The Gift of Finitude

I’ve been thinking a lot lately about finitude. About limits. Incompleteness. Even failure.

Like the friend of a friend who is dying and has just been admitted to hospice, whose young teenaged daughter is facing the prospect of a life without her mother.

Like the colleague who is grieving the loss of both a spouse and a parent within a month of each other.

Like my power wheelchair that keeps breaking down, making everyday activities significantly more challenging.

Like the never-ending “to-do” list that seems to be anything but finite, and never quite seems to get any shorter.

Life is, in a word, full of limits. Boundaries. Unavoidable stopping points.

Or is it?

What if we could transcend our limits, as recent developments in genetic and related technologies (e.g., CRISPR) seem to promise? What if, through genetic manipulations of various sorts, we could significantly reduce our limitations—eliminate specific diseases and disabling conditions, improve cognitive function, “select” for desired physical traits, and so on?

If we could do these things, should we do them?

Of course, as anyone who has followed the field of bioethics for even a short period of time knows, these questions are neither new nor hypothetical. In many ways, the “future” is already here: we “enhance” ourselves, “transcend” limits and boundaries, and otherwise seek to “overcome” finitude in a myriad number of ways, on a daily basis. And much of this is salutary.

Still, it’s always worth pausing to consider: supposing finitude could be eliminated entirely from our lives (which seems extraordinarily doubtful), is it the sort of thing we ought to try to eliminate? Put differently: is there anything good about finitude, such that we ought to embrace it (even if in a qualified way)?

Gilbert Meilaender, a bioethicist and Distinguished Fellow of The Center for Bioethics and Human Dignity, suggests that there is something good about finitude. In a reflection on the “created duality” of our human nature—we are simultaneously both “free” and “finite”—Meilaender observes that this “two-sidedness” to our nature both opens up possibilities and imposes certain limits upon us. We are, he observes,

created from dust of the ground—finite beings who are limited by biological necessities and historical location. We are also free spirits, moved by the life-giving Spirit of God, created ultimately for communion with God—and therefore soaring beyond any limited understanding of our person in terms of presently “given” conditions of life…. Made for communion with God, we transcend nature and history—not in order that we may become self-creators, but in order that, acknowledging our Creator, we may recognize the true limit to human freedom. Understanding our nature in this way, we learn something about how we should evaluate medical “progress.” It cannot be acceptable simply to oppose the forward thrust of scientific medicine. That zealous desire to know, to probe the secrets of nature, to combat disease—all that is an expression of our created freedom from the limits of the “given,” the freedom by which we step forth as God’s representatives in the world. But a moral vision shaped by this Christian understanding of the person will also be prepared to say no to some exercises of human freedom. The never-ending project of human self-creation runs up against the limit that is God. It will always be hard to state in advance the precise boundaries that ought to limit our freedom, but we must be prepared to look for them.[1]

I am inclined to agree with Meilaender. Moreover, as I have shared in an autobiographical essay published recently,[2] my own experiences as a person with a physical disability have taught me valuable life lessons that, arguably, might not have been learned otherwise—lessons such as the value of patience and endurance, accepting my limits (an ongoing struggle, I must admit!), and even the importance of having a sense of humor at the (sometimes ridiculous) circumstances in which one finds oneself. Our limits shape our character, our career, and our life choices as much as do our “freedoms”—often in surprising and unexpected ways, and frequently for the better.

None of these reflections, of course, even begin to scratch the surface of the “what?”, “where?”, “when?”, “how?”, or “why?” questions related to the ethical permissibility (or lack thereof) of pursuing various genetic, reproductive, or other technologies. Nor do they, by themselves, tell us whether (and when) we ought or ought not to avail ourselves of abortion, physician-assisted suicide, euthanasia and the like.

They do, however, remind us of one very simple, yet all-too-often overlooked fact: finitude is, in many ways, a gift. Let us not neglect it.

 

[1] Gilbert Meilander, Bioethics: A Primer for Christians, 3rd ed. (Grand Rapids, MI: Eerdmans, 2013), 3-5.

