Assisted Suicide
Tuesday, January 3rd, 2006Original post and most of the comments can be found Dr. Chris Rangel’s blog.
Monday, December 19, 2005
Rangel on assisted suicide - Moof asked me for my take on this issue in response to the news that a Swiss hospital will allow euthanasia. I realized that I had not yet blogged my thoughts on this so here goes.
I take a more libertarian approach to euthanasia and I hold patient autonomy in very high regard. If a terminal patient is in a great deal of pain and suffering and where the only therapeutic option means living out their remaining days in a drug induced “haze” then I think that society should offer them the option of permanent relief.
I know that physicians take an oath to preserve life but reality is often a sharp contrast to idealistic notions of the healing arts. Medical science does not yet have the ability to effectively treat many types of severe pain and suffering often seen in terminal illnesses. As such the oath to preserve life becomes in essence an oath to preserve suffering in these terminal cases where there is no hope.
This context of suffering when there is no hope of effective relief and when death is inevitable is very important. Opponents of euthanasia and assisted suicide often try to skew the argument to include cases where neither refractory suffering nor a terminal state exists. Or they suggest that a “slippery slope” will occur where euthanasia will be applied to severely debilitated patients or those who are unable to give fully informed consent such as the severely mentally retarded like that seen in Nazi Germany.
But the slippery slope argument is a fallacy. We are not Nazis. Our society has a very high regard for the sanctity of life, otherwise this issue would not be so controversial in the first place. In places like Oregon and the Netherlands where physician assisted suicide is legal, there is no evidence for the slippery slope that many feared.
Such doom-sayers and the fanatical antics of Dr. Jack Kevorkian complicate and cloud this issue and impair what should be a very important dialog in our society about pain and suffering at the end of life. The discussion needs not to be centered on euthanasia itself but upon the definitions of “suffering”, “terminal illness”, and on patient autonomy.
posted by Chris Rangel Permalink |
But the slippery slope argument is a fallacy. We are not Nazis. Our society has a very high regard for the sanctity of life, otherwise this issue would not be so controversial in the first place.
I’m not sure I completely agree with you there. I personally believe that our “regard” for the “sanctity of life” is, indeed, careening down a “slippery slope.”
Give a mouse a cookie …
And even if we’re only now exploring the edges of what could be thought of as the “proper applications” of Euthanasia in medicine, who are we going to be tomorrow?
Look at the societal trends over the last century … and take into account that once you’ve opened that sort of door - the floodwaters will prevent you from ever completely closing it.
30 years ago, with Roe VS Wade, we warned that Euthanasia would soon follow. We were told: “No way! That’s ridiculous! The two aren’t even related.”
… Yet here we are …
Only the inception is difficult … the progression is frighteningly simple - and often silent.
A slippery slope is a fallacy if you assume that one event (legalized euthanasia) will automatically lead to another event (decrease in the sanctity of life) without giving a rational explanation as to why this will happen. I do NOT believe that it is “a prior” evident that legalized euthanasia (not matter how repugnant it may be to many people) will compromise the value our society places in life.
Other than chronological circumstance I see no connection between Roe v Wade and legalized euthanasia. It is exactly the trends over the last century that have lead us here. What trends? How about the trend to recognize patient autonomy? The protections against unethical and involuntary medical research? The movement to ban torture (except recently in this country). The patient bill of rights? The revolution within the medical profession on recognizing and focusing on patient suffering and relief of that suffering (believe it or not, pain control was too often not a very high priority for doctors in decades past). The emergence of the hospice movement. The emergence of and increasing use of “living wills” and other advanced directives. The recognition that medical science has very defined limits and physicians are not God(s) and to allow suffering to continue in cases where further aggressive treatment is futile is unethical.
These trends and many more (not Roe v Wade) have combined to bring us to this point. As I have stated, this issue is about suffering and the relief of suffering not just about death. To view this debate strictly from a perspective of defending the sanctity of life is to see only one side of the coin.
At some point in this country’s history, laws became not about protecting the individual from the unlawful acts of others, but about protecting the individual from him or herself. From seatbelt laws to assisted suicide, we dictate choices to people even though the result of those choices will harm no one but the person making them.
How this shift happened, I don’t know, but I really hope it turns back.
CJD
Please forgive me, but I have to comment on your reply …
“[…] if you assume that one event (legalized euthanasia) will automatically lead to another event (decrease in the sanctity of life) without giving a rational explanation as to why this will happen.“
What assumption? I didn’t assume 30 years ago that Roe VS Wade would erode the “sanctity of life,” I realized it would - and it has. Can I prove that they’re connected? No … but either the “connections” I saw 30 years ago were “fallacious,” and the world just happened to morph into a place where people “terminate” inconvenient children as a method of birth control, and where adolescents go on blood-thirsty shooting sprees in their schools … or I was a prophet (a bit unlikely!) … or there really were visible tendrils of certain mind-sets which connected the “then” to the “now.”
So, can I prove it? … no. But neither can you prove that it didn’t, especially since you state that you can’t even see the contrast.
Dr. Rangel … you want to focus on the good of the advances in the last few decades. That’s fine, because there has been some good … however that good has been more than counter-balanced, and if we can’t see that, then we’re doomed to continue in an endless loop of ever more imbalanced cycles until someone (or many someones) are able to restore some sort of sanity.
Perhaps you would never consider using your medicine in a way that would deliberately harm someone … but you’re only one man. Perhaps you can draw the line: “We’ll take it this far, and no further!” … but - what about the physicians yet unborn? Those young men and women who will perhaps be raised in a society where there are no remaining voices raised against the trend toward “convenience” at the expense of the most silent, innocent lives … what about them? Will they see it the way you do?
I had a dear friend, a Dutch physician, who became very intimately involved with WWII - from both sides - in a concentration camp as a prisoner, and in a concentration camp as a “doctor.” Were he still here today, he could spell out the “chain of events” and highlight the contrasts in ways that I cannot. When a moral, kind human being can evolve from victim to victimizer because of relatively brief circumstances lasting less than a decade, I sincerely believe that a people can mutate into a society that worships convenience above all else - especially above those among us who become useless and inconvenient - much like far too many of today’s unborn babies.
And so, from the seemingly noble desire to “ease pain,” we begin to ask questions like I recently saw on another doctor’s blog: “Treating a patient for the benefit of others” …
There are some doors best left unopened, because we’re not the only ones who will walk through them …
I agree with you on this score: “To view this debate strictly from a perspective of defending the sanctity of life is to see only one side of the coin.” … there are so very many more issues here, but Dr. Rangel, as a physician, shouldn’t defending the sanctity of life be one of your own major issues?
This is such a volatile topic, and I don’t expect you to see what I’m saying … at least not now. You may even believe that you’ve heard it all before, and already have all of the answers … however, for your sake, I hope not. Like society, I think that our experiences and ruminations change us as we go through life. Who knows - if we were to have this discussion in another 20 years, what would we say?
