命の選択

命の選択、この言葉は、災害医療での「トリアージ」やコロナ禍の下での病床や医療機器の不足の時、よく耳にする。しかしその範囲は災害医療やコロナ禍の下での医療に留まらない。

老衰死という用語が死亡診断書でみられるが、その実態は一定でない。もちろん高齢で食べられなくなり、飲めなくなるのは条件だが、高齢とはいえ食べられない、飲めないのが一時的なこともある。私の友人の祖母で、90歳も過ぎて認知症も始まったが手作業が好きで、何を作るのでもないが編み物をして長いマフラーのようなものを作り、笑顔で見せてくれたり、自宅に外泊すると、仏壇のろうそくに火をつけて先祖をまつったりする方だった。ある時食べられず、飲めなくなった。どうしようか悩んだが、点滴をして水分補給をしたら元気になり、「あーぁ、長く寝すぎた」と言ってまたしばらく例の編み物をしておられた。しかし、その後また食べず、飲まず、点滴でも回復せず94歳で亡くなられた。

別に私の患者さんから聞いた話だが、高齢の母が食べたくないというので、もういいかと私の患者である息子は思ったという。しかし、その妻は放っておけないと、本人が好きな和菓子を持って行ったら、パクッと食べたという。しばらく介助はしたが、また普通に食事をするようになったという。しばらくしてまた食べたくないというので、妻がまた和菓子を含めて工夫をしたが効果なく、亡くなられたという。実は私の祖母は、私がパート勤務していた頃、さわ病院に入院していた時期があった。訪室すると、いつも「まあお忙しいのに」とねぎらってくれた。やはりある時期に食べなくなったので、食べることを勧めたが「もう十分生きたから」と食べようとしなかった。胃管から栄養と水分を入れようとしたら、逆に死を早めた。

また、私の伯母は若いころ肺結核をして高齢となって自宅酸素療法をしていた。嫌がって時々外すが、やはり苦しいのか、酸素をつけたり外したりしていた。1人暮らしでかなり高齢まで運転もし、93歳くらいまで自宅で過ごして最後は呼吸器の専門の病院に入院し、「もう長くないが、酸素はどうしましょう」と主治医に尋ねられた。やはりできるだけのことはしてほしいと頼み、酸素投与をしていたが数日「アー、ウー」が続き、親族と相談の上酸素投与中止を頼んだが、開始した以上止められないと言われ、数日家族が付き添い、結局亡くなった。

テレビで老衰死というタイトルで放映があったが、食べず、飲めなくなったら「これが老衰です。看取りに入ります」と医師は詳細に説明をした上だが、家族に宣言した。その後は何時間も「アー、ウー」を繰り返し、息が苦しくなってきていた。家族は何とかならないかと医師に尋ねたが「これが老衰です」というだけであった。

寿命100歳時代到来と聞くが、いずれ人は死ぬが、どこでどこまでサポートするかの答えはない。私は、個人的には言語的疎通はなくても、笑顔や視線やしぐさで、認知症でピントが外れても意思がある間はサポートすべきと考えているし、自分の母にもそのような対応をして、精神的には全く意思が表明されず、治療できない身体疾患による意識混濁の中での意味不明の言語しか見れず、身体的に呼吸循環のサポートを内科医もしてくれても無理とわかったところで、少し死を早めるが、酸素も中止として死亡した。やるだけして、無理なら無理をしないという考えだ。やはり根本は健康時の自分の意思表明であることには変わりない。

1992年から私は尊厳死協会に入会し、さわ病院も尊厳死を表明した人を受け入れる病院に1995年3月に登録した。しかし、同年12月の会報に「アルツハイマー病と診断を受けたら延命措置を断る」という会員が８5％いるとあった。当時まだ啓発が不十分であった点もあったろうが、私は1996年2月に自分の患者で、アルツハイマー病と診断された尊厳死協会会員が体の病気も悪化し亡くなるまでの経過について家族の了解の下理事会に書簡を送り、協会誌に掲載された（1997年9月）。尊厳死協会はその後、今に至るまで、認知症だからといってなにもしないで死に至らせるのを容認していない。私の友人でアルツハイマー病となった人をみているが、その妻には、「ご主人は『今を生きておられる』のだから、何度も同じことを聞いたり、頓珍漢なことを言っても、その瞬間その瞬間は一生懸命生きておられる」と説明している。