[2] See “Why am I Disabled? Reflections on Life’s Questions and God’s Answers,” in the Beyond Suffering Bible (Tyndale, 2016), available at beyondsufferingbible.com and http://www.joniandfriends.org/bible/.

A Conflict of Interest is NOT an Ambiguity

Oregon Senate Bill 494 has been described as a “euthanasia bill” that is “intentionally ambiguous,” and as a piece of legislation that would “allow the starving and dehydrating of patients who suffer from dementia or mental illness.”

What has received less press is the composition of the 13-member committee who would be perpetually in charge of advance directive forms in the state, with no oversight by the legislature. Who would those persons be? According to the bill, the 13-member “Advance Directive Rules Adoption Committee” would include

  • The Long Term Care Ombudsman or that individual’s designee
  • 12 members appointed by the Governor
    1. one representative of primary health care providers
    2. one who represents hospitals
    3. one clinical ethicist affiliated with a health care facility
    4. two health care providers with palliative care or hospice expertise
    5. one who represents persons with disabilities
    6. one who represents “consumers of health care services”
    7. one who represents “the long term care community”
    8. one who has expertise in “advising or assisting consumers with end-of-life decisions”
    9. three members from among those proposed by the Oregon State Bar:
      • an expert in elder law
      • an expert in estate planning
      • an expert in health law

Why is the State of Oregon so interested in making sure their appointees are in charge of advance directives?  Is it because the state is so concerned about the health of its citizens?  Hardly, when those citizens in the health care system are described not as patients, but consumers.  Stacking the committee with lawyers who are experts in estate planning and elder and health law seems to assure the state that they will get their pound of flesh.  The State is aware of this:  deceased consumers no longer need their money or their organs.  The conflict of interest inherent in this scheme is not ambiguous.

 

— D. Joy Riley, M.D., M.A., is executive director of The Tennessee Center for Bioethics & Culture.

Whatever Happened to the Instinct that ‘Doctors Must Not Kill’?

In a 1992 article in the Journal of Clinical Ethics titled, “Doctors Must Not Kill,” renowned physician and bioethicist Edmund Pellegrino reminded fellow physicians—with incisive logic and strong passion—of their historic duty to be healers, not killers. As one who is not a physician but will one day be a patient facing the end of his life, I would take comfort in knowing that my physician was committed to heal me and, if healing were not possible, to provide me comfort and care to the day of my natural death. Pellegrino’s plea that “doctors must not kill,” however, evidently is falling on the deaf ears of more and more physicians.

The notion that mercy can entail ending the suffering of a patient by ending his or her life, combined with an almost uncritical acquiescence to patient autonomy, seem to be the major factors behind the increasing acceptance by physicians of PAS (physician-assisted suicide). According to the Medscape Ethics Report 2016, 57% of physicians believe PAS should be available to terminally ill patients who request it, up from 54% in 2014 and 46% in 2010. This aligns with the increasing public acceptance of PAS. A 2016 Gallup Poll found that 68% of Americans support the legalization of PAS, up 10% from the previous year.

What happened to the instinct that “doctors must not kill?” One would hope that this instinct runs deeper than even the historic commitment of physicians to be healers first and foremost. One would hope that it is, at its most basic and fundamental level, a human instinct.

I personally know a young police officer who recently resigned because he experienced this instinct not to kill. Facing numerous tense situations over the course of five years, he had drawn his service weapon dozens of times but, thankfully, had never been forced to fire. That nearly changed when he was charged by a machete-wielding man sky-high on drugs. “Sir, drop your weapon,” he repeated again and again to no avail, as the man quickly closed the distance. For the first time in five years, he exerted pressure on the trigger of his Glock. Two more steps by the man and two more pounds of trigger pressure by the officer, and both lives would be altered forever. One would be dead and one would have to answer for a split-second decision to use lethal force. Fortunately for both, the man loosened his grip on the machete and it fell to the ground. The officer breathed a sigh of relief.

