Euthanasia

Killing Mercy

Dr Bob

The ethics of euthanasia, which as an issue generally stays just barely on our radar screens, given the host of contentious social issues taking up our political and cultural bandwidth, nevertheless may ultimately prove to be an enormous dilemma, with profound impact on both our lives as a society and as individuals. While the issue has only occasionally nosed into the political limelight–usually associated with some initiative regarding physician-assisted suicide–the underlying currents which keep this matter very much alive are powerful and unlikely to be resolved easily or painlessly.

There is broad appeal for the idea of euthanasia. It seems to fit perfectly into our Western democratic principles of the autonomy of the individual, rights and freedom, and the desire to control our own destinies. It seems as well an ideal solution to an out-of-control health care system, where technology and advances in life-sustaining capabilities seem to have taken on a life of their own, driving health care costs to extraordinary levels in the final years of our life, and seemingly removing much of the dignity we believe should be the inherent right of the dying. Patient’s families watch helplessly as their loved ones appear to be strung along in their dying days, tubes and wires exiting from every orifice, a relentless train of unknown physicians and ever-changing nurses breezing in and out of their rooms to tweak this medication or that machine. We all wish for something different for ourselves as well as our loved ones, but seem to be incapable of bringing that vision to fruition.

Euthanasia offers what appears to be an ideal solution to many of these difficulties. We love the idea that the individual may choose the time and place of their own demise; we see an easy and painless exit to prolonged suffering; we visualize a measure of mastery returning to a situation where are all seems out of control; we see a solution to pointless expenditures of vast sums of money on patients with little or no hope of recovery. It is for these reasons that initiatives to legalize this process are commonly called “death with dignity” or some similar euphemism reflecting these positive aspects–and when put forward, often find as a result a substantial degree of public approval.

This appeal grows ever stronger as our culture increasingly emphasizes personal autonomy and de-emphasizes social responsibility. We are, after all, the captains of our own ship, are we not? A culture which believes that individual behavior should be virtually without limit as long as “no one is harmed” can see little or no rational reason why such individual autonomy should not be extended to end-of-life decisions.

The reality, unfortunately, is that “no one is harmed” is a uniquely inadequate standard for human behavior, and our autonomy is far less than we would like to believe. It assumes that human behavior occurs in a vacuum. Thus we hear that sexual relations between consenting adults are entirely reasonable if “no one is harmed”–a standard commonly applied to relationships outside of marriage, for example, which often end up having a profound and destructive effect both on the spouse–and particularly on the children. “No one is harmed” serves as mere justification for autonomous behavior while denying or minimizing the inevitable adverse consequences of this behavior. When Joe has an affair with Susie at the office, and ends up in divorce court as a result, there can be little question that many are harmed: Joe’s children, not the least; his wife; perhaps the husband and children of the woman with whom he has had an affair. Yet in the heat of passion, “no one is harmed” is self-evident–believed even if false. And to mention these obvious ramifications of a supposedly “harmless” behavior is to be “judgmental” and therefore must be assiduously avoided.

But the consequences are real, and their ripple effect throughout society is profound: to cite one simple example, children from broken homes are far more prone to become involved in gangs or crime, to be abused sexually or physically; to initiate early sexual activity and become unwed mothers; to under-perform academically, and to have greater difficulty with relationships as teenagers and adults. These effects–particularly when magnified on a society-wide scale–have effects vastly broader than the personal lives of those who have made such autonomous choices.

Similarly, an argument is often used by libertarians (and others) for drug legalization using this same hold-harmless rationale. After all, who could argue with personal drug use in the privacy of your home, since “no one is harmed?” No one is harmed, of course–unless the residual, unrecognized effects of your drug use affects your reflexes while driving the next day, resulting in an accident; or impairs your judgment at work, costing your employer money or resulting in a workplace injury; or when, in the psychotic paranoia of PCP use, you decide your neighbor is trying to kill you, and beat him senseless with a baseball bat; or when the drug itself, in those so physiologically prone, leads to addictive behavior which proves destructive not merely to the individual, but to family, fellow workers, and society as a whole. Burning up every spare dollar of a family’s finances to support a drug habit, and stealing to support it–surely not an unusual scenario–can hardly be qualified as “no one is harmed.” To claim that there is no societal impact from such individual autonomous behavior is profoundly naive, and represents nothing more than wishful thinking.

But what about euthanasia? Surely it is reasonable to end the life of someone who is suffering unbearably, who is beyond the help of medical science, and who has no hope of survival, is it not? This, of course, is the scenario most commonly presented when legalization of euthanasia is promoted. It should be stated without equivocation that such cases do indeed exist, and represent perhaps the most difficult circumstances in which to argue against euthanasia. But it should also be said that such cases are becoming far less common as pain management techniques and physician training in terminal care improve: in my experience, and in the experience of many of my peers who care for the terminally ill, is a rare occurrence indeed that a patient cannot have even severe, intractable pain managed successfully.

But the core arguments used in support of euthanasia in such dire circumstances are easily extended to other terminal situations–or situations not so very terminal at all. Intractable terminal pain merges seamlessly into hopeless prognosis, regardless of time frame; then flows without interruption to chronic diseases such as multiple sclerosis or severe disabilities. Once the principle of death as compassion becomes the guiding rule, the Grim Reaper will undergo metamorphosis into an angel of light, ready to serve one and all who suffer needlessly.

To mitigate the risk of this so-called “slippery slope,” it has been suggested that safeguards against such mission creep be crafted. Such measures may invoke mandatory second opinions, waiting periods, or committee review, prior to approval of an act of euthanasia. That such measures are ultimately doomed to fail is self-evident: in effect, they impose a roadblock between patient autonomy and relief of suffering and its amelioration through euthanasia–and thus run counter to the core principle sustaining it. It is not difficult to foresee that such roadblocks will quickly be made less “burdensome,” if not rendered utterly impotent, by relentless pressures to prevent patients from needlessly suffering, regardless of their underlying disease.