It is such a difficult issue, but my feeling, and certainly my practice, is to have no truck with euthanasia. There has been great discussion of “duality of purpose” where a terminally ill patinet requires an amount of medication so great (and usually by syringe driver) that it may hasten his demise. My feeling is that it is extremely rare for this to happen, and often good symptomatic control, good pain releif may actually prolong life.
I am very sympathetic to the views expressed by MOOF. This is a door that that the medical profession must not go through, indeed must not even open. There are profound religisous and spiritual issues here, but for me these are secondary and a matter of personal belief. For me it is more simple. Killing people - and that’s what this is, whatever euphemism you may care to wrap it up in - is not part of my job description. That is not open to debate or compromise for me. I have no problem with people who wish to end their lives though I would alway do my best to talk them out of it. But if they DO end their lives, I am not going to help.As you will all be aware, there has been terrible controversy about Harold Shipman in the UK, and currently another doctor has just been prosecuted for murder for giving i.v bolus doses of morphine/diamorphine which even to those of us with experience of terminal care and used to using largish doses occasionally are utterly incomprehensible.
Patients MUST be 100% certain about the doctors aggenda, and that must always be to preserve life. Once there is a doubt, once, as MOOF suggests, you open the door even by an inch, then confidence has forever gone.
A modern myth has grown up that dieing is pleasant, is a learning experience, or whatever. It is not. But that is not a reason for doctors to hasten death. Ever. It’s not what we do.
Moof, I enjoy a good intellectual conversation and I hope that you don’t take my disagreements too seriously but I will disagree with you.
I’m not sure what connection teens on killing sprees have to do with legalized abortion. True, there have been some horrifically violent events since Roe v Wade but is there really a connection? Has legalized abortion really lead to a lower value for human life and thus more violence in our society?
In reality, the world was a much more violent and unjust place prior to Roe v Wade; public execution, child labor, slavery, genocide, religious warfare, cruel and unusual punishment (the rack anyone?), minority group persecution, indentured servitude, etc. etc. If I go by your line of reasoning then I can assume that Roe v Wade lead to a much more peaceful reality, particularly in this country (and there are some who believe that lower crime rates seen in the last 20 years are in part related to fewer unwanted children who would grow up in an environment of neglect and despair and thus be more likely to resort to crime - but I’m not going there). So you see. For a causality argument to be made you must do much more than say that event B follows event A therefore A caused B!
“So, can I prove it? … no. But neither can you prove that it didn’t, especially since you state that you can’t even see the contrast.”
I’m sorry Moof but the onus of proof is upon you. You made the claim that Roe v Wade is connected to such terrible events as teen killing sprees and the resurgence of the consideration of legalized euthanasia. Not only do I NOT have to prove a connection but also it is completely illogical for you to request that I “prove that it didn’t”. No one can prove a negative, only a positive.
Yet I do understand what you and Dr. Crippen are saying. If we never open Pandora’s box then we never have to worry about it. But this argument is close-ended. You no proof that legalized euthanasia would lead to broad expansion of the practice and a generalized decrease in the value we place in human life. Thus you never address the real issue, which is refractory suffering at the end of life. You never take a look at the other side of the coin and I think that this is a big mistake.
This is often the puritanical nature of western society and America in particular. Too many of us see life in black and white. We think, I we don’t do a certain thing (legalize abortion or euthanasia for example) then nothing bad will happen. Wrong. Life is rarely black and white. Terminal patients continue to suffer and more and more of them and their families are re-examining options and issues at the end of life (you must understand that this is really the source of the demand for legalized euthanasia. It doesn’t come from death loving liberals or fanatical Kevorkian clones).
Assisted suicide is already legal in Oregon and many countries. We can’t continue to hide behind rocks and chant, “don’t open Pandora’s box” over and over hoping that it goes away. We need public discourse from people like you and Dr. Crippen to help define the limits and terms of what is very likely to be many new laws about legalized euthanasia in the future.
I think it is important to focus on the patients that would be able to choose this option of euthanasia before examining the pros and cons. These are usually patients that no longer have quality of life. They lay in a hospital bed, bad enough in and of itself, and are suffering. Death is not a bad thing, only a natural part of life and if our medicines and treatments are extending that life beyond what is natural then why can’t that patient choose the option of what would’ve happened years back without our medical advances?
Everyone here is so concerned of the sanctity of life, but what about the sanctity of death and the comfort that death can be to many of these crippled patients. This is not going to be an option to patients that just want to die but only to those that what to end their suffering. Let’s leave out all of the religious issues because yet again that it for the patient to deal with given that it is their choice.
I want to stress that this is only for the suffering patient that has a terminal illness that we cannot cure or treat, but only extend the time the patient suffers, not for any other patient. For example, we had a patient that we were treating for an arm wound in the O.R. that was admitted to the hospital because she took a Xanex, some Vicodin (don’t know how many), and some Ambien (don’t know how many), and passed out on her arm cutting off the circulation. This was supposedly not a suicide attempt, but given the fact that this patient was a nurse and knew what the combination would lead to, it is hard to say otherwise. My point is that euthanasia would not be an option for this patient who is now suffering from the inability to move her arm, horrible wounds on her arm, obesity, and depression. No medical treatments have prolonged her life beyond its natural expectancy, in fact her lifestyle will probably shorten it, her choice. Patients with terminal illnesses in the last stages have lived longer then expected due to medical treatments which is great, but when it comes to the point where the patient’s quality of life is absent and suffering is prevailing why can’t they choose euthanasia as their peace? Just my point of view.
We need to separate two issues.
1. Do you beleive in euthanasia?
I do, though I would always do my best to talk someone out of it, and would feel as a physician that I had failed if it was my patient.
2. Who should do it?
That is simple. Not me. Not doctors. If a euthanasia servive is needed, then there will be plently of people willing to do it. There does not seem to be a problem getting people to kill criminals, so why should it be difficult to get people to do it in a much more valid cause?
Before I begin, I’d like you to know that I’m copying this “conversation” as it happens into a page on my blog, and have encouraged readers to come to your blog and join the discussion.
———-
Dr. Rangel, of course I’m going to take your disagreements seriously - otherwise this “good intellectual conversation” would be a pointless exercise in rhetoric … what I will not do, however, is take them personally. I also am fond of a good debate, and always keenly interested in understanding what makes people think and behave the way they do.
Let me try to tackle your reply one section at a time. I know that I don’t have all of the answers, and that my own understanding is so limited that I may not do the issues justice, but I will submit my humble effort here, nonetheless, and ask for your patience.
“True, there have been some horrifically violent events since Roe v Wade but is there really a connection? Has legalized abortion really lead to a lower value for human life and thus more violence in our society?“
Can I pull an empirical connection from my little bag of tricks and dangle it in front of you? No. We both know I can’t. I can offer you this, however: In the same way as I know that a child who is abused is more likely to become an abusive adult, I know that a child who realizes that he is only walking this earth because he wasn’t “an inconvenience,” is going to make the connection on some level that convenience supersedes life. He’s going to stack his values in a different order than a child who is taught that all life is precious.