寿命には平均寿命、健康寿命、その人固有の寿命があるが、健康寿命は概念であって、いつまでが健康寿命かなどはっきりは言えない。レーガン元アメリカ大統領が国民向けに「自分はアルツハイマー病の初期と言われた。私は黄昏への旅に出かける」と国民向けに宣言したことがあるが、徐々に日が暮れてくる（宣言後10年で死亡）のであって、事故や突然死のようにトンネルにある瞬間に入って死を迎えることとは別である。

日本で安楽死は認められていないが、オランダでは法律家も入って本人の希望の下、死に至らせる行為が認められているが、それには要件が厳しい。認知症になっては本人の希望が聞けないので、先に述べた尊厳死協会の会員が意思を表明できる間に「なにもしないという消極的安楽死」を認めてほしいという人が85％もいるというのは考えさせられる。

最近特に耳にするのは「命の選択」という言葉である。平等な命に対立する概念である。災害時にトリアージをして援助すれば助けられる命を優先することは以前からあった。映画のカサンドラクロスは感染した人が乗った列車を壊れそうな橋から落として、非感染者の命を選択し、感染者を切り捨てようとしたというストーリーである。

直近ではコロナで医療が逼迫して、酸素が足りない、人工呼吸器が足りない、ECMOが足りない、果ては入院ベッドが足りないといろいろのステージで、命の選択が行われ出した。特に高齢者は優先度が低くなる。私は以前からtwitterで「命の選択をするなら、年齢でなく、patientな人をimpatientな人より先に治療するべきである。マスクもせず、夜中まで飲み歩いたりするimpatientな人は最後に選択されるべき人だ」と言ってきた。

前回の　スペースシャトル地球号でも書いたように、スペースシャトル地球号では、快適な生活を希望し維持しようとすると、さまざまな制限が必要になる。それは資源の利用者が増えるなら資源を増やさねばならなくなるが、それにも限界がある。また資源を増やそうとすると、その活動で増える廃棄物が増えるのでそれを減らす、あるいは廃棄物が出ないようにする、あるいは今でいう「循環型社会」としてスペースシャトル内の状況が変化しないようにする必要がある。それ以外の方法としては、スペースシャトルの資源が一定なら、搭乗人員を増やさないことであろう。しかし現実には、UNICEFから募金活動への協力のお願いをされるが、貧しい子の話を、私たちは暖かい部屋で食事しながらテレビで人ごととして見ているという自己矛盾、切り離しもしながら生活している。

昔は相対的に資源の利用者を増やさないための悲しい行動があった。生まれた子供を殺す「口減らし」、生産に役立たなくなった高齢者を山に捨てに行く、これは「楢山節考」として映画化もされ、翻訳版は1958年のベルナール・フランク訳（仏題：“La Ballade de Narayama”） （1959年のガリマール版（ベルナール・フランク訳）の表題はETUDE A PROPOS DES CHANSONS DE NARAYAMA）をはじめ、各国で行われていると聞く。今でも「子殺し」はいろいろの形で起きている。

怖いのは、人における命の選択に比べると、動物の命の選択にはそれほど問題視されないことである。これまで、鳥インフルエンザでは鶏、他の動物も今ではワクチンができて減ったが、口蹄疫では牛、馬、豚が何十万匹も屠殺されてきたし、ニュースで聞いてそうかという程度となっている。コロナウイルスが猫で発見されたと一時言われたが、たまたま検査に引っ掛かっただけというようなところで止まっているが、もし本当に猫に感染し、猫同士で感染し、人への感染があるするということが事実だとわかったらどうするのだろう。猫好きな人は屠殺などという話が出たら猛烈に反対するだろうし、このようなことを書く私も非難されるだろう。

Choice of Life

This term is often heard in “triage situations” in disaster or in the current shortage of hospital beds and medical equipment under Corona infection.

