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.

Why Dr. Kevorkian Was No Hero…and I Often Am

Admittedly that title is provocative. In a sense, both the late Dr. Jack Kevorkian and I could be considered to be in the business of euthanasia (though I hope I will someday be remembered for far more), but the species of our patients differs. And that, as they say, makes all the difference in the world.

A few weeks ago, I reflected upon how euthanasia of my animal patients offers a glimpse into the debate over human euthanasia, and what trends may be portended by this ethically-accepted practice for animals if starts to become more widely-accepted when applied to humans. But why the distinction? Why do we look at this difficult but necessary part of a veterinarian’s work as a genuinely humane way to end animal pain and suffering but have such qualms about applying it to people? Perhaps it could be found in Leon Kass’s “moral wisdom of repugnance” or good old natural law? A few of my thoughts.

First, even the most strident of animal rights advocates could find that the technological and logical capabilities of human beings compel them to exert some superiority over non-human animals, if only to relieve pain when we see it. If animals have rights, others (specifically humans, who have the wherewithal to act upon them) have responsibilities to those animals. Even those like me, who find little practical use in using the language of rights for animals, can recognize the awesome powers human beings have for good and evil over the natural world, and thereby derive a responsibility to tend to the pain of those animals that cannot provide for themselves. Intellectually we have a hard time believing that we can legally take the lives of healthy animals for food or clothing (even if vegetarians dislike its practice) and yet have no authority to euthanize the gravely ill and dying. While the acceptable criteria for animal euthanasia may well differ (some veterinarians will not euthanize pets that have behavioral problems but are otherwise healthy, for example, whereas others will do so if a pet owner is just “tired of” their pet—that’s a subject for another time), it is well-respected as part of the veterinarian’s principal duty to “relieve animal suffering” as our oath states, and appears well within the ethical bounds of being a good and moral person. I read a piece by another veterinarian today that felt like our oath should well be extended to state “relief of animal AND HUMAN suffering,” as the process of slow pet death can be so poisonous to the human family enduring it. There is a certain restoration of wholeness that comes from the removal of that pain and perceived suffering in a creature that cannot understand it nor benefit from it (see my comments below). When people are given the freedom to address their pet’s AND their family’s quality of life issues, the relief is palpable. Though not ultimately my decision, I can ethically apply the “best interests” standard to both my patients and the human family and recommend euthanasia based on all applicable factors. For a physician to apply those same standards would be alarming.

Second, and obviously, I am not a “people doctor.” The medicine certainly overlaps substantially, but I have heard no one who realistically wishes to merge the professions. I’ve mentioned before that the Hippocratic Oath is primarily focused on healing disease, not relieving suffering, and euthanasia directly violates that. It is a primary reason (though not the only one) that the Oath is under such assault now. Whether we look at the Judeo-Christian view of anthropology as humanity made in the image of God or the secular idea that our species is distinguished by higher capacities than other species, there is an inarguable “otherness” to human beings. We have courts to help ensure justice, but certainly do not expect even brainy animals like dolphins and chimpanzees to do the same. Our fearsome capabilities to exert justice on one another limit, in civilized society at least, the role for taking the lives of other human beings to the domain of the state. As a veterinarian, I don’t need the courts to help me decide if the patient’s “time” has come, because I am acting entirely within ethical bounds and my own professional oath. For a physician, charged with doing all she can to heal disease in a patient, to usurp the role that legitimately belongs to the government and work to end a life is a horror, regardless of whether or not it is carried out in the name of compassion.

Third, the “otherness” of humans carries into the dying process itself. While facing the approach of death can, perhaps counter-intuitively, be a time of growth and transformation for human beings, a time to heal relationships and face eternity, there is nothing to suggest that such things happen in animals. I can find no redemptive purpose in prolongation of life in a moribund pet for the animal itself, but have observed that very thing in the death of a relative of mine, albeit a rather distant relative and as viewed via Facebook, as he very slowly died from cancer. His bad days were bad indeed, but his good days offered him and his family great joy as they treasured the sunsets and the breezes, enjoying the few days left on this Earth and gathering in what it meant for life after death. The privilege of dying with his family surrounding him, to themselves be able to impute his brave submission to a death that they might someday face, would have disappeared had a physician helped to sacrifice his life on an altar of compassion. That’s part of why our oaths are different, and why I can be a hero and why Dr. Kevorkian was decidedly not, even as we ostensibly carry out the same task.

