.comment-link {margin-left:.6em;}
Miscellaneous thoughts and ramblings
Friday, April 28, 2006
Physician Assisted Suicide
In the last week I’ve been digging through my home computer’s hard drive and I found a treasure trove of old emails that were archived there when I left my employment at Major University Department of Medicine to go into private practice. (That’s how I stumbled across Oven’s email.)

I found an email to my friends that must have been written when Dr. Kevorkian was in the news. I think it’s worth posting just because it’s a clear dissection of the legal and ethical issues involved in assisted suicide. My opinions on the matter haven’t changed. Interestingly, while I was on the “pro life” side on the Kevorkian issue (I think he should be convicted on multiple murder counts) I supported letting Terry Schiavo die, much to the disagreement of other Coffeehousers. I don’t think that’s inconsistent. I think patients have a right to refuse care, not to be killed.

Here’s the email.

Finally, a subject I know something about.

Before we can talk intelligently about doctor assisted suicide we have to make a few other terms clear that relate to death and dying.

(1) refusal of care - An informed, competent patient has the legal and ethical right to refuse any medical care, including food and fluids, even if without such care the patient will die. This is totally UNcontroversial and is well established both legally and in the medical ethics literature. Put another way, it is both illegal and unethical to impose on an informed, competent patient medical care that she has refused, even if such care would save her life and even if everyone else in the patient's family and neighborhood wants the patient to receive this care. (I don't have the slightest problem with this. Let me know if you do.)

(2) competence/informed refusal - The requirements for being informed and competent are technical. (It is purely a legal, not medical, construct.) Basically, a patient is informed and competent if he can weigh the risks and benefits of different courses of treatment (e.g. accepting food vs refusing food, or having surgery vs refusing surgery) and decide among them. The physician, the patient's family or anyone else may think that the decision is foolish or sacrillegious or stupid; that doesn't mean that the patient is not competent.

(3) surrogate decision maker - If the patient is not competent to make decisions, a surrogate decision maker is sought who best knows the patient's values and can make decisions for the patient that are hopefully as close as possible to those that the patient herself would have made if she was capable. This surrogate is typically a family member. So everywhere in this letter when I mention patient's refusing certain care or requesting certain care, you may substitute the patient's surrogate decision maker if the patient is not competent. (That's how a comatose patient, for example, can refuse fluids.)

(4) incompetent patient with no surrogate - Occasionally there is an incompetent patient for which no surrogate can be found, for example a man with no living family, or someone who has no close friends. This situation can be legally and ethically tricky, but is rare and is irrelevant to the larger questions of the "right to die". I will therefore ignore it.

(5) suicide - Suicide is the intentional taking of one's own life. Simple, huh? E.g. John shooting himself in his head or driving his car off a cliff. This is illegal in many states, so that the person who attempts it may be incarcerated and given psyciatric help. In California a few years ago, suicide was decriminalized so that the justice system is no longer involved, but people who attempt suicide can still be hosptitalized against their will to treat their injuries and get them to a psychiatrist. That's fine by me. Any voices of dissent on this?

(6) assisted suicide - This is the knowing assistance to another's suicide. If John asks Henry "Could you please bring me a gun so I can shoot myself?" and Henry complies, Henry is commiting assisted suicide. Obviously if John lies and Henry thinks that John is going to use the gun for target practice, Henry is not guilty of anything. Assisted suicide is illegal in all states. Physician assisted suicide is just a special case of assisted suicide. There are no special laws about it (as far as I know). It is simply illegal because all assisted suicide is illegal. Please note that in assisted suicide the assistant (physician or otherwise) is merely helping; the soon-to-be-dead-one is actually doing the act. I will argue farther below that assisted suicide should continue to be a crime, since it is never necessary for the alleviation of suffering. Please argue against me if you dissagree.

(7) euthenasia - The intentional taking of a life by a physician at the request of the patient. As opposed to (6), the doctor is doing the killing now, but still at the patient's request. This is also illegal. There is no specific law against this, and it is simply murder or manslaughter. Sadly it is almost never prosecuted. Since the patient and doctor are in cahoots and the whole thing is done secretly, it is a very difficult crime to discover. I think it's unambiguously evil, and would promptly report any of my esteemed colleagues who did such a thing. (Many of my colleagues have mixed feelings on the matter.)