The child who realizes that his parents only allowed him to be born because they’d already redone the kitchen, and added a bay to the garage, or who’ve preset the number of children they’re going to have because they don’t want to lower their “quality of living,” is not going to see the value of life in the same way as a child who has a half dozen brothers and sisters, not much under the tree at Christmas, usually wears hand-me-downs, but is being taught to rejoice in the love and warmth of family.
“In reality, the world was a much more violent and unjust place prior to Roe v Wade; public execution, child labor, slavery, genocide, religious warfare, cruel and unusual punishment (the rack anyone?), minority group persecution, indentured servitude, etc. etc. If I go by your line of reasoning then I can assume that Roe v Wade lead to a much more peaceful reality, particularly in this country (and there are some who believe that lower crime rates seen in the last 20 years are in part related to fewer unwanted children who would grow up in an environment of neglect and despair and thus be more likely to resort to crime - but I’m not going there).“
Ah … but you just did “go there.” Did you take a minor in law? ;-)
A counterpoint to that little “sound bite” can be found on this very well cited web page. There are some interesting government statistics there. While adult perpetrated crime has gone down overall, violent crimes by children have increased - a lot.
Yes, the world was “violent and unjust” before Roe VS Wade, and it remains so today, only today’s violence can come in a variety of disguises. Violence in our day sometimes hides behind civil (and empty) words, “inclusive” ideas (which are really exclusive in nature,) and the veneer of compassion, which will fail to identify moral sickness by its proper terms for fear of offending anyone, fail to correct those things which make society ill for fear of being of being labeled intolerant, and not only fail to prevent a life from ending, but actually lend a hand to its demise.
Would putting a stop to abortion and preventing euthanasia from making further inroads be an instant cure? No way. There’s been too much water under the bridge. And you know, Dr. Rangel … it’s not like you can reeducate a people who’ve lived the way we have for the last 40 years or so. You can’t reeducate innocence. Once it’s gone - it’s gone. The death of a society’s innocence, I believe, can be seen in the necrotization of that society’s conscience, and in a disregard for that most basic right of all: human life - at any stage of development.
If you don’t care for the fact that I’ve only addressed the ideology behind violence in today’s society as compared to the days before Roe VS Wade … then I’ll toss in a few more concrete examples: sweatshops, slavery (yes, even today,) genocide (Rwanda?), cruel and unusual punishment (the rack??? … *cough!*) … ok, since you can use that kind of example, I’ll have to toss one in too: bracing for the 2008 political debates. *cringe!*
“Thus you never address the real issue, which is refractory suffering at the end of life. You never take a look at the other side of the coin and I think that this is a big mistake.“
The real issue is life. Suffering is one aspect of life. So is joy, depression, health, illness … ad infinitum. I will now address suffering, and as a courtesy, I would like to ask you to address what I consider as a major issue, which is the weight of convenience over life.
( … And by the way, when I was homeschooling my kids, I taught them that it was “always” a mistake … (never not a mistake? ;) … to use terms like “never” and “always” … considering that, most often, neither of them are accurate enough to be useful … )
Suffering is very hard to quantify. As a physician, you’re familiar with the infamous 10 point pain scale - which is something I refuse to use. Like values when compared to morals, it’s a sliding scale of such flexibility that it’s meaningless in any objective study. My 5 points might be someone else’s 3 points … or 9 points! How would you know? And if I do play the number game, how do I know what my answer means to you? In fact - from one medical problem to another, I may not even be able to compare from my own subjective experience.
I know that some people feel pain more acutely than others, and as a physician, I’m sure that even without the pain scale or subjective differences, you have a fair idea of what someone must be experiencing, and how to go about making them more comfortable short of ending their lives. I know for a fact that some who have died from particularly long and painful bouts with cancer spent their last hours in serenity. A Dutch physician I mentioned earlier - died with a smile on his face. Literally.
End of life pain is like any other - treatable to some extent. There is pain that we experience in the course of living which can be worse than the physical pain we’ll experience at our death … will you try to cure that pain by such extreme means? That the pain is happening at the end of life isn’t a valid reason for ending a life, any more than it is when faced when there’s no apparent danger of death.
I know that this is not a definitive - or perfect - answer. There isn’t one. Any more than there’s a definitive or perfect answer to crime, suicide, chronic incurable illness, lives of loneliness, certain infirmities … or the fact that if there are 100 people, there will be 100 views on a single issue! No, it’s not perfect - but ending a person’s life because they’re terminal isn’t a solution - it’s a whole new problem.
“This is often the puritanical nature of western society and America in particular. Too many of us see life in black and white. We think, I we don’t do a certain thing (legalize abortion or euthanasia for example) then nothing bad will happen. Wrong. Life is rarely black and white.“
“Puritanical nature of western society?” Are we talking about the same society that has had legal abortion for 30 years, has legal euthanasia in select areas, is trying to legislate gay marriage … what? Do we only stop being “puritanical” once we cease all resistance and no longer say “enough already!”
I don’t think any of us are foolish enough to believe that preventing (ending?) abortion and euthanasia is going to solve much. We’re way beyond that. Things haven’t been “black and white” for a very long time, Dr. Rangel. There are many shades of gray. Those who think in “black and white” are not often very useful to either side of an issue. The question is - when you do some honest research, do you look for what you hope to find … and if you find something you didn’t want to see, do you accept it?
“Terminal patients continue to suffer and more and more of them and their families are re-examining options and issues at the end of life[…]“
Yes, just as they are at what could be the beginning of a life, but all too often becomes the end of a life. Convenience. It’s all about convenience. Suffering is never convenient, but it is a part of life, and it’s a part of death - and death is also part of life.
Something we will learn - most likely the hard way: just because we can, doesn’t mean we should.
It’s late here, and I should go to bed, and I just checked in on the “debate so far†and I have to comment a little more. I came into this discussion because of my loathing of the idea of doctors being involved in euthanasia. I am not sure that I can go along with the widening of the debate to Roe & Wade, and particularly not to the appalling gun crimes in the USA.
At the risk of throwing a real hot potato in, the gun crimes and killing sprees in the USA are due to your gun laws; no more, no less. All that nonsense the gun lobby puts out about the Second Amendment giving them the right to keep assault weapons in the glove compartment is because most of them are too illiterate to read the first half of the sentence. This is not about respect for life, or euthanasia, or Roe & Wade, it is about the stupidity of allowing anyone who pleases free access to guns.
Abortion is a separate issue to euthanasia and can be distinguished from it legally, medically, ethically and practically. To many it is the lesser of two evils. I think one can support abortion but not support doctor-participation in euthanasia. I cannot go along with Moof’s implicit suggestion that support for one automatically leads to some sort of moral turpitude and lack of respect for the sanctity of life.
For me, as I have said, it is a moral absolute that doctors don’t get involved in euthanasia, and in a way it is a blind faith, not susceptible to argument. Rather like capital punishment. I would not have hanged Hitler and I would not hand Saddam Hussein. So whatever practical arguments Chris puts forward, I cannot be persuaded to take part in euthanasia.
But the lawyer in me likes to consider the practical and legal implications as an intellectual exercise and, Chris, if you are going to have doctor-led euthanasia, you have got to make it water-tight.
So let’s run a few things by you.