When technology limits our choices

We usually think of technology in terms of freeing us from limits, increasing our freedom, opening up new possibilities. With technological advances, we can do more, enhance our comfort, treat more diseases, travel farther, access more information, access more information while we travel farther, etc.

But every new technology also limits freedoms and diminishes possibilities. When a new technology comes along and becomes accepted and widespread, the possibility of choosing not to use that technology is diminished. Think of how difficult it would be to choose to live without electricity, running water, cell phones, the internet, cell phones that can access the internet. . .

In many cases, this is not a bad thing. We are certainly much better off because water treatment and good sanitation are so ubiquitous. But there are technologies in medicine that we have a really hard time choosing not to use, yet whose benefit is questionable at best. For instance, continuous electronic fetal monitoring (EFM) is used in about 85% of live births in this country, despite the fact that in a low-risk pregnancy the potential harms vastly outweigh any potential benefits. However, for many in the medical field, laboring a patient without EFM is almost unimaginable. Or take prenatal genetic screening technology. When I first began practice, it was offered only to women at high risk of having a baby with a genetic defect. Now, it is routinely offered to all pregnant women. The American Congress of Obstetricians and Gynecologists (ACOG) has recommended that the newest such technology, cell-free fetal DNA screening, be offered only to women at high risk; but given our inability not to use a technology everywhere we can, how long will it be before it becomes the “Standard of care,” offered to all pregnant women regardless of risk? And when the test doesn’t show a perfect baby, how hard has it become to choose not to have that “therapeutic” abortion?

The list goes on and on: antibiotics for viral infections, screening tests for prostate cancer, antidepressants for everyone who is not outrageously happy, CT scans and MRIs for — well, just about anything. In fact, the difficulty of not using technology, the compulsion to use technology even when it is inappropriate, is so rampant that 41 medical specialties have joined forces to publish lists of instances when various technologies that are currently commonly employed should NOT be used.

Reflecting on some of last week’s posts on this blog that dealt with euthanasia, I begin to wonder, What if euthanasia becomes an accepted, widespread technology, the “Standard of care”? In a culture in which we warehouse the old and dying in nursing homes, in which people who require expensive treatments in a cash-strapped system might be seen as — who often see themselves as — a “burden,” will euthanasia in such cases subtly begin to be understood as an obligation? Will the option of living with an expensive, terminal illness be limited? Will the freedom to live without euthanasia be diminished?

Euthanasia Week

Last week was “one of those weeks” in the world of small animal veterinary medicine. Somehow all my cases that had been “circling the drain,” as we so elegantly put it, finally were pulled into its vortex, and we had a wave of euthanasia sweep through my practice. Three animals in renal failure in one day, a congestive heart failure, several cancer patients: the usual supects. It is a challenge to keep your spirits up in veterinary medicine as you hasten the passing of the sick and dying, even as you maintain clinical distance. Each case was different, but there was a certain consistency to what I did, maintaining faithfulness to my oath to relieve animal pain and suffering, through euthanasia if that was the only way to do so successfully. By Friday evening, as I placed my umpteenth (it seemed) fatal overdose of pentobarbital into a cephalic vein catheter while tearful family members held the pet they had raised from a puppy or kitten, or rescued from a shelter, or a dozen other stories, I began to think about this process in the context of human beings. For most people, this very difficult, but expected and necessary, part of my profession is well within the ethical boundaries in relation to animals. What if it becomes ethically permissible in the human medical profession someday? What patterns from my experience may be expected to carry over?