However, this term is not limited to disaster situation or under Corona infection situation.

The term “death from old age” （same as death by senility）is used in death certificates, but the reality varies. If a person becomes too old to eat or drink and eventually dies, this can be called senility, but sometimes the inability to eat or drink may be just a temporary event.

Let me tell you a story about my friend’s grandmother. After she turned 90, she began to show signs of dementia. However, she loved to do handcrafts, and she would knit things like a long scarf, which she would show me with a sweet smile. She was also the kind of woman who would light a candle on her Buddhist altar to worship her ancestors when she stayed out at her home after being temporarily discharged from our hospital. One day, she could no longer eat or drink. I did not know what to do, but I gave her a drip infusion to rehydrate her. She got well and said, “Oh, I slept too long,” and started knitting again for a while. However, she was unable to eat or drink again, and this time, even with the drip infusion, she was unable to recover and passed away at the age of 94.

In another story, a patient of mine told me that his elderly mother was no longer able to eat, and he, my patient, thought, “it is enough for her”. His wife, however, said she could not leave her and offered her some Japanese sweets that the mother really loved.  Then she took a bite the Japanese sweets. She needed assistance for a while, but returned to eating normally again. After a while, she again said she did not want to eat, so again, his wife tried various ways, such as offering her some Japanese sweets, but this time it did not have any effect and she passed away. Actually, my grandmother had been hospitalized at Sawa Hospital for a period of time when I was working there as a part-time doctor. Whenever I visited her room, she would always say, “Oh, you have come came here for me despite your busy schedule. “ At some point she stopped eating and I encouraged her to eat. But “I have lived long enough.” she said and refused to eat. I inserted a stomach tube and tried to put nutrients and water into her stomach, but it hastened her death.

Let me tell you about my aunt. My aunt had pulmonary tuberculosis when she was young and was on home oxygen therapy when she got older. She did not like the oxygen equipment and would take it off from time to time, but she still found it suffocating painful and would turn the oxygen on and off. She lived all by herself. She continued to drive until she was quite old and stayed at home until she was about 93 years old. At the end, she was admitted to a hospital specializing in respiratory care. The doctor said, “She will not live so long, what about administering oxygen?” The attending physician asked. I wanted him to do all he could then asked him to do it so I made the request to my doctor. A few days after the oxygen administration was started, the breathing sound “ah, woo” continued. After consulting with her relatives together, I asked her doctor to stop administering oxygen to her. However, once it had started, it could not be stopped. The family stayed with her for a few days and eventually she passed away.

A program titled “Death by Senility” was aired on TV once. One person stopped eating and drinking, and his doctor said, “This is senility. All we can do is to be here for him. ”

the doctor declared to the family after giving a detailed explanation. After that, the patient kept repeating “ah, woo” for hours, and his breathing became increasingly labored. The family asked the doctor if there was anything that could be done, but all the doctor could say was, “This is senility.

The age of 100 years of life expectancy has been called for. People will eventually die. However, there is no answer to the question of how much support should be given to a dying person. In my personal opinion, even if a person cannot communicate verbally or cannot speak coherently due to dementia, we should support him or her as long as he or she can confirm their intention with a smile, a glance, or a gesture. I have taken such a stand with my own mother. When she became not only mentally unable to express her will at all, but also spoke only unintelligible language in a clouded state of consciousness caused by untreatable physical condition , and her internist determined that she could not go any further with respiratory and circulatory support, he stopped administering oxygen to her, which I knew would hasten her death a bit, and she passed away. Do my best. This is my policy. After I have done my best, I do not overdo it. The root of all this is nothing more than a person’s statement of intent when he or she was in good health.