(8) death as a side effect of appropriate medical treatment - The prolongation of life is only one of the goals of medicine. Another is the alleviation of pain. A patient may choose medical therapy which is has the risk of killing him. For example a patient who breaks a bone may choose to have it repaired surgically, rather than the alternative of a lifetime of disability, even though there is a small chance that the general anesthetic will kill him. If he in fact dies, he died as a complication of the surgery, and he is not considered to have been euthanised. Similarly, a patient in terrible pain may choose to have his pain treated with large doses of intravenous narcotics (among the most potent of analgesics) even though narcotics slow down breathing and at high enough doses may stop it. If the patient's primary goal is the alleviation of his pain and not the prolongation of his life, he may choose to have his narcotic dose escalated as high as needed to make him comfortable, with the understanding that a dose that kills him may inadvertantly be reached. This is not euthanasia because death was a side effect and not desired effect of the medicine. It is completely legal and ethical, and I've done it more than once to miserable suffering patients with terminal illnesses that wanted their suffering ended. This has been legal for a long time, so the public fear that doctors will keep suffering people in pain against their will is totally unfounded. We can, and frequently do, treat pain so aggressively that the medicine hastens the patient's death.

If, however, the patient was able to get pain relief at a certain dose of narcotic and still breathe adequately, any higher dose given to hasten death would be euthenasia. I suspect that this happens frequently - comatose comfortable patients are given morphine for their presumed pain, and it kills them. This is euthenasia, and legally it's murder.

Now that we've got some definitions under our belt, I can make my argument against euthenasia and physician assisted suicide pretty short. I don't think they are ever necessary to alleviate pain or to end the misery of someone who doesn't want to go on in his current state. I think currently accepted legal and ethical means are enough to treat everyone humanely and to end their suffering. Moreover, I think that given the ability to actively kill people, doctors (being only human) will abuse this ability as their convenience, financial interests or personalities dictate. Already in Holland where euthenasia has been legal for several years there are many reports of abuse. There are wide spread reports of old, sick people being killed without the request of the patient. (Remember, euthenasia, by definition involves killing a patient at his request. Killing someone without their request is even more clearly murder.) Some old people there fear being hospitalized, thinking that others may decide that they are too far past their prime and kill them. Some patients have actually hired guards to stand at their bedside fearing that while they sleep a nurse may "euthenize" them. Scary stuff.

Just to convince you that the current system does not force anyone to go on living in pain or in a miserable state that makes death preferable, let me show you two very typical examples:

(a) A patient who was previously healthy has a devastating car accident (or stroke, or heart attack or whatever) and is in a coma for weeks. It becomes clear that he will not ever recover, but could potentially live for decades in a coma. The patient's family make it clear that the patient has frequently told them that he would never want to live this way, and therefore refuse further medical care, including food and fluids. He is kept comfortable and expires in a few days.

This happens all the time. The right to refuse care basically allows a patient to die rather than continue in a horrible situation. Without fluids no one can survive longer than about 4 days, and frequnetly sicker patients are receiving more aggressive care, like ventilators or medicine to maintain their heart rhythm or blood pressure. When these supports are withdrawn death is very quick.

(b) A patient is dying of cancer and is fully alert but is in excruciating pain, and the cancer in her lungs makes her always short of breath. She may live for weeks or months but decides that it is more important to her to end her pain than to prolong her life. She wants her pain treated as aggressively as necessary to make her comfortable in her last days. She is given increasing doses of intravenous narcotics. These make her very comfortable and sedated, and help her not sense her shortness of breath. She sleeps comfortably and dies the next day, the narcotics having worsened her already precarious respiratory status.

So if we can already help these people, how does the legalization of euthenasia or doctor assisted suicide help? If patients are in pain or are depressed I can already treat their pain and depression as aggressively as they want me to, even if this hastens their death. Also, any patient whose life depends on medical care, including food or fluids, can kick the bucket at any time by refusing further care. Letting me commit physician assisted suicide would only help if I wanted to kill people who weren't in pain and weren't sick. How can this be defended?

I think Kevorkian is a serial murderer and should spend the rest of his life in jail. Some of his patients have not even been terminally ill, just old women whose pain was not being properly treated. I'm very worried that I have not heard an organized voice from my profession opposing his action. Doctors have become wimpy or stupid or scared.

I hope this wasn't too long. I eagerly await your questions and comments.
I mostly agree with you EXCEPT food and fluids aren't medical treatment, even if delivered by a tube. A patient whose feeding tube is removed suffers greatly, despite the claims of euthanasia proponents.

In the case of somebody who's dying, there are really two categories of medical treatment: regular maintentance and lifesaving measures. If the patient has been taking blood pressure medication for the past 20 years, and is now refusing chemo, there's no reason she should stop taking the blood pressure meds and die from that. Also, if a patient refuses to eat because of lack of appetite, that doesn't necessarily mean he would refuse a feeding tube.