The comparison is imperfect, of course (and, indeed, I hope it would remain so no matter what!). Relationships with animals do not carry the baggage, for good or ill, of our human relationships. But people with their dying pets faced the decision seriously, with a desire to know the “right time,” when a cure was impossible, quality of life issues were substantially diminished, and their pets appeared to be suffering. (As a brief excursus, I don’t know how or if animals suffer; that seems to suggest a level of sophistication that few, if any, nonhumans have, including levels of physical, mental and spiritual dysfunction. That said, a pet euthanasia consultation is rarely a teachable moment for such philosophical sublimities and I just let them know that their pet may be suffering, or at risk of suffering, if they are just in awful condition.)

Most people look to me to give a green light to their choice, perhaps to nudge them past the guilt of a decision. “What would you do if she was your dog,” is asked of me daily, last week by a young married couple clutching an old beagle with inoperable bladder cancer and in end-stage kidney failure. That answer was easy. But they wanted my response to give ethical license for their choice. Legally, animals are “property,” the possessions of their human owners; we even call our clients the “owner” of their pets. Yet people look to us for moral guidance on when to end the life of their property. If human euthanasia is normalized, much more is at stake, and physicians will assume my role. I take comfort that I can provide peace and closure by reassuring my clients that their pet will be better off if we don’t force her to go to the bitter end. I am chilled to think of the comfort that a physician could similarly take in easing the decisions of those left behind to avoid the bitter end for their own family members. My euthanized patients don’t send me heartwarming, career-affirming “Thank You” cards; their families sure do.

I also noted a real, but subtle, dynamic in my staff, one that I think translates to human caregivers as well. My technicians and ward attendants could see full well that these patients would not get better. They heard me pronounce grave prognoses. They knew the patients in their care were dying, and they would find themselves frustrated with the pet owners that tarried on their decision to euthanize. The staff of veterinary hospitals is overflowing with idealists that advocate strongly for their animal patients. Without knowing it, my staff’s body language showed frustration and resignation, and those making the decision could sense the subtle pressure.

Certainly we see nurses and others in the ICU or in nursing homes that advocate for halting treatment they genuinely feel is burdensome to the patient and futile to recovery. Watching a patient slowly die is emotionally and intellectually exhausting. As sad as my staff is to lose a pet in our care, we all know the sense of relief that we feel when the call for euthanasia is made. We’ve usually stopped feeling guilty when we know we’ve done everything we can and that we can hasten the end. It is peaceful and quick, gentle and painless, which natural death so often is not. If human euthanasia is acceptable, expect this same subtle pressure and eventual sense of relief among hospital staff members, too.

This week is better (the positive aspect of losing so many of the moribund in one week is that the circle of life usually swings back the next). But I can’t help but think about the possibilities that the future holds, where human euthanasia is acceptable and even embraced. No, animals are not people ontologically-not yet, at least. But maybe I have seen the future for human medicine from my own vantage point as a veterinarian, and it should concern us all.

Clarifying the arguments regarding physician assisted suicide

The citizens of Massachusetts will be voting on a proposed death with dignity law that would make physician assisted suicide legal in Massachusetts similar to the states of Oregon and Washington. An article in the Atlantic by Wendy Kaminer earlier this week titled “How the Catholic Church Misunderstands Death With Dignity” critiques what Cardinal Sean O’Malley has said in opposition to the proposal. While I am not a Roman Catholic, Cardinal O’Malley’s statements that are being criticized fall within the established ideas of Christian ethics and are not specific to Roman Catholics.

One thing he said was that there is a moral distinction between treating pain with whatever amount of medicine is needed to control the pain even if the pain medicine may unintentionally lead to a shortening of the person’s life and intentionally using medicine to end a person’s life. He is correct that intent is morally significant. A surgeon who undertakes a very risky surgery at the patient’s request even though it is known that the patient is likely to die is doing something morally very different from one who intentionally kills the patient. The importance of intent in the distinction between morally appropriate palliative care and euthanasia was criticized by saying that while God knows each person’s intent, law enforcement officials do not and that physicians would be inhibited from giving adequate palliative care out of fear that they would be accused of killing the patient. This critique neglects to realize that adjusting pain medicine based on the patient’s response to pain is quite different from giving an intentional overdose and can be properly documented to make the intent clear.