1. There would have to be legislation allowing euthanasia. Under UK law, you cannot consent to being murdered. You therefore have to legislate. Supposing, therefore, you do legislate and allow patients to ask a doctor to kill them. Under what circumstances?
2. Could they ask to be killed because of intractable depression that has not responded to treatment? Of course not, you will say. But why not? If that is what the really wants, why not?
3. How terminally ill do you have to be to be allowed to request euthanasia? Life expectancy 5 years? 1 year? Less than a year? One month? You would surely have to draw a line…..but where?
4. Should the patient have to have an independent psychiatric accessment?
5. Does the family have to consent? If they do, is it just the partner? Or the children? Or the parents? Supposing there is a disagreement; would you have a vote? Simple majority required, or maybe two thirds?
6. Having signed a document requesting euthanasia, does the patient have to be conscious at the time he is killed? Supposing he is unconsciousness. Does the doctor still kill him? Supposing at that stage, the wife/husband changes her/his mind and withdraws consent? To whom does the physician owe the greater duty?
7. If he does not kill the patient and the patient regains consciousness, could he then sue the doctor for breach of contract? You can just see the lawyers buzzing round that one!
8. Do you take the patients financial standing into account? What has that got to do with it you may say…well, supposing the patient knows that the on-going medical bills are going to reduce the whole family to poverty (and it happens) and so decides to ask for euthanasia rather than soldier on?I could go on. It is intellectually fascinating. Chris, if you are going to have euthanasia you have to answer all the above questions, and when you are done, I have a dozen more. It’s a can of worms.
This is not spiritual, and not religious; it is practical. Profoundly practical. And complicated.
And that’s my point. Whatever your spiritual belief, life is just………too complicated ……..for us to take it upon ourselves to end it.
Oh! Boy. I’m going to bed now.
Happy Xmas to you all.
Dr. Crippen, Dr. Rangel … please forgive my “pause,” but Christmas busyness carried me in its wake, and I was powerless to resist. However, now that I have a moment, I’d like to comment on Dr. Crippen’s last entry.
I agree with Dr.Crippen that the gun question is indeed a “hot potato,” and perhaps more than this particular thread needs, since it’s already quite “loaded.” Dr. Crippen, why don’t you share with us just what it is you think about “all that nonsense the gun lobby puts out” in a post on your blog, and I’ll be delighted to come visit with you and carry on a discussion from the perspective of an average US citizen who believes in the Second Amendment, and who also hunts. I can bring the pizza, and you could provide the tea.
Dr. Crippen also commented: “Abortion is a separate issue to euthanasia and can be distinguished from it legally, medically, ethically and practically.” I’m afraid that I don’t agree. Abortion and Euthanasia are two sides of the same coin: a loss of respect for human life. I don’t care what perspective you view it from - medically, ethically, practically - it is still the same little black kitty with the white stripe down its back. The legal perspective is another issue completely … and is really larger than the scope of this thread. Besides, Dr. Crippen would have us all at a disadvantage with his knowledge of law.
Regarding euthanasia: I wholeheartedly agree with Dr. Crippen that the euthanasia argument is “not spiritual, and not religious; it is practical. Profoundly practical. And complicated.” Well said. I’m sure that those who are religious would want to add a religious perspective, but that isn’t always helpful, because they lose everyone who is not of a religious bent. I don’t even like calling euthanasia (or abortion) an issue, because that seems to diminish its importance … setting it alongside other “issues” of all stripes, from how large a particular type of fish has to be before you can keep it rather than throw it back into the pond … to the cost of higher education.
Life - pro-actively ending life, at its natural beginning, or before its natural end - is more than an “issue.” Personally, all religion, politics, legalities and medical aspects aside, I simply see it as “murder.”
Thank you, Dr. Rangel, for hosting this fine discussion. I hope you had a wonderful Christmas!
Friday, December 30, 2005
Q&A on assisted suicide - In life there are two absolutes; Death and taxes. Actually there is a third; suffering. Many things cause suffering in life but often none more so than terminal illness (usually cancer). When death is certain within a short amount of time and suffering is expected to continue unabated (only incompletely relieved with standard treatment) within this time period should a patient have the right to request help (usually from a physician) in arranging a painless and effective suicide?
Continuing my first discussion on this topic with Moof, one commenter, Dr. Crippen (from the UK), proposed the following excellent questions that need to be considered before any “right-to-die” legislation is proposed. I will answer each in turn.
1. There would have to be legislation allowing euthanasia. Under UK law, you cannot consent to being murdered. You therefore have to legislate. Supposing, therefore, you do legislate and allow patients to ask a doctor to kill them. Under what circumstances?
First off, assisted suicide is not direct euthanasia under either the Oregon or the Netherlands laws. The term “assisted suicide” is not just a euphemism. Patients are “assisted” by a medical professional in obtaining a lethal combination of medications and the means by which to administer them. The Oregon law prohibits anyone other than the patient from directly administering the medication(s) but requires a “health care professional” to be present.
The Netherlands law is less clear on who would administer the medications (probably to avoid discriminating against patients who are able to give consent but because of their illness would not be able to do it themselves) but several conditions must exist; The patient must be a mentally competent adult. The request by said patient for assisted suicide must be voluntary and persist over time. The patient must have intolerable suffering without any hope for relief. The physician must consult with another physician not involved in the case.
2. Could they ask to be killed because of intractable depression that has not responded to treatment? Of course not, you will say. But why not? If that is what [they] really want, why not?
Depression and other psychiatric illnesses do not fulfill generally accepted criteria for assisted suicide; i.e. that the patient is suffering from intractable physical pain and suffering and that death resulting from the same illness causing the suffering is considered to be inevitable. Both the Oregon and the Netherlands laws do leave it up to physician evaluation to determine if the appropriate criteria exist but the Oregon law makes it very clear that if the physician suspects that the patient’s judgment is impaired by depression or other psychiatric illness, a psychological examination must be done. More about the depressed terminally ill patient on question # 4.
3. How terminally ill do you have to be to be allowed to request euthanasia? Life expectancy 5 years? 1 year? Less than a year? One month? You would surely have to draw a line . .but where?
A terminal patient is commonly defined by hospice programs and by the US Medicare program as having six months or less of expected lifespan. I prefer the inclusion of this criteria in being eligible for assisted suicide because it underscores the futility in continuing palliative care when suffering is incompletely relieved, quality of life is poor and death is inevitable.
However, not everyone includes this criteria because there exists the possibility of suffering chronic severe pain/discomfort and/or debilitation from one or more conditions that are not necessarily terminal. This is a valid point but also a source of a lot of alarm from critics of assisted suicide. In particular, they worry about the possibility that non-terminal patients who have debilitating disease will be put to death by society under the pretext of humane relief of suffering from lives that are deemed to be not worth living. But such a slippery slope would have to cross a huge speed bump in that it violates a critical tenant of assisted suicide; that the patient request must be fully voluntary, persistent, and be free of coercion or other undue influence such as depression or substance abuse.