In the case of surrogate's, they may often make decisions selfishly. I don't believe they should be able to refuse treatment on the patient's behalf unless there is strong evidence that the patient would have made the same decision. Of course, the best solution would be for everybody to have a health care directive.

After Terri Schiavo starved to death over a period of 13 days, I wrote an article detailing all the reasons why it shouldn't have happened. You can read it at http://kiwigeek.blogspot.com/2005/11/terri-schiavo.html
Eeek! I committed one of my own pet peeves! I meant to say "In the case of surrogates".

To clarify, I don't have a problem with somebody refusing blood pressure medication. I just think it needs to be explicit, to avoid denying treatment to somebody who wants it.
I am deeply conflicted over this issue because halacha states very clearly that you can't do ANYTHING to hasten a person's death... yet I can think of many instances where not allowing (or helping) a person to end their life is terribly cruel.

The halachic example commonly given is that if a person is near death and the sound of a person chopping wood in the forest nearby seems to have caught their attention, keeping them from expiring... you are not allowed to even go tell the woodsman to stop chopping wood for fear of hastening their death.
However, having watched several people die slowly in excruciating pain that no amount of medication could fully dull, I often wonder why we allow our animals relief from endless, unbearable suffering... but not our loved ones.

Your post mentioned an opinion that some might consider a slippery slope leading from easing a person's pain to euthenizing them:

"She sleeps comfortably and dies the next day, the narcotics having worsened her already precarious respiratory status."

The idea that you support a situation where a physician can sidestep the Hippocratic oath by actively doing minor or delayed harm is a concept somewhat like a shabbat clock that allows someone to perform a forbidden task because there is a delaying/separating mechanism between him/her and the actual completion of the act.

This lengthy preamble is my way of setting up the following question:

Would you support a euthanasia/assisted suicide machine that would be set up by a doctor (after the necessary duly witnessed consent forms are signed and approved by an impartial legal authority such as a judge) that would allow the patient... or even the doctor (in the case of a comatose patient with a living will or family member with legal authority to make the request)... to trip such a delayed administration of lethal narcotics?

One of the reasons I ask is that so many methods of suicide that people choose present real danger (physical and mental) to family members and bystanders. Think of jumpers who land on pedestrians... gunshot suicides who inadvertently shoot through an adjoining wall... intentional auto accidents that inadvertently involve other vehicles... carbon monoxide suicides whose cars catch fire and burn down the garage and neighboring buildings... and of course the lifetime scars of loved ones who find the victims after the deed. This doesn't even take into account the incredible financial burden that falls upon family, insurance companies and hospitals to care for people who have botched their suicide attempt for lack of proper tools or knowledge.
A patient who is going to die anyway in a very short time does not have to have a feeeding tube inserted halachically speaking -- a bit of water and nutrition can be put in an IV line. Often in old age or advanced cancer, the patient stops eating a few days before death, and it is obvious that death is near.

In Terry Schiavo's case, she wasn't going to die, but could have lived for many years. She didn't need medical treatment to stay alive, she just needed food and water. The halacha does not permit withholding food and water from a patient who can't swallow or eat normally.

Even though you may need a tube or IV line this isn't considered medical treatment, but something that every person needs in order to stay alive.

The halacha does permit withholding medical treatment (eg chemo) but these are really questions that have to be asked on a case-by-case basis of a competent halachik scholar.

It is also possible that in certain cases pain medication can be administered halachically, even though it may carry a risk of hastening death. If it will DEFINITELY cause the patient's death then it is really very questionable.

Although we pray never, never to be in such a situation of such pain, nevertheless there is a certain Jewish way of looking at suffering which may be a little different from the way medical science views it. We agree with the medical community that pain should be alleviated when possible -- and it is a great chessed that physicians perform for their patients -- yet we also see value in suffering, when, for whatever reason, pain is inevitable.

Suffering purifies the neshama and may obviate some unpleasant times in the World to Come.

Obviously if you don't believe in the World to Come or the existence of a soul, then you are going to look at it differently. ("You" is a generic you, not *you* Dr. Bean!)
BTW here are some of my old postings on Cross-Currents about the Schiavo case:



I've had a fair amount of experience with Hospice and unfortunately the issue of Hospice has also come up with regards to personal matters. While I am in favor of them and I think they do great work, I have noted that some Hospice nurses (or it may be an institutional bias) are more aggressive than other with regards to escalating narcotics dosages.