“Dad,” my son told me, “I wasn’t afraid. I would have pulled the trigger if he had taken two more steps. I knew I would have been justified in doing so. But he wasn’t a murderer, a rapist, a bank robber, or a terrorist. He was just a crazy fool out of his mind on drugs. And though he was an imminent threat to my life, I didn’t want to shoot him.” Waxing philosophic, he added, “In that moment, I realized how unnatural it is to take the life of another human being. The instinct not to kill was overwhelming. Yes, I would have shot the man had he taken two more steps. But then I’d have to live with that decision the rest of my life.”

Granted, the case of a police officer deciding whether to shoot is different in many important respects from the case of a physician deciding whether to prescribe lethal drugs where PAS is legal. What intrigues me now, however, is that very strong instinct my son felt that night; that taking the life of another human being – even when legally justified – went against the very grain of his humanity. What does it say, then, when physicians who have sworn historically to be instruments of healing are now willing to be instruments of death? What happened to that instinct and commitment that Dr. Pellegrino so forcefully affirmed, “doctors must not kill”?

Physician-Assisted Suicide and Canada…Again

Though a relative “latecomer” in the legalization of physician-assisted suicide (PAS), Canada seems determined to make up for lost time. Already the question of organ donation after PAS has been raised. Very recently, the medical “savings” made possible by the legalization of PAS in 2016 was brought to light.

The January 23, 2017 volume of the Canadian Medical Association Journal (CMAJ) published the results of a study by Aaron J. Trachtenberg and Braden Manns titled, “Cost Analysis of Medical Assistance in Dying in Canada.” The authors stated that the aim of the study was “to determine the potential costs and savings associated with the implementation of medical assistance in dying.”

The study found that the legalization of PAS will save the Canadian healthcare system between $34.7 and $138.8 million per year; a savings far exceeding the $1.5 to $14.8 million in direct costs associated with the implementation of PAS (physician consultations, drug costs, etc.). Following the lead of a study conducted in the Netherlands (where both PAS and voluntary active euthanasia are legal), the researchers considered the following factors in their calculation: (1) the effect of PAS on patients’ longevity of life (patients requesting PAS would not live as long as patients choosing palliative care); (2) the average cost of care for end-of-life patients suffering from various diseases, especially cancer; and (3) the expected number of PAS deaths. The conclusion was that patients electing PAS will “save” the healthcare system millions of dollars that otherwise would have been spent on their palliative care.

The obvious first question is why would the CMAJ, Canada, or the authors be interested in the cost savings associated with PAS? More than curiosity must have driven the study. Seemingly, the main impetus was to gain assurance that the implementation of PAS was not costing more money than offering palliative care: “Our analyses suggest that the savings will almost certainly exceed the costs associated with offering medical assistance in dying to patients across the country, and that the inclusion of medical assistance in dying in the services covered by universal health care will not increase health care spending.”

Nevertheless, the researchers must have felt some uneasiness about the perceptions this study might generate. Thus, they assure readers of the study: “We are not suggesting medical assistance in dying as a measure to cut costs. At an individual level, neither patients nor physicians should consider costs when making the very personal decision to request, or provide, this intervention.”

Alex Schadenberg, the executive director of the Euthanasia Prevention Coalition, doesn’t feel assured (“Awful Study Says Euthanizing More Patients Will Save the Government Money,” Ottawa, Canada, January 24, 2017). First, he points out that associating PAS with cost savings implies that it is a social good. I agree. When health care costs are covered primarily by the government, as they are in Canada, the prospect of “saving” tens of millions of dollars might easily be seen as best decision for the (financial) good of the country. Second, connecting PAS with significant financial savings pressures patients to elect PAS rather than continuing to live. Again, I agree that this is a legitimate concern. There is evidence that some patients, at the end of life, worry about being an emotional and a financial burden to their loved loves. If patients are aware of the findings of this study, they might also come to feel that their continuing existence is a burden to State as well.