Another thing that was not understood in the critique of Cardinal O’Malley was his use of the concept of a life not worth living. One of the fundamental moral objections to physician assisted suicide is that it assumed by the proposed law that there are some people whose lives are not worth living and that the physician who assists in a patient’s death must confirm that the patient’s life is not worth living. The idea that every human life has meaning and value is a protection for those who are the most vulnerable in society. If we say that someone can make a determination that there is any human life, even that of a terminal patient, that is not worth living, then we are removing that protection from the most vulnerable in society. That has been a reason why some of the most vocal opponents of assisted suicide have been disability rights advocates who cling to the protection provided by the concept that every human life has value. Cardinal O’Malley’s affirmation of the statement by the US Conference of Catholic Bishops that “a society that devalues some people’s lives, by hastening and facilitating their deaths, will ultimately lose respect for their other rights and freedoms” is an expression of the importance of forbidding any determination that a person’s life is not worth living. This is a significant moral concept and not statement that “makes little sense.”

A third problem with this critique of the objections to physician assisted suicide is the idea that it can be logically limited to voluntary, self-administered, lethal prescriptions for the terminally ill. If the intentional ending of human life is accepted as a legitimate way to deal with suffering then there is no way to logically limit it to voluntary action or the terminally ill. This is not an empirical argument, but a logical one. The reasons for accepting the intentional ending of a human life by physician assisted suicide as permissible are seeing it as a form of compassion and seeing it as an expression of the person’s autonomy, but as Gilbert Meilaender has expressed (Bioethics: A Primer for Christians, p 60-61) the arguments from compassion and autonomy do not need to be taken together. If they are reasonable arguments they can stand alone. If compassion is a reason to accept physician assisted suicide, then it is not reasonable to deny the use of death as a way to end the suffering of someone who is suffering just as much but is unable to swallow the prescribed medicine or who has become unable to make her own decisions or who is an infant who is suffering unbearably. If autonomy is a reason to accept physician assisted suicide, then it is a reason to accept death as an end to the suffering of those who choose it whether they are terminal or not and no matter what type of physical or emotional suffering has caused them to choose to die. There is no logical reason to restrict the use of death as a means to relieve suffering to just those who are terminal and able to give themselves the fatal dose of medicine.

When the arguments against the permissibility of physician assisted suicide are looked at more clearly, they provide a more reasonable basis for deciding that we should not allow this to be a part of our society than Ms. Kaminer would suggest. They are not a misunderstanding of physician assisted suicide, but a clear understanding of what accepting the use of death as a means of ending suffering means to our society.

What the German Medical Association declaration has to teach us about codes of medical ethics

 

“The human rights violations perpetrated in the name of medicine under the Nazi regime continue to have repercussions to this day and raise questions concerning the way in which physicians perceive themselves, their professional behavior, and medical ethics.”  – The Nuremberg Declaration of the German Medical Association 2012

 

65 years ago this month the Doctors Trial concluded in Nuremberg, Germany. Sixteen Nazi physicians were found guilty of organizing and participating in crimes against humanity, including ghastly experiments performed on concentration camp prisoners without their consent. Earlier this summer, the German Medical Association (GMA) admitted that not just the doctors on trial but the whole German medical establishment, its leadership, and its most renowned researchers were responsible for the atrocities committed. “In contrast to still widely accepted views, the initiative for the most serious human rights violations did not originate from the political authorities at the time, but rather from physicians themselves,” according to the GMA statement.

Most sobering is that the German doctors thought that they were practicing ethical, Hippocratic medicine.  Their perception of themselves — doctors of the Nazi state rather than individual patients — coupled with their perception that  certain people contributed to the poor health of the state — Jews, Roma, the disabled — led them to do terrible things in the name of Hippocratic medicine.