Perhaps more importantly, the process of assessing and approving an act of euthanasia through second opinions or committee review is not some ethically neutral decision, such as vetting budget items or inventory purchases. Those who serve in such advisory or regulatory capacity must by necessity be open to–indeed supportive of–the idea of euthanasia, lest all reviewed cases be denied. As demand for euthanasia increases, such approvals will become rubber-stamped formalities, existing solely to provide defensive cover for unrestricted assisted termination.

But such arguments against euthanasia are in essence process-oriented, and miss the much larger picture of the effects of individual euthanasia on our collective attitudes about life and death, and our societal constitution. There can be little question that the practice of actively terminating ill or dying patients will have a profound effect on the physicians who engage in this practice. The first few patients euthanized may be done in a spirit of compassion and mercy–but repetition deadens the soul and habitualizes the process. This is routinely seen in many areas of health care training and practice: the first cut of a novice surgeon is frightening and intimidating; the thousandth incision occurs with nary a thought. One’s first autopsy is ghoulish; the hundredth merely objective fact-finding. Euthanasia, practiced regularly, becomes simply another tool: this can be readily seen in the statistics from the Netherlands, where even 15 years ago, a startling percentage of reported cases of euthanasia by physicians took place without explicit patient request — reflecting far more a utilitarian attitude toward euthanasia than some diabolical conspiracy to terminate the terminal. The detached clinicians, utterly desensitized to the act of taking a life, now utilize it as they would the initiation of parenteral nutrition or the decision to remove a diseased gallbladder.

Such false assumptions about the objective impartiality of the decision-making process leading to euthanasia can be seen as well when looking at the family dynamics of this process. We are presented with the picture of the sad but compassionate family, quietly and peacefully coming to the conclusion that Dad–with his full assent, of course–should mercifully have his suffering ended with a simple, painless injection. Lost in this idyllic fantasy is the reality of life in families. Anyone who has gone through the death of a parent and the settlement of an estate knows first-hand the fault lines such a life crisis can expose: old grievances brought back to life, old hot buttons pushed, greed and avarice bubbling to the surface like a toxic witch’s brew. Does brother John want Dad’s dignified death so he can cop the insurance cash for his gambling habit? Does sister Sue, who hates her father and hasn’t spoken to him in years, now suddenly want his prompt demise out of genuine concern for his comfort and dignity? Are the children–watching the estate get decimated by the costs of terminal care–really being objective about their desire for Mom’s peaceful assisted death? And does Mom, who knows she’s dying, feel pressured to ask for the needle so she won’t be a burden to her children? Bitter divisions will arise in families who favor euthanasia and those who oppose it–whether because of their relationship, good or bad, with the parent, or their moral and ethical convictions. To make euthanasia the solution to difficult problems of death and dying, as suggested by its proponents, will instead require the death of our spirits: a societal hardness of heart whose effects will reach far and wide throughout areas of life and culture far beyond the dying process. Mercy killing will kill our mercy; death with dignity so delivered will leave us not dignified but degraded.

The driving force behind legalized euthanasia and physician-assisted suicide is patient autonomy: the desire to maintain control over the dying process, by which, is it hoped, we will maintain our personal dignity. But the end result of legalized euthanasia will instead, in many cases, be loss of patient autonomy. When legalized, medical termination of life will by necessity be instituted with a host of safeguards to prevent its abuse. Such safeguards will include restricting the procedure to those in dire straights: intolerable suffering, a few months to live, and the like. Inherent in these safeguards are the seeds of the death of patient autonomy: such determinations must rely on medical judgments–and therefore will ultimately lie in the hands of physicians rather than patients. It will be physicians who will decide what is intractable pain; it is physicians who will judge how long you have to live; it is physicians who will have the last say on whether your life has hope or is no longer worth living. Such decisions may well be contested–but the legal system will defer to the judgment of the health care profession in these matters. Patient autonomy will quickly become physician autocracy. For those who request euthanasia, it will be easy; for those who do not wish it, but fit the criteria, it will also be far too easy.

This has been the legal and practical evolution of euthanasia in the Netherlands. The legal progression from patient autonomy with safeguards to virtual absence of restrictions on euthanasia is detailed in a superb paper from Brooklyn Law School’s Journal of International Law (available here as a PDF), in which this evolution is detailed:

Soon after the Alkmaar case was decided, the Royal Dutch Medical Association (KNMG) published a set of due care guidelines that purported to define the circumstances in which Dutch physicians could ethically perform euthanasia.

The KNMG guidelines stated that, in order for a physician to respond to a euthanasia request with due care,

  • The euthanasia request must be voluntary, persistent, and well-considered.
  • The patient must suffer from intolerable and incurable pain and a discernible, terminal illness.

Thereafter, Dutch courts adopted the KNMG guidelines as the legal prerequisites of due care in a series of cases between 1985 and 2001. Despite the integration of the KNMG’s due care provisions, courts remained confused regarding what clinical circumstances satisfied the requirements of due care. In 1985, a court acquitted an anesthesiologist who provided euthanasia to a woman suffering from multiple sclerosis. The court thereby eliminated the due care requirement that a patient must suffer from a terminal illness. By 1986, courts decided that a patient need not suffer from physical pain; mental anguish would also satisfy the intolerable pain due care requirement.

Similarly, all reported prosecutions of euthanasia prior to 1993 involved patients who suffered from either physical or mental pain. Then, in the 1993 Assen case, a district court acquitted a physician who had performed active voluntary euthanasia on an otherwise healthy, forty-three year old woman. The patient did not suffer from any diagnosable physical or mental condition, but had recently lost both of her sons and had divorced her husband. With the Assen case, Dutch courts seemed to abandon the requirement that a patient suffer from intolerable pain or, for that matter, from any discernible medical condition as a pre-condition for the noodtoestand [necessity] defense.