Which is to say that I can often predict that if a patient is admitted to a particular hospice program, the odds are good that he will be dead very shortly.

I've had calls from nurses asking for absurdly high doses of narcotics for patients whom I know for a fact don't happen to be in physical pain. Often they will ask for it "just in case", or to alleve supposed respiratory distress, or for excessive "secretions".

I often worry that by aquiescing so easily to their requests that I will be in some way supporting euthanasia.

And unfortunately, it has made me think twice about recommending hospice care for people who have limited life spans, but are not necessarily suffering.

Treat the pain--absolutely. There is no excuse for withholding adequate pain medication from a dying man. But do not use this medication to "put an end to the patient's suffering." I think a line is being crossed there.
Dear everybody: Thank you for your thoughtful and detailed comments. They deserve a thoughtful and detailed reply, and you will get one. This week, however, is insanely busy with an out-of-town conference, sick patients, and an old frail distant aunt of mine who broke her hip. I promise to comment on Sunday. Thanks for your patience.
Did I actually promise to comment on Sunday? Crap! I FORGOT! I'll try to do it tonight.


Of course by now not a soul is reading this thread. Oh well. Serves me right.
Ummm... Never mind.
Dude. waiting.
Yeah, I'm still hanging around.
OK. Sorry, everyone. I had a million things going on after I posted this and was hoping to be able to quietly ignore all of your comments, but as Ralphie and Kiwi are agitating, I’m back.

Kiwi: Secular medical ethics holds that intravenous fluids and tube feedings are medical treatments that may be refused like any other. The problem with asserting that they are not medical treatment is that a consequence of that is that they may not be discontinued, even by a fully informed and aware patient. I find that an intolerable violation of autonomy. If I want my tube feedings stopped they should be stopped. Period. Re the suffering of patients whose feedings are discontinued: that doesn’t mean that they wouldn’t refuse the feedings and want morphine to block the suffering. I’ve had lots of patients whose tube feedings and intravenous fluids were stopped. They didn’t suffer.

Re the frequent problems with surrogates not acting in the patients’ interest. Your solution is that absent clear prior instructions (like a health care directive) surrogates not be allowed to refuse treatment. Given that only a tiny fraction of patients have health care directives and that most who do don’t really understand the decision they’re making when they complete it (trust me, I’ve gone over lots of them with my patients), you are essentially insisting that every single patient who doesn’t die at home gets lots of CPR and spend a month in an ICU on a ventilator receiving a ton of futile care until their vital signs stop. It is only the surrogates’ refusal that prevents this most of the time.

Treppenwitz: My understanding is that Jewish law (halacha) is quite confused about this too, which is not surprising given the huge difference in the rates at which medicine and halacha change. There are certainly the rules that you cite that forbid hastening a person’s death, but there are also rules that state that if the death of an ill person is imminent (whatever that means) that prolonging the death is also forbidden. I know some religious Jewish doctors who practice Jewish medical ethics; I am not one of them. I think Jewish medical ethics is completely unworkable in the real world. For example, Jewish medical ethics (or halacha in general) has no concept of autonomy. It doesn’t matter in general, what the wishes of the patient are, or who is making a decision. The presumption is that there is one right decision, and since all life belongs to the Almighty, everyone should make that right decision for the patient. Nice, except what happens when an informed patient disagrees? There is no right to refuse life saving treatment in halacha. I actually don’t think there is a right to refuse any treatment, after all if your doctor wants to increase your diabetes medicine which will slightly decrease your risk of heart attack or stroke a decade from now, that’s potentially life-saving. Who are you to risk your life? So in real practice, how would any of this work? Do you physically force treatment on your refusing patient? I’ve never heard an adequate explanation for this. Doctors who actually think they practice Jewish medical ethics simply refer the patient to another doctor at this point, taking advantage of the fact that they are a small minority of ethical opinion. But how would a whole community practicing this way handle it? What happens in an ICU in Mea Sharim (an ultra orthodox neighborhood) if such a community actually produces physicians?

To get to your actual question: I would not support assisted suicide or euthanasia under any circumstances. I have yet to meet a patient who still wanted to die after his pain and depression and fear were addressed. Knowing that I will give them as much (but no more) morphine as it takes to keep them comfortable even if that hastens their death is usually all they want. I have not heard of people committing suicide by endangering others, though I’m sure it happens. I think those people needed antidepressants or pain relief, or both, not euthanasia.