The apparent breakdown in the millenia-old Hippocratic ethos led to the elaboration of the Declaration of Geneva to reinforce the humanitarian goals of medicine, and the Nuremberg code to protect human subjects of research. But if the example of the Nazi physicians teaches us anything, it is that neither Hippocrates, Nuremberg, Geneva, nor any other code of medical ethics can protect us if we do not acknowledge the basic human dignity inherent in all human beings. As witness, the original Declaration of Geneva reads, “I will maintain the utmost respect for human life, from the time of its conception . . .” The current version has been shortened to, “I will maintain the utmost respect for human life.” It is not difficult to see which class of humans has been quietly removed from the protections of the Declaration.

Is the AMA in danger of committing the same crimes as those for which the GMA has recently admitted responsibility? Are there some humans whose human dignity we have decided not to acknowledge? No, we don’t practice eugenic sterilization; but we do practice prenatal genetic screening and perform eugenic abortion. No, we don’t declare a “Life not worth living,” but we implicitly (and explicitly) use the calculus of “Quality of Life” as we make ethical decisions. No, we don’t do horrific experiments on prisoners; but we do experiment on the youngest and weakest of our species, our own embryos. And we do it all in the name of practicing good, ethical, humanitarian, Hippocratic medicine.

Some have declared in recent years that the concept of “human dignity” is useless in medical ethics. The GMA declaration shows us that, to the contrary, codes of medical ethics are useless without a robust concept of human dignity.

Physicians’ role in assisted dying

In a recent Perspective article in the 7/12/12 issue of the New England Journal of Medicine, Julian J.Z. Prokopetz and Lisa Soleymani Lehmann take an interesting perspective on what physicians’ role in assisted dying should be. Although they admit that assisted dying, in which patients acquire a lethal dose of medicine with the explicit intention of ending their life (also known as assisted suicide), is generally illegal, they take the position that assisted dying is a desirable way for terminal patients to express their autonomy. They see anything that would hinder patients from being able to do this as a barrier that needs to be removed. They mention several of the objections that have been raised against assisted dying, but do not give much credence to any of them including the concern that participating in the intentional ending of a human life goes against the sanctity or inherent value of human life.

What is most interesting, particularly for Lehman who is a physician, is how they regard the objections to allowing assisted dying that are made by physicians. They note that in a 2003 survey of AMA members 69% objected to physician assisted suicide, and that there are national and state medical associations (including the AMA) that are officially opposed to physician assisted suicide. They note that those physicians “believe it’s inappropriate or wrong for a physician to play an active role in ending a patient’s life.” Their response to that is to suggest that physicians be relieved of the role of providing the lethal dose of medicine to those who request assisted dying. They propose that physicians be limited to determining the patient’s prognosis so the patient can take that information to a government agency to prescribe the lethal medication.

This proposal has some interesting implications. It assumes that the majority of physicians who are opposed to physician assisted suicide have no good reason for why they are opposed. It says that when those who care for the dying say that they do not think that helping those who have a terminal illness kill themselves is the best way to care for those patients we should pay no attention to them. It takes respect for autonomy to the extreme that says the physician should just provide diagnostic and prognostic information and the patient should get their treatment from a technician who simply does what the patient asks, even if that is to help kill the patient.

It is correct that one of the objections to participation in physician assisted suicide that physicians and physician organizations have is that it runs counter to the fundamental principles of the medical profession which is focused on providing care that is in the best interest of their patients and not doing harm to those patients by helping them kill themselves. Rather than suggest that physicians who have those principles should be circumvented, it would be good to recognize that the underlying principles of the medical profession which make assisting in suicide incompatible with the profession are good principles for anyone who is caring for those who are ill or dying. It is not just that assisted dying is incompatible with the medical profession; it is incompatible with caring for those who are dying in a way that respects the value of their lives as human beings.

Finding a way around those physicians who want to protect their patients by not participating in assisted suicide is like finding away to drive around those pesky crossbars at a railroad crossing that keep me from going where I want to go. Both are assertions of autonomy that fail to understand that there are good reasons that there are some things we should not do.

More “Life not worth living”

 

The BBC News ran a story this week about Tony Nicklinson, an unfortunate man suffering for the last seven years from locked-in syndrome. The result of a stroke, locked-in syndrome has left him with a paralyzed body but a fully-functioning mind. He cannot even communicate without the aid of a special computer. Mr. Nicklinson is going to court to try to have a doctor kill him legally.