The requisite ambiguity of all such safeguards will invariably result in their legal dilution to the point of meaninglessness–a process which increasingly facilitates the expansion not only of voluntary, but also involuntary euthanasia. This is inevitable when one transitions from a fixed, inviolable principle (it is always wrong for a physician to kill a patient) to a relative standard (you may end their lives under certain circumstances). The “certain circumstances” are negotiable, and once established, will evolve, slowly but inexorably, toward little or no standards at all. When the goalposts are movable, we should not be surprised when they actually get moved.

Another effect rarely considered by those favoring euthanasia is its effect on the relationship between patients and their physicians. The physician-patient relationship at its core depends upon trust: the confidence which a patient has that their physician always has their best interests at heart. This is a critical component of the medical covenant–which may involve inflicting pain and hardship (such as surgery, chemotherapy, or other painful or risky treatments) on the patient for their ultimate benefit. Underlying this trust is the patient’s confidence that the physician will never deliberately do them harm.

Once physicians are empowered to terminate life, this trust will invariably erode. This erosion will occur, even were involuntary euthanasia never to occur–a highly unlikely scenario, given the Dutch experience. It will erode because the patient will now understand that the physician has been given the power to cause them great harm, to kill them–with the full legal and ethical sanction of the law. And the knowledge of this will engender fear: fear that the physician may abuse this power; fear that he or she may misinterpret your end-of-life wishes; fear that he may end your life for improper motives, yet justify it later as a legal and ethical act. The inevitable occurrence of involuntary euthanasia–which in an environment of legalized voluntary euthanasia will rarely if ever be prosecuted–will only augment this fear, especially among the elderly and the disabled. In the Netherlands, many seniors carry cards specifying that they do not wish to have their lives terminated–a reflection of a widespread concern that such an occurrence is not uncommon, and is feared.

Montana judge: man has right to assisted suicide

Effects on physicians:

Helen

Effects on Physicians

PHYSICIAN-ASSISTED SUICIDE IN OREGON:
A MEDICAL PERSPECTIVE

The Children Whom Reason Scorns

Dr Bob

Nazi German euthanasia posterIn the years following the Great War, a sense of doom and panic settled over Germany. Long concerned about a declining birth rate, the country faced the loss of 2 million of its fine young men in the war, the crushing burden of an economy devastated by war and the Great Depression, further compounded by the economic body blow of reparations and the loss of the German colonies imposed by the Treaty of Versailles. Many worried that the Nordic race itself was threatened with extinction.

The burgeoning new sciences of psychology, genetics, and medicine provided a glimmer of hope in this darkness. An intense fascination developed with strengthening and improving the nation through Volksgesundheit–public health. Many physicians and scientists promoted “racial hygiene” – better known today as eugenics. The Germans were hardly alone in this interest – 26 states in the U.S. had forced sterilization laws for criminals and the mentally ill during this period; Ohio debated legalized euthanasia in the 20’s; and even Oliver Wendall Holmes, in Buck v. Bell, famously upheld forced sterilization with the quote: “Three generations of imbeciles are enough!” But Germany’s dire circumstances and its robust scientific and university resources proved a most fertile ground for this philosophy.

These novel ideas percolated rapidly through the social and educational systems steeped in Hegelian deterministic philosophy and social Darwinism. Long lines formed to view exhibits on heredity and genetics, and scientific research, conferences, and publication on topics of race and eugenics were legion. The emphasis was often on the great burden which the chronically ill and mentally and physically deformed placed on a struggling society striving to achieve its historical destiny. In a high school biology textbook – pictured above – a muscular German youth bears two such societal misfits on a barbell, with the exhortation, “You Are Sharing the Load!–a hereditarily-ill person costs 50,000 Reichsmarks by the time they reach 60.” Math textbooks tested students on how many new housing units could be built with the money saved by elimination of long-term care needs. Parents often chose euthanasia for their disabled offspring, rather than face the societal scorn and ostracization of raising a mentally or physically impaired child. This widespread public endorsement and pseudo-scientific support for eugenics set the stage for its wholesale adoption — with horrific consequences — when the Nazi party took power.

The Nazis co-opted medicine fully in their pursuit of racial hygiene, even coercing physicians in occupied countries to provide health and racial information on their patients to occupation authorities, and to participate in forced euthanasia. In a remarkably heroic professional stance, the physicians of the Netherlands steadfastly refused to provide this information, forfeiting their medical licenses as a result, and no small number of physicians were deported to concentration camps for their principled stand. As a testimony to their courage and integrity, not a single episode of involuntary euthanasia was performed by Dutch physicians during the Nazi occupation.

Would that it were still so.

The Netherlands was the first country in the world in which euthanasia and assisted suicide was legally performed, having fully legalized the practice in 2006 after several decades of widespread illegal–but universally unpunished–practice. The Dutch have come into the public consciousness periodically over the past 30vyears, initially with the consideration of assisted suicide laws in Oregon, Washington, Michigan and elsewhere in the early 90’s, and again with their formal legalization of physician-assisted suicide and euthanasia in 2001. Once again they are on the ethical radar, with the disclosure last week of the Groningen Protocol for involuntary euthanasia of infants and children.

The Groningen Protocol is not a government regulation or legislation, but rather a set of hospital guidelines for involuntary euthanasia of children up to age 12:

The Groningen Protocol, as the hospital’s guidelines have come to be known, would create a legal framework for permitting doctors to actively end the life of newborns deemed to be in similar pain from incurable disease or extreme deformities.

The guideline says euthanasia is acceptable when the child’s medical team and independent doctors agree the pain cannot be eased and there is no prospect for improvement, and when parents think it’s best.

Examples include extremely premature births, where children suffer brain damage from bleeding and convulsions; and diseases where a child could only survive on life support for the rest of its life, such as severe cases of spina bifida and epidermosis bullosa, a rare blistering illness.

