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Editorials Kindliness Is Next to Godliness Nor LONG AGO I was a member of an audience listening to a presentation on medical ethics, death, and dying. The message was to assure good, fair decisions. The speaker espoused "death with dignity." An older physician in front of me leaned toward a long-time colleague and muttered, "There's no such thing as death with dignity." I snapped to full attention. Surely death is not always a struggle. But many people, comfortable with having made plans for dispersing their goods and having said I love you and I forgive you and I cherish and respect you to important people in their lives, welcome the idea of dying in their sleep-on their own schedule. No one wants to linger; no one wants to linger in the disoriented way reported in one of the Lessons From the Practice appearing in this issue.I But wishes may not come true; fate may not honor preferences. How can physicians work toward assuring a patient's death with dignity, "dying in character," as Elisabeth Kiibler-Ross calls it?2 Several forces act distinctly against death with dignity. Although the use of technology presents great opportunities, it has unmistakable drawbacks. It can reverse downhill trends. It can foster a return to normal. It can make marvels. But it can also be unnecessary, uncomfortable, downright painful. It can prolong life, and death. Its beneficence can be countered by side effects and inappropriate use. The same is true for our impressive pharmacopeia. In addition, the fast pace of life and the ever-growing size and complexity of the health care system compound the impersonal brush-off that many patients feel as they are tossed in a churning current, seeking care. They long, as do we, for a still time, a healing time, a time when we can put into effect the implications of the Asian aphorism: We are given two ears and one mouth. Even during these turbulent times, there are beacons and anchors, principles to guide us. As we study, discuss, and debate biomedical ethics, we absorb concepts about patients' autonomy, about giving them choices and about respecting their choices. We also acknowledge the need for care that is whole and equitable and not based on the ability to pay or on social class. We are reminded that primum non nocere is a powerful directive, probably even more powerful than preventing harm and doing the right thing. Of course, we can assure the thoughtful use of technology and pharmacology. We can resist other forces that act against death with dignity by being sensitive to the oft-unspoken needs of patients. We can also add another litmus test to our armamentarium. This test may be the most important of all, yet it seems neglected in canons and weighty discourses. It is pure. It is personal. It is quiet. It is the test of kindness. Poets and playwrights, authors and philosophers have noted through the centuries that kindness brings warmth to the giver and the receiver. William Wordsworth valued "that best portion of a good man's life, his little, nameless, unremembered acts of kindness and of love."3 Robert Burns, a few years earlier, lauded "The heart benevolent and kind . most resembles God."4 Along with our capabilities, we need to develop our sensibilities. The challenge is to temper the wind to the shorn lamb. We have many strong "winds" -of machines and medications, of haste and distraction. We have many vulnerable
patients. Fortunately, we have ways to light our path, to lighten our path, to assure death with dignity. One is, be kind. LINDA HAWES CLEVER, MD REFERENCES 1. Watts WE, Watts DT: Denying the inevitable-The misplaced use of technology (Lessons From the Practice). West J Med 1992 Mar; 156:325-326 2. Kubler-Ross E: On Death and Dying. New York, Macmillan, 1969 3. Wordsworth W: Lines Composed a Few Miles Above Tintern Abbey on Revisiting the Banks of the Why During a Tour, line 33 4. Burns R: A Winter Night, lines 95 and 96
The Medical Waste Stream THE QUESTION OF WHERE and how to get rid of our solid waste is one of the latest issues to affect heavily populated areas of the United States. There are many background stories that have made headlines throughout the country and raised the issue as a major item on the political agenda. In the summer of 1987 a barge loaded with garbage from Long Island, New York, was refused entry at various ports of the United States and Latin America. The barge eventually went to New York City, where after considerable political wrangling its load was accepted for incineration. In 1987 and 1988 newspapers were filled with stories of medical waste washing up on beaches of various states along the coast. This adversely affected the beach areas' tourist trade. The movement to increase the regulations governing the disposal of medical and solid waste has been further accentuated by environmental concerns, such as the closure of many landfills, the dwindling capacity of others, the interstate shipment of garbage, and the difficulty of finding new sites for waste disposal facilities. Vociferous local opposition groups frequently prevented the establishment of new landfills or incinerators in their communities.1 In addition, some waste haulers have been charged with having organized crime connections or with restraint of trade through noncompetitive agreements. Some states have initiated licensing programs for waste haulers that require a police background check, comprehensive regulation of business practices, a policy of directing where and how the hauler will carry the solid waste, and a disposal fee and other taxes to fund an effective regulatory enforcement program. The cost inflation, the decreasing availability of alternate disposal sites, growing local opposition to changing solid waste management practices, health concerns about alternate disposal methods such as incineration, and fears about hazards perceived to be associated with medical wastes have increased political involvement. This has led to new laws and regulations that are designed to implement a cradle-to-grave regulated waste management program. Health and political concerns may result in especially stringent regulations to control medical waste.2 Federal regulations became effective on June 22, 1989, pursuant to the federal Medical Waste Tracking Act of 1988. The law directs the US Environmental Protection Agency (EPA) to establish a 2-year demonstration program for tracking medical wastes. The states of Connecticut, New Jersey, New York, and Rhode Island and the Commonwealth of Puerto Rico are participating in the program.3 The regulations list the medical wastes to be tracked and designate standards for separating, packaging, and labeling medical