The study might well assure Canadian power brokers that PAS will greatly strengthen the financial stability of the health care system. As Schadenberg points out, “Dead people don’t need palliative care.”

However, the study does little to encourage sick and dying patients to live out their remaining days, convinced that a willing and compassionate healthcare system will provide necessary and effective palliative care. When patients are struggling with the decision to request PAS or to continue living, I wonder if the findings of this study will ever rattle around their minds. Will any patients think at this very vulnerable moment, “But I could save the country a lot of money and my family a lot of trouble if I would just go ahead and die”? I hope not. But with the publication of the findings of this study, it is not unimaginable that they would.

Do Polls about PAS Tell the Whole Story?

By many indications, support for the legalization of physician-assisted suicide [PAS] is increasing. On November 8, 2016 Colorado voters passed Proposition 106, “Colorado End of Life Options Act,” by a 65% to 35% margin, making Colorado the sixth state to legalize PAS, joining Oregon, Washington, Montana, Vermont, and California. The following question appeared in a 2015 Gallup poll: “When a person has a disease that cannot be cured and is living in severe pain, do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patients requests it?” 68% of respondents answered “should” while only 28% answered “should not.”

That to which people are saying “yes,” however, does not always match the reality of the practice of PAS in the states in which it has been legalized. Note the wording of the question in the Gallup poll. The question pictures a medical situation in which: (1) The disease is incurable; (2) The patient makes a voluntary request; and (3) The patient is “living in” severe pain, which suggests constant, relentless, and untreatable pain.

Most likely, in my judgment, people are prompted by mercy in saying “yes” to PAS because they think that a large percentage—perhaps even a majority—of patients suffer unrelenting and untreatable pain, making PAS a compassionate option. If this is indeed what respondents are thinking, they are mistaken in large measure. Granted, pain is intractable and difficult to manage for some dying patients, but certainly not for the majority of patients, thanks to advancements in palliative care. Even the patients who avail themselves of legalized PAS tell us that. According to the official 2015 report on Oregon’s Death with Dignity Act, patients requested medical assistance in dying for these top three reasons: (1) Decreasing ability to engage in activities making life enjoyable (96.2%); (2) Loss of autonomy (92.4%); and (3) Loss of dignity (75.4%). “Inadequate pain control or concern about it” was in sixth place, mentioned by 28.7% of patients. Yet, even here, it is difficult to break down the percentage of patients who were actually experiencing inadequate pain control from the percentage of patients who were merely concerned they might. It seems likely that some patients request PAS on the basis of what they might experience in the future, not on the basis of what they are experiencing in the present.

Motivated by mercy, a majority of Americans are beginning to say “yes” to PAS. I wonder if the level of support would change if respondents realized that, in the vast majority of cases (though admittedly not in all cases), pain can be effectively managed. In no study that I’ve read has “relief from pain” been a top-tier reason patients give for requesting PAS in states in which it is legal. That to which respondents are giving a merciful “yes” does not seem to match the reality.

Late Term Zika Abortions: Thankfully not Euthanasia

If I were the editor of a recent Newsweek article by Cornell Law Professor Sherry F. Colb, the above title would have been my choice for her article. I must encourage you to read the actual article, lest you believe that the summary that follows is somehow taken grossly out of context. Her concern is that a late term abortion to terminate the life of a Zika-infected baby might be morally problematic because it might be misconstrued as euthanasia rather than simply a late term abortion.

She begins factually with her concern for the increasing prevalence of Zika, a virus causing severe microcephaly of babies born to parents with the infection. Further complicating the matter is that the birth defects are not apparent until well into the third trimester. Thus, per Professor Colb, Zika pregnancies require us to answer two moral questions. The first question is whether it is “…right to end a pregnancy because the baby would be severely disabled if brought to term?” The second wonders whether it is “right to take the life of a fetus late in pregnancy, regardless of the reason?” (I was encouraged at this point that she conceded both that the fetus was alive and that a baby was a direct result – my optimism did not last long.)