The hospital revealed last month it carried out four such mercy killings in 2003, and reported all cases to government prosecutors. There have been no legal proceedings against the hospital or the doctors.

While some are shocked and outraged at this policy of medical termination of sick or deformed children (the story has been widely ignored by the mainstream media, and has gotten only limited attention on the Internet), it is merely a logical extension of a philosophy of medicine widely practiced and condoned in the Netherlands for many years, much as it was in Germany between world wars. It is a philosophy where the Useful is the Good, whose victims are the children whom Reason scorned.

Euthanasia is the quick fix to man’s ageless struggle with suffering and disease. The Hippocratic Oath — taken in widely varying forms by most physicians at graduation — was originally administered to a minority of physicians in ancient Greece, who swore to prescribe neither euthanasia nor abortion — both common recommendations by healers of the age. The rapid and widespread acceptance of euthanasia in pre-Nazi Germany occurred because it was eminently reasonable and rational. Beaten down by war, economic hardship, and limited resources, logic dictated that those who could not contribute to the betterment of society cease being a drain on its lifeblood. Long before its application to ethnic groups and enemies of the State, it was administered to those who made us most uncomfortable: the mentally ill, the deformed, the retarded, the social misfit. While invariably promoted as a merciful means of terminating suffering, the suffering relieved is far more that of the enabling society than of its victims. “Death with dignity” is the gleaming white shroud on the rotting corpse of societal fear, self-interest and ruthless self-preservation.

It is sobering and puzzling to ponder how the profession of medicine – whose core article of faith is healing and comfort of the sick – could be so effortlessly transformed into a calculating instrument of judgment and death. It is chilling to read the cold scientific language of Nazi medical experiments or Dutch studies on optimal techniques to minimize complications in euthanasia. Yet this devolution of medicine, with some contemplation, is not hard to discern. It is the natural gravity of man detached from higher principles, operating out of the best his reason alone has to offer, with its inevitable disastrous consequences. Contributing to this march toward depravity:

 ♦ The power of detachment and intellectualization: Physicians by training and disposition are intellectualizers. Non-medical people observing surgery are invariably squeamish, personalizing the experience and often repulsed by the apparent trauma to the patient. Physicians overcome this natural response by detaching themselves from the personal, and transforming the experience into a study in technique, stepwise logical processes, and fascination with disease and anatomy. Indeed, it takes some effort to overcome this training to develop empathy and compassion. It is therefore a relatively small step with such training to turn even killing into another process to be mastered.

 ♦ The dilution of personal responsibility: In Germany, the euthanasia of children was performed with an injection of Luminal, a barbiturate also used for seizures and sedation of the agitated. As a result, it was difficult to determine who was personally responsible for the deed: was it the nurse, who gave too much? The doctor, who ordered too large a dose? Was the patient overly sensitive to the drug? Was the child merely sedated, or in a terminal coma? Of course, all the participants knew what was going on, but responsibility was diluted, giving rationalization and justification full reign. The societal endorsement and widespread practice of euthanasia provided additional cover. When all are culpable, no one is culpable.

 ♦ Compartmentalization: an individual involved in the de-Baathification of Iraq said the following:

There is a duality in Baathists. You can find a Baathist who is a killer, but at home he’s completely normal. It’s like they split their day into two twelve-hour blocks. When people say about someone I know to be a Baathist criminal, ‘No, he’s a good neighbor!’, I believe him.

Humans have the remarkable ability to utterly separate disparate parts of their lives, to accommodate cognitive dissonance. Indeed, there is probably no other way to maintain sanity in the face of enormous personal evil.

 ♦ The banality of evil: Great evil springs in countless small steps from lesser evil. Jesus Christ was doubtless not the first innocent man Pilate condemned to death; soft porn came before child porn, snuff films, and rape videos; in the childhood of the serial killer lies cruelty to animals. Small evils harden the heart, making greater evil easier, more routine, less chilling. We marvel at the hideousness of the final act, but the descent to depravity is a gentle slope downwards.

 ♦ The false optimism of expediency: Solve the problem today, deny any future consequences. We are nearsighted creatures in the extreme, seeing only the benefits of our current actions while dismissing the potential for unknown, disastrous ramifications. When Baby Knauer, an infant with blindness, mental retardation and physical deformities, became the first child euthanized in Germany, who could foresee the horrors of Auschwitz and Dachau? We are blind to the horrendous consequences of our wrong decisions, but see infinite visions of hope for their benefits. As a child I watched television shows touting peaceful nuclear energy as the solution to all the world’s problems, little imagining the fears of the Cuban missile crisis, Chernobyl and Three Mile Island, the minutes before midnight of the Cold War, and the current ogre of nuclear terrorism.

Reason of itself is morally neutral; it can kill children or discover cures for their suffering and disease. Reason tempered by humility, faith, and guidance by higher moral principles has enormous potential for good – and without such restraints, enormous potential for evil.

The desire to end human suffering is morally good. Despite popular misconception, the Judeo-Christian tradition does not view suffering as something good, but rather something evil which exists, but which may be transformed and redeemed by God and grace, to ultimately produce a greater good. This is a difficult sell to a materialistic, secular world, which does not accept the transformational power of God or the existence of spiritual consequences, or principles higher than human reason.

Yet the benefits of suffering, subtle though they may be, can be discerned in many instances even by the unskilled eye. What are the chances that Dutch doctors will find a cure for the late stage cancer or early childhood disease, when they now so quickly and “compassionately” dispense of their sufferers with a lethal injection? Who will teach us patience, compassion, unselfish love, endurance, tenderness, and tolerance, if not those who provide us with the opportunity through their suffering, or mental or physical disability? These are character traits not easily learned, though enormously beneficial to society as well as individuals. How will we learn them if we liquidate our teachers?

