive to conquer, working with the war model of cancer and offering chemotherapy to every patient. Open communication is important, and it is taking place; we have made tremendous progress with help for the dying in the hospice movement, including the knowledge that dying is not a failure, but rather is a process fundamental to care.

LILIPOH: What words of advice or encouragement would you offer?

DR. SZEKELY: I encourage every patient I meet to be clear as to what their wishes are, and to convey them to their loved ones. It is awkward to talk about what will happen when I die, but other people need to be comfortable, and it does not have to be done in a tone of finality. There are legal documents to be filled out; besides the "living will" a Durable Power of Attorney for Medical Decisions is particularly important. This latter empowers a trusted individual to make decisions when we no longer can. ]'he advantage is that it specifies someone with whom we have a relationship and who understands our values, because we cannot always anticipate situations. We may need someone we trust rather than a stranger. These documents are just as important as the will that designates who gets the jewelry; they simply extend the thinking to the dying process. They allow us to stay in control in uncomfortable circumstances and not to feel abandoned.

Daniel Szekely, MD directs women's health with the Alaskan Native Population in Anchorage Alaska. He is also active with the medical ethics committee in his hospital. You may contact him with questions at: dszekely@yahoo.com