In the video accompanying the story, Mr. Nicklinson gives some of the justifications for his request. He feels he is being discriminated against, just because he is disabled, in exercising the right to determine when, where, and how his life will end, which he calls “the basic human right.” In the story, his barrister is quoted as saying that with modern medical care, Mr. Nicklinson could be expected to live “another 20 years or more. He does not wish to live that life.”

I cannot begin to imagine what Mr. Nicklinson’s life and suffering are like. I have no trouble believing that he does not wish to live the life that he has. But in fact there are many, many in this world in various situations — granted, most of them not as extreme as Mr. Nicklinson — who do not wish to live the life they have, not just because of terrible physical symptoms but because of suffering brought on by toxic family relationships, or oppressive social structures, or grinding poverty, or enslavement to an addictive substance. Is the fact that they do not wish to live the life they have justification enough to allow them to exercise their “basic human right” to end their lives when, where, and how they will? Is there a certain level of suffering which, once one has achieved it, allows one to exercise that right?

Modernity is all about control. With our reproductive technologies we have gained increasing control over the beginning of life, and with that control has come the enumeration of a number of dubious “reproductive rights.” This story is an example of another salvo in the battle to win control over the end of life. However, it ends up just being another way of defining a life as being a “life not worth living.” We have seen in history what happens when a person or persons were granted the power to determine that another’s life was “not worth living.” The results will be no less appalling if we give people the right to decide whether or not their own lives are worth living — and then grant them the power to act on that decision.

 

 

 

On Oaths…

There is a joke told among veterinarians that physicians are essentially veterinarians that have limited their practice to a single species. It is true that great similarities exist between humans and animals physiologically, and much medicine overlaps. But there’s a big difference between the ethical practice of veterinary and human medicine. The Veterinarian’s Oath diverges from the Hippocratic Oath in its focus. Physicians are charged within their oath to a primary emphasis on healing and curing disease, the relief of suffering assumed secondary. Veterinarians, instead, are foundationally called to “protect animal health” and relieve suffering through their oath. These are important distinctions.
Nigel Cameron has chronicled the migration that human medicine, with its growing emphasis on the relief of suffering, has made toward the veterinary model. In The New Medicine: Life and Death after Hippocrates, he laments this change, finding the drift to be a source of double-minded tension which pits healing and relief of suffering against each other. Veterinarians must deal with some of this tension, where the cure for a disease process cannot create undue pain and cause substantial detriment to the quality of an animal’s life. For example, some of the stronger chemotherapy drugs, from which human patients may be willing to endure the more difficult side-effects (at a great loss of quality of life, at least temporarily) are not reasonable options for dogs or cats. The default position in veterinary medicine is avoidance of suffering. Additionally, the protection of animal health can entail taking one life for the betterment of another, an accepted fact within a profession that has multiple obligations and must make decisions from among animals and between the “non-equals” of animals and humans. Euthanasia in the face of pain or suffering is entirely consistent with the stated aims of the Veterinarian’s Oath. It is entirely inconsistent with the Hippocrtatic Oath and centuries of tradition in human medicine.
Some eschew the Hippocratic tradition in medicine as they favor an ethic that skews toward radical patient autonomy and perverse avoidance of anything that would be considered a burden or could negatively impact the perception of dignity, all in the name of compassion. Ironically, as some of human medicine migrates toward a veterinary model, veterinarians may be heading the other way. As advancements in drugs and technology intersect a stronger human-animal bond, treatments that would be burdensome to humans are increasingly used in companion animals. Some veterinarians can fall headlong into a vitalism that seeks to prolong animal life at any cost. We may find that physicians are becoming more like veterinarians just as veterinarians seem to become more like physicians, with both groups violating the underlying premises of their respective oaths.
But humans are different from animals. We must understand personhood ontologically, and the distinctions in moral status between humans and animals, to recognize the variation between the two oaths. With these blurred (or maybe even reversed in some cases) the risks to the integrity of human dignity, and the Hippocratic tradition, become great indeed.