Higher moral principles position roadblocks to our behavior, warning us that grave danger lies beyond. When in our hubris and unenlightened reason we crash through them, we do so at great peril, for we do not know what evil lies beyond. The Netherlands will not be another Nazi Germany, as frightening as the parallels may be. It will be different, but it will be evil in some unpredictable way, impossible to foresee when rationalism took the first step across that boundary to kill a patient in mercy.

On Assisted Suicide

Dr Bob


In a previous post on physician-assisted suicide, I had the following exchange with a commenter named Van:

Van: I take it you are are against assisted-suicide?

Let me ask you this – how can we say we live in a free nation if we cannot do what we wish to our own bodies, as long as we do not impact the life, liberty and safety of others?

I have mixed feelings on the subject, but I really have a hard time with others telling me what to do with my body.

Dr. Bob: Yes, very much against it.

You are, of course, perfectly free to end your own life, with or without such legislation. A handgun and a single bullet will do the job very nicely–along with a hundred other ways.

The issue with this public policy is that you are asking your physician to kill you — and therefore it is no longer just about what you do with your body, but very much involves other people–the doctor, the families, and society as a whole.

The problem with the “it’s my body” radical self-autonomy is that it focuses solely on the self, while conveniently ignoring the enormous consequences of such legalization on others and society as a whole.

Van: So your key issue is the doctor assisting in the suicide, thereby involving others?

Let’s say you have a 90 year old individual with no family, suffering from cancer, who has no meaningful impact on others. If they take their own life, you are OK with it?

Just trying to understand where you are coming from.

Van’s question is a valid one, to be addressed shortly, but in a digression, one should note what often passes for arguing from principles in our current culture: the argument from the exceptional. When promoting or defending some contentious social or moral issue, we seem always to find the most extreme example imaginable and argue from this specific instance, then applying our conclusions from the specific to the general.

So, for example, when arguing for government prescription health coverage, we must first find some old woman who has to eat cat food in order to pay for her prescriptions; when discussing gay adoption, we must find the idyllic gay couple, lifelong partners (or so we are told), ecstatically happy with nary a relational dispute, as parents; when arguing for assisted suicide, we must find the patient in unbearable pain with a loving husband passionate about ending her life “in dignity” by slipping her a deadly cocktail — or one who is dying utterly alone, with nary a friend or family member to share their suffering. That such argumentation almost invariably presents a false dichotomy is never considered: that far better alternatives might exist to solve the problem is never pondered; that applying the suggested solution based on emotion without consideration for its broad implications or ramifications may well prove disastrous — such complications are never considered as possibilities. We press for great social and policy changes with profound effects on culture and society using pop emotionalism and pulp fiction.

But I digress. So, to answer the question: I would not find suicide of such a sadly-abandoned individual justified, simply because no physician was involved. Suicide is the ultimate repudiation of life, of relationships, of hope, the product of the deep hopelessness and self-absorbed insanity of depression. My point was simply this: we all have free will. Each of us may choose, if we decide to do so, to end our own lives. There is a pernicious distortion of the idea of freedom which is a product of our radical individualism, to wit: I live in a free society, therefore by necessity I must be free to do whatsoever I please. Others must not only allow me to do so, but must bear the consequences of my actions, and must be actively engaged in enabling my behavior, because it is my right. Hence, I must be free to say anything I wish, without consequence, including any criticism of my speech; I must be free to terminate my pregnancy, without guilt or restriction, though my unborn child pays the ultimate price; I must be free to end my life when I wish, and my physician must be required to deliver the lethal potion — or at least must be coerced into finding another doctor who will, if his “values” (defined as mere subjective opinions) don’t agree with mine.

Many of the “rights” which are being promulgated and promoted by today’s secular culture are in reality straw men, fine-sounding proxies for demands and desires far less salutary than they sound. Thus, gay marriage is not about gays getting married (hence the lack of enthusiasm among gay rights advocates for civil unions which provide all the legal benefits of marriage), but is instead an effort to undermine traditional heterosexual marriage as normative in culture, thereby removing not merely legal but cultural restraints on all forms of sexual and relational heterodoxy. The high standard — heterosexual marriage, with its enormous advantages in the raising of children and establishment of societal self-restraint, morality, and relational stability — must be brought down to the lowest common denominator of any two (or more) people getting “married” — with the sole purpose of muting societal condemnation for self-gratifying, dysfunctional and heterodox partnerships. Unrestricted abortion, a.k.a. “freedom of choice” — or, “women’s health care”– is about the uncompromising (albeit delusional) demand for unconstrained sexual license without consequences — especially for women, but also for their sperm donors who want no responsibility for their casual hookups: dispose of the unplanned pregnancy, move on to your next “partner”, and you have achieved the perfect “zipless fuck.”

Likewise, physician-assisted suicide is not at all about “death with dignity”, but rather about actively enlisting the culture in support of radical individual autonomy. Not only must we exert full control over the time and manner of our death — which we have always been able to do, by simply killing ourselves — but we demand that society support, honor, and praise this decision, without the faintest whiff of criticism or condemnation. It is not sufficient that we be able to kill ourselves. Rather, it is necessary that we actively kill those societal sensibilities and strictures which condemn such a choice as morally misguided and potentially destructive to our human dignity and social fabric.

Were some silver-suited alien from Alpha Centuri to visit our noble globe, he would no doubt find our passion for self-extinction puzzling, to say the least. What manner of sentient being seeks to facilitate its own demise, only to perpetuate the illusion that they control their own lives? Has their existence no purpose but to be ended at their own discretion? Are their relationships so shallow that they choose death over life; has their suffering no meaning; will their precious time with life partners, friends, and offspring be traded for the dark comfort of a deadly cocktail? Who are these intelligent fools, our visitor would ask, who hand over the power of death to their doctors, oblivious to the evil which dwells in the hearts of men, waiting to be empowered by cold rationalism, scientific professionalism, self-justification, and sterile repetition?