She was quick to point out that she considers “…the reasons for a woman’s choice to terminate her pregnancy to be irrelevant to the question of whether she should be legally permitted to do so…” as she is “…entitled to be free of the bodily intrusion that is pregnancy, even if her reason for wanting to assert her bodily integrity is an offensive one.” Her reason for even bothering to discuss the moral issues is because she anticipates that large numbers of women may be wanting to terminate their pregnancies so the discussion is worth having, “…even if our answer will not affect the legal conclusion that the woman should be free to terminate.”

In answering her first question in the affirmative, she effectively equates routine abortion to contraception and considers the fetus to be a “potential” life, arguing that even in Down Syndrome, parents choose abortion, and since Zika is a worse condition (her stipulation), “…it may be that an abortion will spare not only the parents but their child a life that is, in some sense, not worth living.” (I have always wondered what it is we are sparing a specific child by not having it live – a non-entity cannot be spared anything – the concept seems incoherent)

The second question is more troubling for her. Her “no-go” line for abortion and moral significance is sentience but she admits that others have different criteria. However she further concedes that the later one goes in the third trimester, “…the more likely that people will have the moral intuition that we are no longer talking about a ‘potential’ child but are instead talking about either an existing child or at least someone worthy of nearly as much moral consideration as a newborn baby.” For her, the moral calculus has changed. Bodily image abortion arguments fail (simply birth the child alive, “…thereby ending the internal occupation…”). Terminating the pregnancy at this point does not need to terminate the life of the fetus or baby, and “…the choice to have an abortion (one that kills the fetus or baby) is really a choice to take the life of the fetus or baby because it is not considered a life worth living.” She is equating late term abortion to euthanasia. (Correctly in my mind, and, since I have different criteria for abortion, specifically, nothing post conception, therefore, all abortion is euthanasia)

She solves her moral dilemma by hiding inside a legal loophole. “If one nonetheless concludes that because of the potentially catastrophic nature of the birth defects, children with Zika are better off not existing than living severely compromised lives that they would otherwise live, the fact that they live inside a pregnant woman may give people a legal –if not a moral—loophole through which they can achieve their desired end, though it is really euthanasia.” The pregnant woman can do all this “…without beginning the slide down the euthanasia slippery slope, because we can fit what she has done under the heading of “abortion” instead of “euthanasia.”

Let that last bit of mental gymnastics sink in.

From what vantage point does one judge the slippery slope of one moral issue whilst sliding down the slope of another?

A novel strategy for suicide prevention

In the Netherlands, a doctor will not be prosecuted for assisting a patient to die either through euthanasia or assisted suicide (EAS) if certain conditions are met, among which are the following: The patient’s request for aid-in-dying must be voluntary and well-informed, without coercion from others, and uninfluenced by psychological illness or drugs; their suffering should be unbearable and hopeless, with no prospect for improvement and without reasonable alternatives; and an independent physician should be consulted, who should concur with the aforementioned conditions. Supporters aver that these guidelines have made physician-assisted death safe and have avoided the “slippery slope” that detractors and fear-mongers fulminate about.

A commentary (preview available here) in last week’s JAMA gives cause to question the rosy picture some paint of the Netherlands experience. The commentary refers to a study that appeared in the April 2016 JAMA Psychiatry. The study describes the practice of EAS for psychiatric disorders in the Netherlands, reviewing 66 patient reports filed by physicians from 2011 to 2014. Surprisingly, only 49 of the 66 patients experienced depression. Thirty-four had at least one prior suicide attempt. Six had substance abuse, two a diagnosis of autism. Thirty-four had personality disorders; 13 had never had a psychiatric hospitalization; 37 described social isolation or loneliness. Thirty-seven of the patients had refused some recommended treatment. In eight cases, the involved psychiatrist believed that the criteria for EAS had not been met. Eighteen cases involved physicians who had not cared for the patients before the EAS request; most had met the patients through mobile euthanasia clinics. (As Paul Appelbaum writes in an accompanying editorial [preview available here], “One might wonder whether a clinic intended to make assisted death more available will have a lower threshold for approving requests.”) In 16 patient cases, three independent physician reviewers could not agree among themselves as to whether the patient was making a competent request, or whether there was treatment that offered some prospect of improvement.