However, the possibility that a patient with a non-terminal illness may be allowed to chose assisted suicide is of continued concern to opponents of such laws (advocates for the disabled are vehemently opposed). How do we know that a cure or effective treatment for their disability and/or source of suffering won’t soon be discovered? How do we know that their lives will not improve with effective treatment and even how do we truly know that a terminal illness is truly terminal (the case of Stephen Hawking who has ALS is often invoked)?
These are valid concerns however opponents assume that these theoretical hypotheticals (the possibility that a cure will be found, for example) usurp the importance of patient autonomy and the reality of human suffering due to physical illness. Opponents have never provided a good argument to why patient autonomy should stop at how, when, and where a terminal/suffering patient decides to die (hence the “right-to-die” debate). Again I raise the question; Does the importance of life always trump the relief of suffering and of patient autonomy?
4. Should the patient have to have an independent psychiatric assessment?
Dealing with psychiatric conditions in terminal illness is tricky for any proposed assisted suicide law. Depression is very common in terminally ill patients and as such I think it’s very important that the patient be evaluated for impaired judgment resulting from such depression or other psychiatric illness. The problem is that an automatic requirement for a psychiatric evaluation may amount to an undue hindrance and delay for the patient who will not benefit from it. Such a requirement will also suggest to these patients that the system (and society) automatically considers them to have some degree of “mental imbalance” for wanting to die. After all, what sane person wants to die? Only depressed or crazy people want to commit suicide! This requirement seems reasonable on the surface but can become quite problematic.
5. Does the family have to consent? If they do, is it just the partner? Or the children? Or the parents? Supposing there is a disagreement; would you have a vote? Simple majority required, or maybe two thirds?
Since this is a question of patient autonomy and self-determination the concerns and wishes of the family are not taken into account in most cases. In addition, the Oregon law makes very clear that the family cannot make a request for assisted suicide on behalf of the patient in the event that the patient is unable to communicate (i.e. in a coma). The request must be voluntary and come from the patient and the patient alone.
6. Having signed a document requesting euthanasia, does the patient have to be conscious at the time he is killed? Supposing he is unconsciousness. Does the doctor still kill him? Supposing at that stage, the wife/husband changes her/his mind and withdraws consent? To whom does the physician owe the greater duty?
Both the Netherlands and the Oregon laws make it clear that a request for assisted suicide be voluntary and be made by a competent and well informed patient and that such request persist over time. The Oregon law specifically states that the patient can resend the request at any time. If the patient is not conscious then obviously he/she cannot continue to give consent nor are they able to resend the request if so desired. In Oregon the patient must self-administer the medication(s), which is another protection against involuntary euthanasia.
In the event that the patient is no longer able to give consent then from a legal aspect it appears that the request is no longer considered to be valid. As mentioned above, consent for assisted suicide cannot be given nor rescinded by anyone other than the patient. Ergo, the physician’s duty is strictly to follow the request of the patient so long as the patient is able to give consent.
7. If he does not kill the patient and the patient regains consciousness, could he then sue the doctor for breach of contract? You can just see the lawyers buzzing round that one!
Considering that this is America (which means “Land of the Lawyers” in Potawatomi) this is a very important question. If the assisted suicide does not work and results in additional pain and suffering of the patient and it can be proven that this was a result of improper procedure, prescribing, and/or monitoring then it should fall into the venue of medical malpractice (ironically). As with question #6 if the patient is unable to give consent for any reason then the physician cannot be held liable for not going through with the assisted suicide in accordance with the law.
8. Do you take the patients financial standing into account? What has that got to do with it you may say, well, supposing the patient knows that the on-going medical bills are going to reduce the whole family to poverty (and it happens) and so decides to ask for euthanasia rather than soldier on?
Ahh. Excellent question. Or to put it another way; What if the patient has reasons other than intractable pain and suffering that are pushing them to request assisted suicide? Many an elderly or terminally ill patient may not want to subject their family not only to the expense of their illness but also to the pain of seeing their loved one suffer and slowly die.
But then again, financial considerations or other concerns not directly related to intractable pain and suffering in a terminal patient do not fulfill the accepted criteria just as depression alone does not (see question #2). What if a terminal patient does have intractable pain and suffering but other concerns like the financial well being of the family do play a part in the patient’s reasoning and decision to request assisted suicide?
If this is known to the physician then a request for a psychological evaluation should be made to ensure that the patient is making the request for assisted suicide appropriately and not under undue influence or pressure. But just because the family may save money from the patient’s early demise does not necessarily mean that this alone supercedes that patient’s right to self-determination!
There are still so many more questions that need to be asked with regard to assisted suicide.
Is it appropriate for the physician to FIRST bring up the option of assisted suicide to a terminal patient who is obviously suffering? Just what is the family’s role in this? What if the family approaches the physician with a request to “convince” the patient to consider assisted suicide? Can family members sue or get a court order to stop the assisted suicide? Exactly how do we determine and document “pain and suffering” in a terminal patient? What does the physician do with a patient who is not in any pain yet but has been diagnosed with a terminal illness and who wants assistance with suicide before the inevitable pain and suffering start? Should we require patients to endure pain and suffering first before we consider a request for assisted suicide?
Yes, euthanasia and assisted suicide is a can of worms waiting to be opened. But in my opinion it needs to be opened and these questions need to be asked because intractable pain and suffering is a very real issue and patient autonomy needs to be discussed and debated within this context. If you believe that we can make the issue of assisted suicide go away by not opening that Pandora’s box then you must believe as well that the issues of futile human suffering at end of life and patient autonomy and the right of self determination will also go away with it. Obviously this will not happen. It is a box that we must open.
posted by Chris Rangel Permalink
Dr. Rangel - you’ve very carefully answered all of Dr. Crippen astute questions.
In the process, you’ve created an article worthy of being refenced in research work … and it appears as if you do, indeed, have all of the legalese right there - nice and neat.
There are still bits and pieces, however, that you haven’t addressed - at least, not to my satisfaction.
Not being a physician, I don’t approach the issue from same perspective as yourself or Dr. Crippen … and neither do I approach it from a religious perspective, but rather from a merely human perspective.
Also, I do so with an eye on history, and man’s propensity for not knowing where to draw the line - or if an issue should even be broached.
And … that once we have begun to do so, the argument will change from the morality of allowing it at all, to making it more available … or in these circumstances … or for those people … or … ad nauseam. It will not stop there, and it will not only be utilized by those with altruistic aims. To think otherwise is to be shortsighted.
You say:
If you believe that we can make the issue of assisted suicide go away by not opening that Pandora’s box then you must believe as well that the issues of futile human suffering at end of life and patient autonomy and the right of self determination will also go away with it. Obviously this will not happen. It is a box that we must open.
That is exactly why “Pandora’s Box” will be opened. You’re right. The reasons you give for wanting to do so, however, in my own mind, do not outweigh the reasons for not doing so.
Without legal euthanasia, we’ve already had Terri. Imagine the joys that await!
I will add your very articulate post to my Euthanasia page tonight, and I’ll be thinking about what you’ve written.
Have a safe and happy New Year.