Yet were our starship sojourner to examine the society which breeds such nihilism, he would, by turns, find his answer: we are, for all our technological advances and unbounded prosperity, a culture without meaning, a people without purpose. We have embraced unquestioningly the mantra of materialism: we have come from nothing, and to nothing shall return. Our relationships mean naught but what we may gain from them; our suffering gains us nothing but rage and resentment; our deaths are like our lives — without hope, without a future, joyless and empty. We desperately push the buttons and mix the potions which promise to make us happy and whole, yet find they only echo forlornly through our hollow souls, singing that siren song:

“I am my own master.”

Assisted Suicide: Coming to a State Near You

Dr Bob

I hope to have more to say on the issue of euthanasia and assisted suicide in the near future. In the meantime, I highly recommend this article by Herbert Hendin, M.D. Dr. Hendin’s book, Seduced by Death: Doctors, Patients, and Assisted Suicide, is an excellent resource on the topic, the result of extensive research and multiple interviews taken while studying euthanasia practices in the Netherlands. This article provides a nice summary of his research and experience, which builds a solid case against euthanasia and physician-assisted suicide.

Washington has recently become the second state to pass an assisted suicide initiative, and, legislating from the bench, a Montana judge has ruled that man has right to assisted suicide.

This movement is on a roll, and you will want to be informed about why this is such a ghastly public policy trend.

A few highlights from the article:

Concern over charges of abuse led the Dutch government to undertake studies of the practice in 1990, 1995 and in 2001 in which physicians’ anonymity was protected and they were given immunity for anything they revealed. Violations of the guidelines then became evident. Half of Dutch doctors feel free to suggest euthanasia to their patients, which compromises the voluntariness of the process. Fifty percent of cases were not reported, which made regulation impossible. The most alarming concern has been the documentation of several thousand cases a year in which patients who have not given their consent have their lives ended by physicians. A quarter of physicians stated that they “terminated the lives of patients without an explicit request” from the patient. Another third of the physicians could conceive of doing so.

An illustration of a case presented to me as requiring euthanasia without consent involved a Dutch nun who was dying painfully of cancer. Her physician felt her religion prevented her from agreeing to euthanasia so he felt both justified and compassionate in ending her life without telling her he was doing so. Practicing assisted suicide and euthanasia appears to encourage physicians to think they know best who should live and who should die, an attitude that leads them to make such decisions without consulting patients–a practice that has no legal sanction in the Netherlands or anywhere else.

Assisted-suicide laws are always framed as being “compassionate” — appealing to the universal fear of dying a prolonged and painful death. Yet the unintended consequences of giving physicians the unrestricted power of life and death are often anything but:

Compassion is not always involved. In one documented case, a patient with disseminated breast cancer who had rejected the possibility of euthanasia had her life ended because, in the physician’s words: “It could have taken another week before she died. I just needed this bed.”

He also extensively studied Oregon’s experience with assisted suicide — the legislation which served as the model for Washington’s law — and found plenty of problems here as well:

Oregon physicians have been given authority without being in a position to exercise it responsibly. They are expected to inform patients that alternatives are possible without being required to be knowledgeable enough to present those alternatives in a meaningful way, or to consult with someone who is. They are expected to evaluate patient decision-making capacity and judgment without a requirement for psychiatric expertise or consultation. They are expected to make decisions about voluntariness without having to see those close to the patient who may be exerting a variety of pressures, from subtle to coercive. They are expected to do all of this without necessarily knowing the patient for longer than 15 days. Since physicians cannot be held responsible for wrongful deaths if they have acted in good faith, substandard medical practice is encouraged, physicians are protected from the con-sequences, and patients are left unprotected while believing they have acquired a new right.

The idea of assisted suicide has enormous allure in a culture of self-gratification and increasingly-shallow moral and ethical principles. Don’t be surprised when it comes your way — be prepared.

Crossing That Dark River

Dr Bob

Often in the sturm und drang of a world gone mad, there comes, through the chaos and insanity, some brief moment of clarity. Such times pass by quickly, and are quickly forgotten — as this brief instance might have been, courtesy of my neighboring bell weather state of Oregon: (HT: Hot Air)

Last month her lung cancer, in remission for about two years, was back. After her oncologist prescribed a cancer drug that could slow the cancer growth and extend her life, [Barbara] Wagner was notified that the Oregon Health Plan wouldn’t cover it.

It would cover comfort and care, including, if she chose, doctor-assisted suicide.

… Treatment of advanced cancer meant to prolong life, or change the course of this disease, is not covered by the Oregon Health Plan, said the unsigned letter Wagner received from LIPA, the Eugene company that administers the plan in Lane County.

Officials of LIPA and the state policy-making Health Services Commission say they’ve not changed how they cover treatment of recurrent cancer.

But local oncologists say they’ve seen a change and that their Oregon Health Plan patients with advanced cancer no longer get coverage for chemotherapy if it is considered comfort care.

It doesn’t adhere to the standards of care set out in the oncology community, said Dr. John Caton, an oncologist at Willamette Valley Cancer Center.

Studies have found that chemotherapy can decrease pain and time spent in the hospital and increases quality of life, Caton said.

The Oregon Health Plan started out rationing health care in 1994.

We have, at last, arrived. The destination was never much in doubt — once the threshold of medical manslaughter had been breached, wrapped as always in comforting words of compassion and dignity, it was only a matter of time before our pragmatism trumped our principles. Once the absolute that physicians should be healers not hangmen was heaved overboard, it was inevitable that the relentless march of relativism would reach its logical port of call.