The description of some of the patients is compelling. The study reports that a “woman in her 70s without health problems … and her husband had decided some years before that they would not live without each other. She experienced life without her husband, who had died 1 year earlier, as a ‘living hell’ and ‘meaningless.’ A consultant reported that this woman ‘did not feel depressed at all. She ate, drank, and slept well. She followed the news and undertook activities.’ ” About patients who reported social isolation or loneliness: ” ‘The patient indicated that she had had a life without love and therefore had no right to exist’ . . .  and ‘The patient was an utterly lonely man whose life had been a failure.’ ” A Dutch regional euthanasia review committee found one case that did not meet due care criteria: “. . .a woman … in her 80s with chronic depression who sought help from the End-of-Life Clinic. The clinic physician met with her 2 times (the first time was 3 weeks before her death), and the patient was not alone on both occasions, with family members present. The physician was not a psychiatrist, did not consult psychiatrists, was unaware of the Dutch Psychiatric Association Guidelines, and yet ‘had not a single doubt’ about the patient’s prognosis.”

These stories are tragedies. I do not deny that the patients in this study were truly suffering. But is EAS really an appropriate way to treat the suffering, by killing the sufferer? If someone fails in an “illegal” suicide attempt, can they just go to the doctor and have it done legally? Is EAS to be the new solution for loneliness, social isolation, and grief? Is it not a slippery slope to go from “Doctors must not kill,” to “Doctors can kill in the case of terminal illness,” to “Doctors can kill people who don’t have a terminal illness but just want to be dead”?

Physician assisted suicide on YouTube

Physician assisted suicide (PAS) is in the news in a way that is different than before. It is not because it is election time and a state has a ballot initiative about legalizing PAS. It is because a 29 year old woman with an aggressive malignant brain tumor, Brittany Maynard, has chosen to use PAS to end her life and chosen to do it very publicly by using her story to promote the legalization of PAS in a video about her choice produced in cooperation with the euthanasia advocacy group Compassion and Choices.

The video focuses on her desire to be autonomous. She states very clearly that she wants to be in control of the circumstances of her death and that she considers it her right to choose the manner of her death. There is no denying that PAS can be seen as the ultimate act of autonomy. The question is whether insisting on our own autonomy and being in control is what is morally right. God has given us the ability to make choices and he allows those choices to have real effect, but that does not mean that all choices are good. We can at times exercise our autonomy in ways that are not good. We can be prideful or controlling or self-centered. I say we because I am not saying that this particular person’s choice necessarily involved those wrong motives. It is simply that as fallen human beings our autonomous choices often involve those things and are wrong. One hint of what underlies Brittany Maynard’s choice is found in the section of the video in which her mother begins to cry when she talks of her daughter convincing her to take a trip to Machu Picchu where the mother is afraid to go by telling her that she will meet her there. There is a suggestion that she desires not only to control her own death, but her mother’s life as well.

A second video that was released a few days before the day Brittany Maynard had announced she was going to end her life is addressed to her by Maggie Karner, a woman in Connecticut who shares with her the diagnosis of stage 4 glioblastoma multiforme and will also soon die of her brain cancer. Her video, which was produced by the Family Institute of Connecticut (an advocacy group for traditional Judeo-Christian family values), pleads with Brittany not to end her life, but to live out as much of it as she can. Her perspective is that life is valuable and living life, even when autonomy and ability are impaired, is meaningful to her family and others who love her. To make her point she relates the story of her father who lived for five months after becoming quadriplegic and tells of how much the intimacy she shared with her father during the time she helped care for him in his helplessness meant to her. She does not condemn Brittany for her choice but calls out to her like one would call out a plea not to jump to someone preparing to jump off a building (her analogy).