Editorials Kindliness Is Next to Godliness Nor LONG AGO I was a member of an audience listening to a presentation on medical ethics, death, and dying. The message was to assure good, fair decisions. The speaker espoused "death with dignity." An older physician in front of me leaned toward a long-time colleague and muttered, "There's no such thing as death with dignity." I snapped to full attention. Surely death is not always a struggle. But many people, comfortable with having made plans for dispersing their goods and having said I love you and I forgive you and I cherish and respect you to important people in their lives, welcome the idea of dying in their sleep-on their own schedule. No one wants to linger; no one wants to linger in the disoriented way reported in one of the Lessons From the Practice appearing in this issue.I But wishes may not come true; fate may not honor preferences. How can physicians work toward assuring a patient's death with dignity, "dying in character," as Elisabeth Kiibler-Ross calls it?2 Several forces act distinctly against death with dignity. Although the use of technology presents great opportunities, it has unmistakable drawbacks. It can reverse downhill trends. It can foster a return to normal. It can make marvels. But it can also be unnecessary, uncomfortable, downright painful. It can prolong life, and death. Its beneficence can be countered by side effects and inappropriate use. The same is true for our impressive pharmacopeia. In addition, the fast pace of life and the ever-growing size and complexity of the health care system compound the impersonal brush-off that many patients feel as they are tossed in a churning current, seeking care. They long, as do we, for a still time, a healing time, a time when we can put into effect the implications of the Asian aphorism: We are given two ears and one mouth. Even during these turbulent times, there are beacons and anchors, principles to guide us. As we study, discuss, and debate biomedical ethics, we absorb concepts about patients' autonomy, about giving them choices and about respecting their choices. We also acknowledge the need for care that is whole and equitable and not based on the ability to pay or on social class. We are reminded that primum non nocere is a powerful directive, probably even more powerful than preventing harm and doing the right thing. Of course, we can assure the thoughtful use of technology and pharmacology. We can resist other forces that act against death with dignity by being sensitive to the oft-unspoken needs of patients. We can also add another litmus test to our armamentarium. This test may be the most important of all, yet it seems neglected in canons and weighty discourses. It is pure. It is personal. It is quiet. It is the test of kindness. Poets and playwrights, authors and philosophers have noted through the centuries that kindness brings warmth to the giver and the receiver. William Wordsworth valued "that best portion of a good man's life, his little, nameless, unremembered acts of kindness and of love."3 Robert Burns, a few years earlier, lauded "The heart benevolent and kind . most resembles God."4 Along with our capabilities, we need to develop our sensibilities. The challenge is to temper the wind to the shorn lamb. We have many strong "winds" -of machines and medications, of haste and distraction. We have many vulnerable
patients. Fortunately, we have ways to light our path, to lighten our path, to assure death with dignity. One is, be kind. LINDA HAWES CLEVER, MD REFERENCES 1. Watts WE, Watts DT: Denying the inevitable-The misplaced use of technology (Lessons From the Practice). West J Med 1992 Mar; 156:325-326 2. Kubler-Ross E: On Death and Dying. New York, Macmillan, 1969 3. Wordsworth W: Lines Composed a Few Miles Above Tintern Abbey on Revisiting the Banks of the Why During a Tour, line 33 4. Burns R: A Winter Night, lines 95 and 96
The Medical Waste Stream THE QUESTION OF WHERE and how to get rid of our solid waste is one of the latest issues to affect heavily populated areas of the United States. There are many background stories that have made headlines throughout the country and raised the issue as a major item on the political agenda. In the summer of 1987 a barge loaded with garbage from Long Island, New York, was refused entry at various ports of the United States and Latin America. The barge eventually went to New York City, where after considerable political wrangling its load was accepted for incineration. In 1987 and 1988 newspapers were filled with stories of medical waste washing up on beaches of various states along the coast. This adversely affected the beach areas' tourist trade. The movement to increase the regulations governing the disposal of medical and solid waste has been further accentuated by environmental concerns, such as the closure of many landfills, the dwindling capacity of others, the interstate shipment of garbage, and the difficulty of finding new sites for waste disposal facilities. Vociferous local opposition groups frequently prevented the establishment of new landfills or incinerators in their communities.1 In addition, some waste haulers have been charged with having organized crime connections or with restraint of trade through noncompetitive agreements. Some states have initiated licensing programs for waste haulers that require a police background check, comprehensive regulation of business practices, a policy of directing where and how the hauler will carry the solid waste, and a disposal fee and other taxes to fund an effective regulatory enforcement program. The cost inflation, the decreasing availability of alternate disposal sites, growing local opposition to changing solid waste management practices, health concerns about alternate disposal methods such as incineration, and fears about hazards perceived to be associated with medical wastes have increased political involvement. This has led to new laws and regulations that are designed to implement a cradle-to-grave regulated waste management program. Health and political concerns may result in especially stringent regulations to control medical waste.2 Federal regulations became effective on June 22, 1989, pursuant to the federal Medical Waste Tracking Act of 1988. The law directs the US Environmental Protection Agency (EPA) to establish a 2-year demonstration program for tracking medical wastes. The states of Connecticut, New Jersey, New York, and Rhode Island and the Commonwealth of Puerto Rico are participating in the program.3 The regulations list the medical wastes to be tracked and designate standards for separating, packaging, and labeling medical
