The current health care model mandates that discharge planning begins the day a person enters the hospital. On a grander scale, life follows this model; from the day of birth, a person moves toward his demise. Maureen Holtz’s novel The Last Resort explores a future in which a small country in Africa bases its economic survival on providing a place where self-determination at the end-of-life is legal, thus generating a unique sort of medical tourism. Using an American “everyman,” Holtz intertwines the lives of Livvy and Simon Harper, who reside in Illinois, with the politics and health care of both America and Mkanda, Africa. She explores a not-too-distant future (2020) in which an aging population burdens not only family, but also the finite resources of health care.
The questions raised by this novel are not pretty, not easy to discuss, nor are there any quick fixes or ready answers. This is what makes it must reading for anyone: health care providers who offer extreme options without assessing post-procedure quality of life, family members who pursue what’s radical and new without considering outcome, the young who will be responsible for a portion of the costs through taxation, the aging who will leave a legacy of health care debt with the coming generation.
Ms. Holtz complicates the overall picture by introducing the conflict between faith and medical ethics. When a family faces health care decisions, what role does faith play in making medical choices? Quite simply the novel poses two important questions: Who decides? And who should decide?
Livvy and Simon Harper know tragedy. They have lost a child. Simon’s parents have died. Livvy’s mother succumbed to cancer. Now Livvy’s father, Hank, a successful journalist with an inquisitive, brilliant mind, has been diagnosed with ALS and early Alzheimer’s.
As these family problems unfold, President Adebayo, of Mkanda, must live up to his campaign promises and revitalize his country’s economy. He proposes the Euthanasia Legalization Act. In Mkanda access to health care is negligible. Adebayo watches a worker dies by the roadside in agony because of the impoverished country’s lack of resources. As a doctor, Adebayo wrestles with his pledge to “do no harm” and the harm caused by allowing suffering to continue. He and his aide Kwesi come up with the idea for The Last Resort, a place where those who wish to end their lives can come to a pristine setting, plan their last days, and exercise control over their final moments.
Ms. Holtz illustrates the subtle mental and obvious physical decline of Hank with accuracy. She allows the reader to see these changes from different points of view. Hank shares his perception through an inner dialogue filled with candor and doubt. Livvy frets over what’s next and how she and her husband will manage Hank’s care. Hank’s friends surround him with support and the therapy of good memories. Hank, ever the investigator, hears about Mkanda and begins to talk about choosing how he wants to die.
Hank’s decline occurs as President Adebayo’s plans come to fruition. The Last Resort opens. Gradually the number of clients increases. As people experience a different way of dying and Mkanda’s economy flourishes, a modicum of acceptance comes to the country and its people.
This book has many strengths. In Livvy Ms. Holtz creates a character who draws the reader into the horror of a family member wasting away not just physically, but mentally as well. Livvy struggles with suicide as a sin in the context of her religion. As she watches Hank deteriorate, she questions her faith. The reader can’t help but join in vicarious debate about life, faith, and final days. Hank speaks for all who perceive nursing homes as warehouses for the frail and elderly who are managed by drugs rather than any sort of individualized care. Even the family dog, Sherlock, introduces a thematic element and allows the reader to establish the contrast between the humane therapies given a dying pet versus the options given a human being.
One sub-plot of this unsettling novel is the role of pharmaceutical companies in medical care. Before The Last Resort can open, a price of the drug used to end life must be negotiated. The usual dickering over cost and profit occurs. After The Last Resort opens, a plant that produces a drug which causes a rapid, pain free death is discovered in Mkanda. A taste of white collar espionage and greed ensues. The novel alludes to the complex process of FDA drug approval in this country. This element flows well in a story laced with multiple medical-moral issues.
As someone with a health care background, I wish Ms. Holtz had created scenes that addressed some missing pieces. I asked myself why there was no scene where Livvy sought serious counsel from the clergy. When faith was so important to her, it would seem a logical step in the process of finding out how best to support Hank. I also think to show the potential benefit of such a discussion would add much to what this novel has already taught about living and dying.
Ms. Holtz skims over the use of Advance Directives and Durable Power of Attorney for Health Care in end-of-life situations. These legal concepts represent strong, albeit not absolute, tools in self-determination. She also fails to address the role of palliative care and hospice in the lives of the terminally ill. In some institutions, a palliative care consultation is required when a patient is considered for certain therapies. Comfort and quality of life represent top priorities. In the overall context of this thought-provoking and controversial novel, these are minor omissions.
The Last Resort is an imaginative novel that forces the reader into the tempest of human truth: from the day of birth, a person moves toward his demise. Ms. Holtz offers a means by which a person can direct his course.
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