My view of assisted suicide as practiced in Oregon is that physicians, if they feel it is morally right, can participate without concern that they are hurting medical professionalism. That is because they are not actively initiating or participating in the suicide. Yes, the physician is providing pills but the patient could collect their own supply of a lethal dose of pills on their own. The patient is deciding on their own whether to take the pills, when or whether to throw them out. However, as a physician, I would not want to participate because I just feel uncomfortable about the intent of prescribing the pills.
With regard to active euthanasia. If society wants that with controls, it’s OK with me but this is an activity that no physician should particpate. If active euthanasia is considered desirable by society, then society should provide patients with a “euthanasia technician”, who is not a physician, to do the job. A physician might be involved only in submitting the patient’s history, with patient approval, to the governmental “euthanasia screening committee”. That’s it! Beyond that, it is the responsibilty of the committee and the technician. Anyway, these are my personal views of the issues. ..Maurice.
Just recovering from the family revelling and I need a day to digest your excellent response to the questions I raised. There are no easy answers, and it is full of paradoxes as you say, but before going through your points, a couple of general questions, observations.
I have been a family doc for 20 years, working in a practice with 18000 patients, 10 doctors, and a primary health care team of nurses, physios, psychologists etc etc. We have a de-stressing, non-structured “coffee at 12†meeting most days which is often more educational than educational meetings. So I brought up this discussion (again!) last week.
The first question I asked was, leaving aside the question of euthanasia, how many patients could we remember over the years who had had “intractable pain and suffering†that we could not cope with. No one could really remember one. We talked about a patient with MND who definitely had a difficult time, but it was not pain, it was frustration more than anything.
The next question, was, OK, how many times have you had a patient who had “asked†for euthanasia. We have not had a single one. Not one. We have lots of patients who have filed “living wills†with us in which they ask not have there lives unnecessarily prolonged, but these are of dubious practical meaning, and none of the patients who has left such a document has ever even mentioned it when it comes to the crunch and they became terminally ill.
The message from Dame Cicely Saunders (surely one of the “greats†of 20th Century medicine) has permeated through the whole medical and allied professions in the UK. The symptomatic relief of symptoms in terminal illness is not difficult – once you have thought of it. It’s a bit like the invention of the wheel… well, that was pretty obvious, wasn’t it. Or Semmelweiss spending 20 years of his life trying to get his colleagues to wash their hands. What Cicely Saunders taught us is that there comes a time to stop worrying about the serum rhubarb, stop doing EKGs etc and just look at how to help the patient. Stop the nonsense, much loved by stern old nurses, of analgesia being a “reward†for “at least four hours pain, and it ought to be bad.†Give analgesia, anti-emetics, whatever, regularly, pre-emptively and at what ever dose is needed to achieve symptomatic control. Seems obvious now, but Cicely Saunders devoted her life to getting the message through.
So when the time comes, we put up syringe drivers with diamorphine, methotrimeprazine, midazolam……what ever is needed. We have an excellent local hospice who will admit the patients who wish to be admitted, and have physicians who will advise and visit at home as/if/when needed. We have what is called a “Marie Curie†nursing service who provide a nurse full-time over night to sit with the patient and so allow the family to get a little sleep. We try to manage people at home because we believe being at home with the family is the place to be. Most but not all patients want this; some elect to go into the hospice.
I must say I have a slight beef about the hospice movement (gosh, I’ll be criticising motherhood and apple pie soon) as it is (in the UK at any rate, can’t speak for you guys) giving the impression, much put about by the media that death and dying needs to be removed from the home environment.
Anyway, the creaking old socialised NHS provides all this, so I bet it is even better over there. As I say, I cannot remember ever being asked for euthanasia, though I have often had patients say, “I have had enough.â€
There is one question I have skirted around, and I am surprised you have not challenged me with it yet, and that is the “duality of purpose†question. Are the doses of diamorph or whatever sometimes so large that they actually hasten demise? And if they are, why are you being so prissy about euthanasia, because that is what you are doing.
My answer to that one is that I believe that by and large symptom control does not shorten life in the terminally ill, indeed may prolong it. I accept, however, that occasionally it may shorten life. But then we have to look at the “mens rea†as the lawyers would call it. If there is a risk giving medication for pain relief will shorten life, then occasionally that risk has to be taken, just as the cardiac surgeon, for example, may loses a patient during a valve replacement opertation. I don’t see any difference there.
And the even more difficult one, of omission and commission. I go into the local nursing home to see a 96 year old lady who has been dememted for ten years. The caring family are at the bed side. Over 24 hours she has stopped taking fluids, she has a temperature, she has signs of pneumia. She is peaceful and not distressed. Right: drip, CXR, biochemisty, antiobiotics, phyiso…….of course not. But a decision is taken here, often barely discussed, and no one disagrees. Is it right? It is right to me (need not strive officiously to keep alive…) but clearly one can argue this one backwards and say, OK, where do you draw the line. To which I would say, as the lawyer do, it is difficult to say where the line is, but not difficult to say on which side of the line each case falls. And so we are back in the minefield. I would be really interested to hear Moof’s view on this one. Where would she draw the line?
Now on to some of the points you raise:
1. Yes, we are all watching Oregon aren’t we? “The patient has to self-administer the drug.†Supposing he is not physically capable of so doing? Can you put the tablets in his mouth? Can you give him the drink?
And then we have to ask, how exactly are you going to do it? By self-administered injection (are you going to put the line in?)? Are we talking thiopentone and potassium? You would have to get it right. The idea of having to have a second go does not bear thinking about.
This is where for me it just gets too macabre for words.
The patient must be mentally competent. Hmm. I could produce reputable doctors who would argue that a wish to commit suicide raises questions about mental competence…. Catch 22
2. Depression. I struggle in this area. In the UK the hospice nurses are very keen on putting terminally ill patients on anti-depressants. This is pet peeve number 22 for me. I don’t like it. I do NOT find that most terminally patients are psychiatrically depressed. There seems to be an assumption these days that dying is “funâ€, a “learning experience†and all that sort of guff. Dying is an unpleasant business. People hate it. They get angry, resentful, fed up (Elisabeth Kübler Ross covers this comprehensively) etc but they don’t need†happy pillsâ€. So I would not be comfortable to bring in a psychiatrist – it is sort of insulting.
3. “A terminal patient is commonly defined by hospice programs and by the US Medicare program as having six months or less of expected lifespan.†Hmm…. Don’t you love lawyers, and protocols and things? I remember telling a patient with inoperable lung cancer that he had “a year if you are luckyâ€. He had radiotherapy and lived 12 years to die of prostate cancer. OK, unusual, but how can you tell for certain. And can you imagine the rather macabre procedure of as a physician having to certify that someone was in the “six-month period†and therefore “eligible†for euthanasia. Oh dear me!
You say “the futility in continuing palliative care when suffering is incompletely relieved, quality of life is poor and death is inevitableâ€. There is no getting away from the fact that quality of life is poor when you are (probably) bed-ridden, unable to work, possibly catheterised and so on. On the other hand, you are intellectually competent, you are at home surrounded by your family, and you pain is controlled. I accept that your “suffering†is not full relieved because you are facing the certainty of imminent death, and that is unpleasant. But is that not where family, support from nurses, from the family doc, the church if you are a believer, and so on come in?
