Neutrality Kills

In 1994, Oregon became the first state to pass a physician-assisted suicide law. This came after the Oregon Medical Association changed its position from opposition to neutrality. 21 years later and after multiple failed attempts, the California state legislature approved the latest physician-assisted suicide law after the California Medical Association changed its opposition to neutrality.

The message sent-and received- was that if doctors themselves don’t strongly oppose physician-assisted suicide laws, why should the public?

Now the American Medical Association is set to reconsider changing its traditional opposition to assisted suicide to neutrality. This would be another, even more far-reaching disaster in terms of national impact.

For years, the euthanasia/assisted suicide activists of Compassion & Choices have successfully lobbied groups like the California Medical Association, the American Public Health Association, The American College of Legal Medicine, American Medical Student Association and American Medical Women’s Association and The American Academy of Hospice and Palliative Medicine to support legalized physician-assisted suicide or at least take a “neutral” position.

As a former home health and hospice nurse, I am particularly outraged that the latest organization to crumble to Compassion & Choices is the Visiting Nurses Associations of America.

According to its website, Compassion & Choices says that the VNNA had Compassion & Choices as part of the their Public Policy Leadership Conference “where they discussed their federal agenda for 2016 and the important role that members of the VNAA play in end-of-life care.”

With millions of dollars from donors to advance its agenda, a supportive media that ignores dangerous facts, popular ethicists who change positions with the polls and a legal system that has helped to undermine protections for the medically vulnerable, it may seem that Compassion & Choices is getting closer to achieving its goal of forcing doctors and nurses to supply medically assisted death on demand.

For example, a 2014 survey of over 21,000 American and European doctors responding to an ethics survey conducted by Medscape (a password-protected website for medical professionals) showed that-for the first time-a majority of doctors polled supported assisted suicide.

However, here are a few ways any of us can help turn around this dire situation:

 

  •  Educate yourself on the facts and consider joining others to publicly oppose medically assisted suicide/euthanasia in our courts, legislatures and media outlets.
  • Demand that suicide prevention and treatment must be made available to all, not just the young and physically healthy.
  • Ask your health care professionals about their position on assisted suicide/euthanasia and support only health care providers who will not assist suicide or refer for it.
  • Discover and reach out to at risk individuals and their families who may be in your neighborhood or church. Loneliness and isolation can be debilitating.
  • Consider volunteering at a local nursing home or facility. Some churches have even started programs to encourage church members to visit one hour, once a week with one patient.

None of us can afford to be neutral- or silent-when it comes to this life or death issue.

Assisted Suicide and the Psychiatrist

When a person is suicidal, it is standard to get a psychiatric or psychological evaluation to help treat the suicidal person-except in states that have physician-assisted suicide laws. In those states when a suicidal person wants assisted suicide, there is only a so-called “safeguard” that leaves it up to the opinion of the assisted suicide doctor as to whether or not such an evaluation is necessary.

Not surprisingly, very few such consultations are done since assisted suicide advocates insist that suicide is rational when a person is terminally or incurably ill.

But even if such an evaluation is done, would it be done according to the same standards as the evaluation of a suicidal person not seeking medically assisted suicide?

In my opinion, probably not.

PSYCHIATRIC AMBIVALENCE

In a recent Psychiatric Times article “Death and the Psychiatrist”,  editorial board member and ethics writer Dr. H. Steven Moffic struggles with the topic of medically assisted suicide:

The role of the psychiatrist is generally to determine whether psychiatric illness is contributing to the decision to die. The assumption is that the mental illness is treatable if it is diagnosed. Another related role is to assess competence to make a decision.