Ms. Katz: I think my response to Treppenwitz above covers your comment as well, except for your statement
Suffering purifies the neshama [soul] and may obviate some unpleasant times in the World to Come.
In that case I pray that my soul and the souls of those I love leave this world having gone through the least purification possible. I must tell you that the strains in all religions that attempt to elevate suffering by connecting it to some benefit in the next world make the best arguments for being secular.

Psychotoddler: I haven’t had experiences in which I thought a patient was euthanized, but it certainly could have happened without my knowledge. Usually in hospice, the orders I leave are to escalate the doses as long as there is pain or shortness of breath, without a maximum parameter. So I don’t see why they have to come to you for a specific dose. Maybe you’re setting a maximum and they want a higher number just in case the patient is in distress at 3 am. Try it my way, and see how it goes.
"There is no right to refuse life saving treatment in halacha." -- I am not a halachic scholar but I don't think that's correct, a patient can refuse treatment, eg chemo or antibiotics or surgery.

About suffering -- I said "Suffering purifies the neshama [soul] and may obviate some unpleasant times in the World to Come." and your response to that was:
"attempt to elevate suffering by connecting it to some benefit in the next world make the best arguments for being secular."

I think that is only true if the religion forbids the alleviation of suffering in order to give the soul the benefit of suffering.

Judaism definitely believes in doing everything possible to alleviate suffering. It's a mizva and a chessed to help others, most definitely including alleviating other people's pain.

If your objection is that it seems to you there cannot be any positive side to pain -- well then you have the ancient problem of how to reconcile the existence of pain in the world (or the existence of evil) with a benevolent G-d -- the problem of theodicy, justifying G-d's ways to man. You are not the first and will not be the last to face this question.

You think His actions should be understandable on a simple level to us humans. Or you think that we should all "rage, rage against the dying of the light" and never accept that suffering could possibly have any benefit.

But why not? Why should a person not believe in a G-d who is good even we suffer, but whose ways are inscrutable to mere mortals?
Even if feeding isn't medical treatment, I don't see why a patient shouldn't be able to refuse it. AFAIK, nobody forces patients to eat when they have a lack of appetite.

I didn't say there should have to be an advance directive for a surrogate to refuse treatment, just that there should be 'strong evidence'. If the patient never mentioned the issue, or made statements implying that denial of treatment was wrong, (as in Terri Schiavo's case) there's no evidence that the patient would have agreed.
Toby Katz: The problem of evil and theodicy is something I studied a lot as an undergrad. Of course you’re right. You prefer the answer that all suffering is connected to a greater good, and I understand how that doesn’t diminish our mandate to ease as much suffering as possible. I prefer that the reason for suffering is unknowable to humans, or that (though the universe is ruled in infinitesimal detail by a benevolent omnipotent Ruler, from our very limited perspective) there is no reason. I’m willing to admit that my preference is likely subjective/emotional.

Kiwi: Oh, OK. Usually when people try to decide whether something is medical care or not, it’s because medical care can be stopped while basic custodial care (like bathing and bringing the patient trays of food) may not. If you lump tube feedings in with non-medical custodial care, many would argue that you can’t stop it. That’s why I (and secular medical ethics) have it in the “medical care” column.

I understand what you’re saying about strong evidence, just understand as a practical matter that this almost never exists. I would want all medical care withdrawn if I were in Terry Schiavo’s condition, including tube feeding and fluids, but the only evidence I’ve left of this is my many conversations with my wife to that effect. Without rehashing and redebating the Schiavo case, your standard for surrogate refusal would have kept her and would keep me in her state until we were fortunate enough to contract pneumonia.
You've discussed this with your wife, but nobody else, ever? I'd say this blog entry is pretty good evidence, and you've probably discussed this with your parents, siblings, and/or friends at some time. I sure have.

If a patient really refused to be bathed or fed, I don't see how you could force them, although it would make sense to require that it be offered regularly.
Kiwi: I may have discussed it with some friends, but they're not the ones who I want making decisions for me, my wife is. Discuss it with my parents? Are you out of your mind? Oh, that's right, you don't know them. They're well-meaning but are as capable of making a difficult decision under emotional strain or of remembering a crucial fact about my wishes as I am capable of proving the Riemann Hypothesis.
I don't mean that your friends, much less blog readers would be making the decision. Obviously your wife would. However, other people and the written record could provide the "strong evidence" I mentioned.
Decision, schmecision. I'm smothering Bean with the nearest hospital-issued pillow the second he's transferred from the ER.
I've printed out a copy of this thread and mailed it to my lawyer.
Stay away from Ralphie. He doesn't sound very pleasant. ;o)
Post a Comment

<< Home

Powered by Blogger