Death, after all, is expensive — the most expensive thing in life. It was not always so. In remote pasts, it was the very currency of life, short and brutal, with man’s primitive intellect sufficient solely to deal out death, not to defer it. There followed upon this time some glimmer of light and hope, wherein death’s timetable remained unfettered, but its stranglehold and certainty were tempered by a new hope and vision of humanity. We became in that time something more than mortal creatures, something extraordinary, an unspeakable treasure entombed within a fragile and decomposing frame. We became, something more than our mortal bodies; we became, something greater than our pain; we became, something whose beauty shown through even the ghastly horrors of the hour of our demise. Our prophets — then heeded — triumphantly thrust their swords through the dark heart of death: “Death, where is your victory? Death, where is your sting?” We became, in that moment, something more than the physical, something greater than our short and brutish mortality. We became, indeed, truly human, for the very first time.

That humanity transcended and transformed all that we were and were to become, making us unique among creation not only in the foreknowledge of our death, but our transcendence of death itself. Life had meaning beyond the grave — and therefore had far more weight at the threshold of the tomb. Suffering became more than mere fate, but rather sacrifice and purification, preparation and salvation. The wholeness of the soul trumped the health of the body; death was transformed from hopeless certainty to triumphant transition.

But we knew better. We pursued the good, only to destroy the best. We set our minds to conquer death, to destroy disease, to end all pain, to become pure and perfect and permanent. We succeeded beyond our wildest dreams. The diseases which slaughtered us were themselves slayed; the illnesses which tortured and tormented us fell before us. Our lives grew long, and healthier, more comfortable, and more productive. Our newfound longevity and greater health gave rise to ever more miracles, allowing us to pour out our intemperate and precipitous riches with drunken abandon upon dreams of death defeated.

Yet on the flanks of our salient there lay waiting the forces which would strangle and surround our triumphant advance. Our supply lines grew thin; the very lifeblood of our armies of science and medicine, that which made our soldiers not machines but men, grew emaciated and hoary, flaccid and frail. We neglected the soul which sustained our science; the spirit which brought healing to medicine grew cachectic and cold.

So here we stand. We have squandered great wealth to defeat death — only to find ourselves impoverished, and turning to death itself for our answers. The succubus we sought to defeat now dominates us, for she is a lusty and insatiable whore. We have sacrificed our humanity, our compassion, our empathy, our humility in the face of a force far greater than ourselves, while forgetting the power and grace and the vision which first led us and empowered us on this grand crusade. Our weapons are now turned upon us; let the slaughter begin.

We will, no doubt, congratulate ourselves on the wealth we save. We will no doubt develop ever more ingenious and efficient means to facilitate our self-immolation while comforting ourselves with our vast knowledge and perceived compassion. Those who treasure life at its end, who find in and through its suffering and debilitation the joy of relationships, and meaning, and mercy, and grace, will become our enemies, for they will siphon off mammon much needed to mitigate the consequences of our madness.

It has been said, once, that where our treasure is, there will our heart be also. We have poured our treasure in untold measure into conquering death — finding succor in our victories, while forgetting how to die. The boatman now awaits us to carry us across that dark river — and we have insufficient moral currency to ignore his call.

Memorial Hospital Euthanasia Update

Dr Bob

As many have heard, the grand jury in New Orleans declined to bring charges against the physician, Anna Pou, and two nurses, arrested and charged with euthanizing patients at Memorial Hospital in the days following Katrina.

In New Orleans and elsewhere, many — including numerous physicians and the AMA — sighed in relief, hoping to put the nightmare — which many regarded as a gross injustice against heroic health care workers in unimaginably difficult circumstances — behind them.

But CNN is reporting that the issue may not be put to bed quite so easily:

A New Orleans grand jury that declined to indict a doctor on charges that she murdered patients in the chaotic days after Hurricane Katrina never heard testimony from five medical experts brought in by the state to analyze the deaths.

All five concluded that as many as nine patients were victims of homicide.

In detailed, written statements, the five specialists — whose expertise includes forensic medicine, medical ethics and palliative care — determined that patients at Memorial Medical Center had been deliberately killed with overdoses of drugs after Katrina struck New Orleans in 2005.

The grand jury had been asked to consider second-degree murder charges against a doctor and two nurses in four deaths. But in July, the grand jury decided that no one should be indicted…

In a decision that puzzled the five experts hired by the state, New Orleans District Attorney Eddie Jordan never called them to testify before the grand jury.

The experts themselves were puzzled and frustrated to have their evidence ignored:

“They weren’t interested in presenting those facts to the grand jury,” said Dr. Cyril Wecht, the former coroner of Allegheny County, Pennsylvania, and a past president of the American Academy of Forensic Scientists.

“The hard scientific facts are those from five leading experts, [the patients died] from massive lethal doses of morphine and Versed. As far as I know the toxicological findings were not presented to the grand jury and certainly not with quantitative analysis.” …

“I was never called to the grand jury,” said Caplan. “As far as I know, the grand jury never saw my reports. As far as I know, none of the reports prepared by these experts, who looked at all the cases, who were independent, and came to the conclusion that massive amounts of drugs were used as the cause of death and that they couldn’t have been requested [by the patients], they had to be given involuntarily. That’s evidence that I think a grand jury would want to be familiar with before it made its decision as to whether or not to proceed with an indictment.

“Now you can still get into a dispute about the evidence,” Caplan added. “You can get into a dispute about the circumstances and all the rest of it, but at face value there is no other conclusion I think that’s possible, other than these people — or someone — killed them.”

Dr. Pou testified that she had sedated patients to keep them comfortable in the intolerable conditions; the forensics experts found this an implausible explanation:

“The primary and immediate cause of death for each of these patients was acute combined drug toxicity, specifically morphine and Versed,” wrote Wecht. “The manner of death would be classified as homicide.”

“Large doses of these drugs were present in patients and the administration of the drug was not documented,” wrote James Young, the former chief coroner of the province of Ontario, Canada, who, like Wecht, once served as president of the American Academy of Forensic Sciences.

“Accidental overdoses would need to have occurred nine times between 12 noon and 3:30 p.m., all on one floor, to every patient who was left on the floor,” Young wrote. ” Again, it is noted that morphine was not ordered for seven of the patients and Versed was not ordered for any. Therefore it seems highly unlikely that nine patients died on the same floor on the same afternoon of accidental overdose.”