Unfortunately Brittany Maynard did not head that call and took her life a few days later.

Euthanasia, pediatric and adult, and the underlying concept of a life not worth living

Jon Holmlund’s recent post about pediatric euthanasia in Belgium made me think about what I had posted a couple of weeks ago about PGD and lives not worth living. There is a way in which the concept of a life not worth living underlies a whole spectrum of ethical issues from PGD and selective abortion to pediatric and adult euthanasia. There is a basic conflict between those who take different ethical positions on these issues over whether there are certain quality of life issues that can allow one person to decide that another person’s life not worth living.

For those who take the position that it is permissible for couples who are at risk to have a child with a serious genetic disorder to use PGD or prenatal diagnosis with selective abortion to try to insure that any child that is born is free from the genetic disorder, a part of the argument for their position is that it is permissible to discard the embryos found to have the disorder or abort the fetuses found to have the disorder due to the poor quality of life that would be experienced by those children if they were born. That is saying that the lives of those children would not be worth living. That decision is being made by the parents for their children and being confirmed by the physicians and others who participate in the process.

Those who support the permissibility of active infant euthanasia as practiced in the Netherlands under the Groningen protocol are also saying that the infants whose lives are being ended have lives that are not worth living. Again this decision is being made by the parents and confirmed by the physicians involved that the infant’s life is not worth living.

The situation with voluntary euthanasia of children as it has recently been allowed in Belgium is more complex. If the child does not actually have full decision making capacity or is being overtly or covertly coerced, it is again someone other than the child who is making the decision that the child’s life is not worth living and the situation is similar to infant euthanasia. If the child has full decision making capacity then it could be reasonable to consider the situation to be the same as adult voluntary euthanasia.

With adult voluntary euthanasia some would argue that the concern about one person deciding that another person’s life is not worth living is not an issue because it is the one whose life is being ended who is making that decision. However, whether what is being done is voluntary active euthanasia in which a physician is administering a lethal drug or physician assisted suicide in which the physician prescribes the drug with the intent that the patient will self-administer it, the physician who is involved must make the decision that the act of ending that patient’s life is warranted. Few would be willing to take respect for autonomy so far as to say that anyone who requested assistance to end his or her life should be provided the means to do so without a judgment by the physician that the decision to do so was an appropriate one. Assisting someone to commit suicide who is despondent over a break-up of a relationship is irresponsible. Thus physician participation in voluntary active euthanasia or assisted suicide requires an independent decision by the physician that the decision to request assistance in ending life is reasonable. The only way a physician can make the decision to participate is to decide independently that the patient’s life is not worth living.

The only situation in which ending a life to avoid a poor quality of life could be done without one person deciding that another person’s life is not worth living would be unassisted suicide. There are Christian and Kantian arguments for why that is not morally permissible, but that lies outside the realm of these thoughts.

Since all of these actions, from PGD to adult voluntary assisted suicide involve one person making a decision that another person’s life is not worth living, a crucial issue is whether it is morally permissible for us to make such a decision about another person’s life. For those of us who have an understanding that every human life has value simply because of being human, we must answer that it is not permissible to make that decision. We understand that no matter how difficult a life may be that person still has value and our response to those whose quality of life is poor and who are having to endure more suffering than it would seem that they ought to is to affirm the value of that person’s life by caring for the person’s needs. We cannot say that another’s life is not worth living.

Can Vets Help Physicians Consider Euthanasia?

I had no plans to write on the issues of human versus animal euthanasia, since it seems like I’ve spent more than enough words on the topic previously. Then I began to tackle the mail, journals and newsletters in my mailbox and came across a submission that made me want to re-open the whole issue. In the July issue of “Veterinary Practice News,” Dr. Alice Villalobos, a well-respected palliative-care veterinary oncologist and previous president of the Society for Veterinary Medical Ethics, submitted a “ViewPoint” piece that asked, “Can vets help physicians consider euthanasia?”