Now here is an interesting question. Take a patient who has e.g. severe rheumatoid arthritis. He has coped with this for years, but then gets leukaemia, has had the full whack of chemo etc and is no longer responding. The haematologists say “six months if you are luckyâ€. The leukaemia is not causing his suffering, but the arthritis is, and now he is fed up with it. Can he apply for euthanasia event though he admits it is for reasons other than this “terminal†illness?
4. The rule about self-administration and being conscious brings up all sorts of anomalies. A patient who is riddled with cancer says, “Look doc, I know where this is going. Once I get to the stage that I am unconscious, I don’t want to go any further. Please end it for me.†You can’t do that, can you? Why not? The request is reasonable on the euthanasia construct. So you say, no, I can’t do that, you have to be conscious. And he says, but if I am conscious, I don’t want to do it. I just don’t want to lie there like an unconscious vegetable.
5. Who brings up the question of assisted suicide? Wow, hadn’t thought of that one. Not the doctor for sure. Has to be the patient. Clearly not the family (I don’t want Dad to suffer, can’t you just…….). But I am still not happy with the legalities. These would be bad in the UK but I suspect a nightmare in the USA. Let us suppose you assist a suicide with the written consent of the patient. Then the family sues. He had more than six months. The diagnosis was wrong. He was depressed. And so on and so on. Vexatious, litigious nonsense but I am absolutely certain it would happen. How would you defend yourself? Imagine living through the three years that the case would take? Imagine if the jury found against you? You can see the headlines, can’t you? Would you be automatically struck off or would it just an unfortunate error.
Have the US medical insurance companies expressed a view on this? Will they be happy to cover doctors who do “assisted suicide� What will it do to your already massive insurance premiums?
I am rambling a bit.
Let me put one final argument. It has nothing to do with spirituality, or the disparate views that we all have. It is a simple, practical argument and it is this:
The moral, legal, ethical and practical problems of doctor-assisted suicide are so complex, so fraught with danger and so difficult to cover with legislation that it is not practical so to do particularly as requests for assisted suicide are rare.
Happy New Year.
Happy New Year!
Ok, now that that’s out of the way . .
Should it surprise Dr. Crippen that none of his patients have requested assistance with suicide in the UK where this is illegal? But even in Oregon where this IS legal it appears that patient requests are few and far between.
A total of 23 persons receiving prescriptions were reported to the Oregon Health Division; 15 died after taking the medications, six died from the underlying illnesses, and two were still alive as of January 1, 1999. The 15 assisted suicides accounted for five out of every 10,000 deaths in Oregon in 1998.
Yet, I’m not sure what Dr. Crippen’s point is on this. Are we supposed to tell patients, “I’m sorry but not enough of you request assisted suicide so we can’t offer it to you”? His experience as a primary care physician mirrors mine but like any anecdotal evidence there are few if any conclusions you can draw. I’m sure his experience with terminal patients and intractable pain would be much different were he an oncologist or a trauma surgeon.
And I am very aware that (at least in this country) we come extremely close to active involuntary euthanasia (usually in patients on the verge of inevitable death) with the administration of doses of analgesics that can hasten or even cause death. We certainly enter into the realm of indirect involuntary euthanasia quite often when we treat a terminal minimally conscious patient with “comfort care treatments†only (usually at the request of the family) that includes the withholding of food and water and the administration of only analgesics and the avoidance of any treatment that may prolong life (hence prolong suffering).
These types of UNOFFICIAL euthanasia happen all the time and the lay public including many who are adamantly opposed to assisted suicide appear to be blissfully unaware of this common practice (that is until a family member is suffering and on the verge of inevitable death). And yet I have avoided this issue because it involves euthanasia and not assisted suicide and it would be fallacious to conclude that assisted suicide should be legal because we practice euthanasia commonly though unofficially.
However, I will bring up this issue to make a few points. First, Dr Crippen appears to accept the fact that there is a risk that liberal pain medication use in the suffering patient may hasten or directly lead to death but one of his (and Moof’s) objections to assisted suicide is the possibility of numerous slippery slopes. But is not a slippery slope the same as risk of inadvertent and unintended consequence and is not the death of a terminal patient from dehydration, respiratory suppression, aspiration, or overdose from the liberal use of pain medication an inadvertent and unintended consequence? What’s the difference?
Second, it should be noted for Moof’s sake that despite the very common use of unofficial euthanasia in suffering terminal patients on the verge of death, this has not lead to the slippery slope of the expanded acceptance and use of this practice. I.e. I am unaware of a case where a patient has a terminal illness but is not anywhere near death is placed on a morphine drip and allowed to die either with or without their conscent.
Third, one of the main (and most disturbing) differences between unofficial euthanasia and assisted suicide is that unofficial euthanasia, as commonly practiced in this country, is almost always involuntary, while assisted suicide has as it’s one central tenant the persistent consent of a well informed and fully conscious patient. What this difference is, obviously, is one of patient autonomy and self-determination. In everywhere except Oregon and the Netherlands, a patient’s right to die comes only after they are no longer capable of making their own decisions. That’s painfully ironic.
The importance (or unimportance) of patient autonomy is something that is still not addressed to my satisfaction by Dr. Crippen or by Moof. In Oregon the majority of patients who requested assisted suicide did not cite pain as a major factor. It appears that self-determination was and is a major consideration among patients who seek assistance under this law! What interest does the state have in denying a patients with a known terminal illness to have available a method of effective and painless suicide thus in effect forcing them to proceed into the inevitable physical decline and suffering that comes with said illness? Without any proof (from the Oregon or Netherlands experiences) for the existence of slippery slopes or the decline in the sanctity of life in society leading to greater killing, the main societal damage of such laws appears to be to the sensibilities of opponents of such laws!
Lastly, I have to heavily disagree with Dr. Crippen’s ending statement;
The moral, legal, ethical and practical problems of doctor-assisted suicide are so complex, so fraught with danger and so difficult to cover with legislation that it is not practical so to do particularly as requests for assisted suicide are rare.
The rareness of requests and the perceived complexities of such assisted suicide laws have practical implications to the implementation of such laws but in and of themselves are not effective arguments against assisted suicide. Indeed, the successful experiences of the Oregon assisted suicide law appear to directly contradict Dr. Crippen’s beliefs that these laws are dangerous and too complex to be practical! As I stated above, these issues need to be discussed so as not to ignore the problems of end of life suffering and patient autonomy but to say that assisted suicide is too dangerous and complex to be considered is not necessarily true and itself a fallacy (in effect an appeal to fear or to ignorance).
There are many things that humans have proceeded to do despite the perceived dangers and complexities because the benefits were considered to outweigh the risks and it was considered the right thing to do i.e. democracy, nuclear power, other technological advancements, the abolition of slavery and segregation, American involvement in WWII, etc. etc. etc. etc.
“We choose to go to the moon in this decade and do the other things, not because they are easy but because they are hard” - John F. Kennedy, 1962
Hi Chris. That was quick. My first name is John, by the way. (Really.)