Since 1992, I have been a member of Japan Society for Dying with Dignity. In March 1995, Sawa Hospital registered as a hospital that accepts people who have declared their intention to die with dignity. However, in the December of the same year, the society’s newsletter stated that 85% of its members “refused life-prolonging measures when they diagnosed with Alzheimer’s disease”. Although awareness-raising was probably still insufficient at that time, I sent a letter to the Board of Directors in February 1996, with the consent of my own patient and a member of Japan Society for Dying with Dignity, regarding the process leading up to his death with Alzheimer’s disease and physical problem, with his family’s approval. It was published in the society’s newsletter (September 1997). Since then and until now, Japan Society for Dying with Dignity has not accepted the practice of letting a patient die without any treatment just because he or she had dementia. I see my friend who suffers from Alzheimer’s disease. I told his wife, “Your husband is living in this moment. He will ask you the same questions over and over, or say something absurd. He is living in the moment, in the moment, for the rest of his life.” I explains.

There are various concepts of “life span,” such as average life expectancy, healthy life expectancy, and so on. There is no clear definition of healthy life expectancy. In a message to the nation, former U.S. President Ronald Reagan said, “I have recently been told that I am one of the millions of Americans who will be afflicted with Alzheimer’s disease. I now begin the journey that will lead me into the sunset of my life.” He gradually, as if by sunset, died 10 years after declaring his illness. This death is different from an accident or sudden death, as if he suddenly entered a tunnel.

In Japan, euthanasia is not allowed to be enforced. In the Netherlands, on the other hand, euthanasia is permitted at the request of the patient, with the intervention of a lawyer. However, the requirements are very strict. When a person suffers from dementia, it is no longer possible to confirm his or her will. Going back to the above-mentioned Japan Society for Dying with Dignity it is thought-provoking that 85% of the respondents expressed that they would like “passive euthanasia” to be allowed while they are still able to express their will.

The term “choice of life” is the one that I have been hearing a lot about lately. It is a concept that is at odds with equal life. In the event of a disaster, the act of triage and selection of the lives that can be saved has been around for a long time. In the movie “The Cassandra Crossing,” people tried to cut off the infected, choosing to save the lives of the non-infected by dropping a train full of infected people off a bridge that was about to break.

Currently, medical care is tight under a Corona infection. Lack of oxygen equipment, ventilators, ECMO, and finally inpatient beds, are beginning to make the choice of life in many situations. In these situations, the elderly in particular are given less priority. I have long been saying on twitter, “When it comes to choosing a life, don’t choose based on ages; the PATIENT people should be given priority over the IMPATIENT people who do not wear masks and drink until midnight.”

Let me refer to my previous article on ” The space shuttle EARTH “. In the Space Shuttle Earth, if people want to maintain a comfortable life, various restrictions are necessary. If there are more users of resources, resources will have to be increased, but there are limits to resources. If we try to increase resources, we will in turn increase waste. What is important is to reduce the waste, or more specifically, to prevent the generation of waste. It is necessary to ensure that the situation inside the space shuttle does not change as what is now called a “recycling-oriented society”. From another perspective, if the resources of the space shuttle are known to be constant, there is an option not to increase the number of people on board. However, when we look at reality, we are watching the stories of poor children, such as the one in the UNICEF request for fundraising cooperation, as a personal matter on TV while eating in a warm room. We live in such a self-contradiction.

In order not to increase the number of resource users, there have been sad actions throughout history. Such as the “slaughtering”(kill newborn child), or dumping elderly people who are no longer useful in production into the mountains. This story has been made into a film, “Narayama Bushikou,” translated by Bernard Franck in 1958 (French title: “La Ballade de Narayama”), and published in 1959 in the Gallimard edition (translated by Bernard Franck) ETUDE A PROPOS DES NARAYAMA. In other countries, sadly, “infanticide” still occurs in various forms.

The scary thing is that the choice of animal life is not seen as much of a problem compared to the choice of human life. So far, chickens and other animals have been slaughtered for avian influenza, which has been reduced because a vaccine is now available, but hundreds of thousands of cows, horses, and pigs have been slaughtered for foot-and-mouth disease. When we hear such reports on the news, our reaction is just limited to “Oh, I see”. It was briefly reported that Corona virus had been found in cats. The story stops at something like “it just happened to be caught in a test contamination,” but what if it turns out to be true that it really infects cats, is transmitted between cats, and can be transmitted to humans? Cat lovers would vehemently object to such things as slaughtering cats. They would also greatly condemn me for writing this.