First of all, I have great respect for Dr. Villalobos as a veterinarian who has made a great contribution to the welfare of animals by the development of a “quality of life” scale that helps assess, in a more tangible way than to attempt a determination of “suffering,” when an animal patient should continue to receive treatment, including palliative or hospice care, or when euthanasia should be considered the most humane option. The article that includes this information, by the way, is found at the ”Pawspice” (rhymes with “hospice”) website. You may find it a fascinating read.

Her piece starts solidly, with the reflection that the veterinary standard for hospice care, including euthanasia, is spilling into human hospice, in some states at least: “…there is no way to deny that there is a societal trend for crossover to the way veterinarians assist animals at the end of life.” Indeed. Ask the legislatures in Vermont, Oregon, Washington, and Montana. And she further reflects that it goes the other way as well: some veterinarians adopt a vitalist model that would place enough guilt to convince someone into spending resources, financial and emotional, on an end-stage renal failure patient to try “’…one more day to keep her going,’” ultimately ending in a pet that dies in the hospital and away from human family members. Some veterinarians increasingly imitate some of their human medical colleagues that wish to extend life at all costs.

I find it appropriate to condemn this kind of practice—it is paternalistic and unkind to human and animal alike. The patient, of course, has no voice, and a veterinarian can effectively bully a client into doing extensive and futile procedures or face the shame of “killing” their pet. Where Dr. Villalobos goes off the rails is in the next section of her piece. Here she makes her argument for human euthanasia:

“Many seriously sick, old and frail people receive brilliant medicine and supportive care as hospital patients. Then they get transferred into a facility where they become humiliated persons whose bodies are being warehoused until they die.

“Baby boomers fear that they will get futile medicine or live too long in chronic pain, past their desired time, languishing year after year in tomorrow’s thriving extended care industry.”

Okay, perhaps this is just genuine emotion, and not an ad hominem attack on the human medical field. There is plenty to criticize in the way we treat human beings at the end of life. But she goes on:

“What about the horrendous emotional suffering of people whose bodies and/ or minds have withered into vegetative tissue barely resembling their original self? The distraught families of warehoused persons feel guilty and hopeless because they are barely recognized or not acknowledged at all during visits.”

Several critiques here: how does one who is in a vegetative state (curiously defined as “bodies and/ or minds”—I am curious what a “vegetative body” resembles) have the wherewithal to suffer so horrendously? I thought their minds had already withered to an unrecognizable degree. Must we resemble our “original self” to maintain human dignity? A visit to a fifty-year high school reunion will challenge that view. And how did we shift the focus to the guilt and hopelessness of family members, not the patient? Ought these, then, be the predominant foci of our ethical decisions?

But my greatest criticism is the ethical leap Dr. Villalobos makes here: A decision to forego burdensome medical treatment that would extend life necessitates euthanasia. She infers (at a minimum) that a decision to forego treatment is the same as the decision to have a physician actively end life, perhaps even absent the patient’s will. They are certainly not, and effective palliative medicine in human medicine has shown this. Allowing a patient to die as a result of the underlying disease is not euthanasia. While this is not generally practical or advisable in veterinary medicine, humans can “die with dignity,” to use that wretchedly-abused term, without being euthanized. Yes, it is different.

Euthanasia is a big part of how I, and other veterinarians, can fulfill our mission to relieve animal pain when they become moribund or face intractable pain. It has always been ethically sound for us to do so. We recognize that an extension of the process of dying offers little of value to our patients. The same cannot be said of human beings, where interpersonal relationships are more complicated—and the risks of hastening the end of life are far more complex. To make this jump is ethically unsound and, frankly, rather sloppy.

We must ultimately decide if ethical principles must apply to humans and animals identically or if human beings are a different sort of being, based on our innate “human-ness.” And we must realize that, as our technology develops further and can extend life longer, popular sentiment and cultural ethics will equate the decision to cease or withhold treatment with euthanasia. Maybe we have our work cut out for us, even if it means revisiting the issue a few more times than we think we have to do.