I agree with you that the point on “difficulty†is a weak argument in terms of human endeavour and achievement.
It’s still difficult though; that is for sure
I don’t know how it works with oncologists in the USA, but in the UK they are rarely involved in the last bit of terminal care. This is handed right back to the family doctors often without the truth being told beforehand.
The patient will be told something like, “Well, we have no more active treatment to offer, so we will see you again in 3 months.†The really bad communicators will say, “And would you like me to get a hospice nurse to come and see you?†at which stage the patient begins to realise that the chips are down!
Then the family doc has to pick up the pieces of that. So no, I don’t think oncologists have more experience of this than us.
Traumatologists? Wish we had some, Chris, wish we had some. I blogged on that a while ago. (http://nhsblogdoc.blogspot.com/2005/12/read-this-or-die.html)
I’ve just read through what you have written several times. The comments you make on the difference between overt “assisted-suicide†and “helping a patient to die†are right, and they are challenging. Very challenging.
I do want to believe that there is a huge difference in terms of physician “intentâ€. Masterly inactivity may result in a patient’s death and taking the example I gave of the elderly dement in the nursing home I am sure it is something we would all do. Even Moof. But are actions of omission morally worse than acts of commission. I am not so sure that morally they are. They may be legally. If I walk past a puddle in which a baby is face down drowning, I commit no legal offence, but morally….?
Maybe, in reality, we are not too far apart; maybe we are both doing similar things, or want to do similar things, but rather disagree about nomenclature, semantics and so on. And I do agree, that however many times they have “done†them at the dinner party, many families do not really appreciate these issues. Then they come face to face with the dying relative and are only too happy when the syringe driver goes up.
Maybe I am kidding myself about what I am really doing; all I can say is that in terms of INTENT I just don’t feel I am supervising “assisted suicideâ€. And I don’t think I could.
Let’s spell it out, then. Maybe what a lot of physicians are doing at the moment is in fact surreptitious murder. That frightens me even more. Maybe your position is the more honest of the two. But we are highly trained, we have to work on difficult professional boundaries some of which cannot be policed. That is what we are paid for.
Looking back over the last comment, my wife says the “Happy New Year†looked a bit sarcastic. Gosh, I hope not. It wasn’t meant to be!
As I have said in several places, I only got involved in blogging last month, not sure why really, and it sure has hell has stimulated a lot of thought and self-questioning.
You two have gotten so far ahead of me in such a short time that I can’t hope to catch up! I’m going to try to at least hit the high parts, because there’s so much I’d like to say.
Both of you provide some very well expressed, compelling ideas.
Dr. Rangel, on a few points which Dr. Crippen made, I’m not sure if you accidentally missed what he was saying, or if you’re deliberately overlooking his point. But this really is too important to not bring to the fore yet again …
I believe, and I’m counting on Dr. Crippen to correct me if I’m wrong, that since there has not been much demand for “Assisted Suicide,” that the moral and legal complexities may weigh against the value of charging into such a dangerous and ambiguous area. That idea leads right into the following one …
Dr. Crippen, with your elderly lady who is 96 yrs. old, has dementia, has stopped eating and drinking, could have developed an infection … and is not in apparent distress, the line has already been drawn. There was no choice for her family to make, or for you to make - the natural course of her age, condition, whatever - had it made for all of you. You could perhaps have made her far more uncomfortable, and tried desperately to give her a few more hours … but I don’t think anyone questions that the sane, compassionate, humane thing to do at that point was to let nature continue what it had begun.
When the line is so ambiguous that it looks different to each viewer, and would appear with completely different parameters depending on which hand held the pen … that’s when we enter your minefield.
In not cases, I do not believe that you can’t control pain - even in a terminally ill person - short of causing death. I’m not a physician, and haven’t seen the pain (and death) that either of you have, however I have seen quite a bit of it. Almost all of the deaths I’ve seen were due to cancer, and all of them were peaceful. I would have to do some research on how many people die in unrelieved physical agony … and I would also have to question how much care was being put into palliation, in those instances.
There is one thing which Dr. Rangel said …
[…] it should be noted for Moof’s sake that despite the very common use of unofficial euthanasia in suffering terminal patients on the verge of death, this has not lead to the slippery slope of the expanded acceptance and use of this practice. I.e. I am unaware of a case where a patient has a terminal illness but is not anywhere near death is placed on a morphine drip and allowed to die either with or without their conscent. […]
There is very much that I could say here, but I’m afraid that I’m still so shocked and upset over something I witnessed last spring that I would still be reacting through my emotions rather than my logic.
The “oops!” euthanasia you speak about is indeed quite common, and not only where the terminally ill are concerned … and I’d venture a guess that it might even involve more than a miscalculation, at times.
There seems to be a growing indifference - right across the board - toward the “value of human life,” and the consequences of our often cavalier choices regarding its worth … or lack of it. (Regarding its existence, or lack of it?) Consciences are becoming hardened and calloused by too much relativism.
Dr. Rangel, you wrote that “The importance (or unimportance) of patient autonomy is something that is still not addressed to my satisfaction by Dr. Crippen or by Moof.“
I don’t ever want to be accused of deliberately evading any issues - so here we go.
Patient autonomy is important. As a patient, I can’t tell you how important I think it is. However, what you’re talking about here is suicide, not autonomy. It’s no less suicide when the patient is nearing the end of his life because of a terminal illness, than it is if he takes his life at an earlier time in a fit of depression. Should autonomy even be the question? How can you invoke patient autonomy when we’re talking about people ending their lives because of pain that you could control for them?
I believe in autonomy - but I also believe that it’s being abused already, and not only in this area. My autonomy should stop where your autonomy begins, and although it sometimes doesn’t, it isn’t all-inclusive. It doesn’t even include whether I can choose to not wear a seatbelt … and it should not include whether I have a right to end a life - my own or anyone else’s. Our “autonomy” is hemmed in from all sides … soon, the only autonomy I will have left will be whether I can terminate life - my unborn baby’s or my own.
Talking about issues which have not been addressed … neither of you gentlemen have addressed to my satisfaction that euthanasia is part of an a growing disregard for human life, which also includes abortion. And I see all of it as pertaining to an astounding imbalance between convenience, and our willingness to deal with those things we consider “inconvenient.” I would still dearly like your take, Dr. Rangel, on the weight value of convenience over life.
Dr. Crippen said, “Let’s spell it out, then. Maybe what a lot of physicians are doing at the moment is in fact surreptitious murder.“
Yes, and I don’t use “maybe” when I repeat that line to myself. The tear that this is making in the fabric of medicine is getting larger and larger … and I wonder, when and if we find reason again, if the patch applied to the gaping perforation will really hide it enough for us regain our faith in those who, and the system which, we are supposed to trust with our lives.
Nota bene: Comments on this post have been temporarily deactivated due to the post’s address having been included on some comment-spamming list. If you would like to comment, please email the comment to: moof@blogsplot.net.
Sorry for the inconvenience. I hope to be able to reactivate comments within a week at most.