Caplan wrote that there was no evidence any patient asked to be given assistance in dying, and no evidence that any consented to be given an overdose of medication to end their lives.

“In reviewing the facts and opinions, my conclusion is that the deaths of the nine persons at Memorial Medical Center in New Orleans are all cases of active euthanasia,” Caplan wrote. “Each person died with massive doses of narcotic drugs in their bodies.”

The grand jury’s findings remain secret, although there are legal challenges to disclose them. The experts’ summary, however, also includes some chilling testimony, although the witnesses are not identified:

In its executive summary report included with the forensic experts’ findings, the attorney general’s office paints a chilling picture of what its investigators say happened four days after the hurricane hit New Orleans.

The summary cites a number of people — whose names are blacked out in the report — as having offered statements through their attorneys and having sought immunity from prosecution.

The summary states that Pou told the nurse executive of Lifecare, the acute care facility on the seventh floor of the hospital that housed the nine patients, that “a decision had been made to administer lethal doses of morphine to Lifecare patients.”

According to the report, none of the nine was a patient of Pou’s and there was no indication she had talked to their doctors before seeing them on the day they died.

The attorney general’s report also said that other medical personnel told Pou that one of the patients, Emmett Everett Sr., was conscious and alert. Everett was 61 years old, weighed almost 400 pounds and was confined to a wheelchair.

“Dr. Pou decided (patient name blacked out) could not be evacuated. He could not be taken out by boat because he was not ambulatory and Dr. Pou felt he was too heavy to be evacuated by helicopter,” according to the report.”

While we may never know the exact details of what happened at Memorial Hospital, the ghosts of that tragedy may continue to haunt us for years to come.

Grading on a Curve

Dr Bob


My previous post, an update on the investigation into deaths at Memorial Hospital during hurricane Katrina, elicited this comment from a reader, Carla:

It was not the district attorney who had these people arrested. It was attorney general of the State, Charles Foti, who had them arrested despite that they were not charged. He made a big grandstand about it saying they were murderers, much like Mike Nifong said the Duke lacrosses players were rapists. The atty. general can investigate pursuant to his powers under the Medicaid Fraud Act. Then he has to turn things over to the local district attorney. Now the district attorney has convened a grand jury to see if he can charge the nurses and doc. that the atty. general arrested. The local coroner says he cannot determine cause of death. May I suggest heat, lack of medical equipment, stress and failure of government. But not lack of care from those who chose to stay behind to help patients and did not leave until all patients were evacuated.

I stand corrected on referring to Charles Foti as district attorney, rather than Louisiana Attorney General. And I wholeheartedly agree that he may well have used the Memorial death case opportunistically for personal political gain: the shadow of Mike Nifong looms long, and politically ambitious prosecutors can destroy lives by abusing the power of their office.

In fact, almost everything about this case begs for dismissal — it is fraught with extraordinary circumstances which solicit quick judgment and counsel hasty condemnation. A raging storm roars through a fragile city long known for its vulnerability, frail aging levies its sole defense against certain disaster. A city flooded, its weakest citizens trapped in a hospital-turned-hellhole. Heroic doctors and desperate nurses battling impossible circumstances, tending to the sick and dying, utterly abandoned by corrupt, inept civil servants and emergency services overwhelmed and overtaxed. An Attorney General exploiting public horror at the trapped and hopeless, sacrificing valiant healers to the gods of political ambition and self-aggrandizement. We desperately want to avert our eyes in disgust, having witnessed yet another example of corrupt politicians and cynical civil servants. The news is old; heap scorn and hurry along; judge harshly and hastily dismiss; feel that self-righteous contempt which comforts the mind while killing the spirit.

Yet pause we must. This perfect storm of pathos and perfidy masks a simple question which we ignore at our peril:
Continue reading “Grading on a Curve” →

Katrina Euthanasia Update

Dr Bob

Lost in the dustbin of inconvenient memories, left behind in the light-speed pace of internet information mania is the story of the deaths of patients at Memorial Hospital in New Orleans in the wake of Hurricane Katrina. A physician and two nurses were arrested after the Louisiana District Attorney charged them with murder, accusing them of having injected a lethal cocktail to terminate frail patients who had no hope of rescue from the hell-hole the hospital had become.

The arrests were widely decried in the medical community — most of whom clearly had read none of the rather compelling and chilling testimony of other physicians and nurses who were present at the hospital. The case quickly became mired in charges of political grandstanding by the DA, who was considering running for governor and using the publicity around the case to raise money for his campaign. It subsequently went to a grand jury, which has used deliberate — some would say glacial — speed in investigating the case.

CNN today reports an update on the grand jury proceedings, where two of the involved nurses have been offered immunity to testify against the physician accused, Dr. Anna Pou.

The CNN update mentions this previously-unknown side story:

Craig Nelson, a New Orleans lawyer who is convinced his mother was killed by a lethal dose of morphine, has taken steps to file a civil lawsuit.

Nelson had an autopsy performed on the body of his mother, Elaine Nelson. The 90-year-old Jefferson Parish resident died inside Memorial Medical Center during the aftermath of the hurricane. Nelson said her death is not part of the murder investigation because his mother was elderly, frail and sick.

She was a patient of LifeCare, a long-term care facility run inside Memorial Medical Center’s seventh floor. Nelson said his sister was helping to care for his mother during Katrina, but was asked to leave. It was after his sister was evacuated that he was told his mother had died.

Test results conducted by a private lab hired by the lawyer indicate high levels of morphine in Elaine Nelson’s liver, muscle tissue and brain, Nelson said. He said his mother should have had no morphine in her system, since none had been prescribed to her in the week and a half before she died.

My prior discussion of this event may be found here, along with a substantial list of links for more information.