However, data indicate that psychiatrists are seldom called in by other physicians when they should be. Moreover, in the Netherlands and Belgium, physicians can now be called on to help mentally ill patients die.2 (Emphasis added)

Dr. Moffic goes on to note that:

Polls indicate that like the public, physicians and psychiatrists have mixed and ambivalent opinions about euthanasia, and—for moral reasons—few of us want any involvement.5” (Emphasis added)

And:

There are obvious financial considerations as Baby Boomers age and become ill. End-of-life medical costs are high and physician-assisted suicide offers a cheap, quick solution to conserve health care resources. (We in psychiatry know this all too well, since we were an early target of for-profit managed care cost savings.)13 (Emphasis added)

Yet he concludes:

Beyond the personal, what do I believe professionally about euthanasia? I lean toward the AMA position—that physician-assisted death could take us too far away from our healing role. Perhaps, though, a special cadre of physicians can be trained and dedicated to this role. (Emphasis added)

However, ambivalence does nothing to  stop or even limit medicalized suicide.

CONCLUSION

The traditional Hippocratic Oath was routinely taken by graduating medical students and promoted the standard of incorruptible virtue in the practice of medicine.  In the 1960s, that began to change and new Oaths were promoted as more up to date and relevant.

Significantly, one of the first parts of the Hippocratic Oath to be eliminated was:

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion. (Emphasis added)

Now we have medicalized deaths actually promoted as civil rights.

Without strong ethical standards, enforceable laws and honorable health care providers,  how can we be expected to just automatically trust our health care system?

 

 

 

 

 

 

Ethics and Alzheimer’s-Part Two: Feeding Tubes

In 1988 during the Nancy Cruzan case involving a young, non-terminally ill woman in a so-called “persistent vegetative state” whose parents wanted her feeding tube withdrawn so she would die, I was asked if I was going to feed my mother who had Alzheimer’s disease. At the time, my mother had no problems with eating but I knew the real question was about a possible feeding tube later on.

Ironically, I had just written an  op-ed on the Cruzan case titled “Feeding is not Extraordinary Care  and I pointed out that if the withdrawal of food and water from people with severe brain injuries was accepted, the pool of potential victims would expand.

I was thinking about people like my mother and, sadly, I was right.

In 1993, just 3 years after Nancy Cruzan died a long 12 days after her feeding tube was removed, a letter in the Journal of the American Medical Association by Dr. Ezekiel Emanuel, one of the future architects of Obamacare, acknowledged that the actual proof purported to show that the Cruzan case met Missouri law requiring “clear and convincing evidence” that Ms. Cruzan would not want to live in a so-called “vegetative” state rested only on “fairly vague and insubstantial comments to other people”.

However, he noted that

“…increasingly it will be our collective determination as to what lives are worth living that will decide how incompetent patients are treated. We need to begin to articulate and justify these collective determinations.” (Emphasis added.) Source: The American Journal of Medicine January 1993 Volume 94 p. 115

ALZHEIMER’S AND FEEDING TUBES

When I was asked about whether I would feed my mother with Alzheimer’s, I gave the same answer I gave when my baby daughter Karen with Down Syndrome and a heart defect was critically ill in 1983: Their anticipated deaths must be from their conditions, not from deliberate starvation and dehydration.

In the end, neither one needed a feeding tube. My daughter’s kidneys and other organs shut down and, since food or water would cause worse fluid overload, Karen was not given extra fluid and her heart gave out a short time later. In my mother’s case, she eventually needed to be spoon-fed until she quietly died in her sleep.

As a former hospice and ICU nurse, these scenarios are very familiar to me. Multiple organ failure sometimes occurs with critical illness and dying patients often gradually lose their appetites as they approach death. In those cases, we would give what little these people want or need until death. But for people not dying or near death, we made sure that they had at least basic  medical care and the life essentials of food, clothing and shelter. This is-or used to be-simple common sense.

ALZHEIMER’S AS A FATE WORSE THAN DEATH

The easiest way to get people to accept death by starvation/dehydration is to get them to choose it for themselves even before they have a problem.

Thus, media stories of people and their families suffering tremendously because of Alzheimer’s are very persuasive. People fear becoming an economic and emotional burden on their families. Not surprisingly, many people then willingly check off feeding tubes and other medical treatments in their advance directives.

Position papers like that from the American Geriatrics Society and the Alzheimer’s Association can also paint a dark picture:

The Association asserts that research evidence support no medical benefit from feeding tubes in advance dementia and that feeding tubes may actually cause harm in the advanced state of Alzheimer’s. Additionally, it is ethically permissible to withhold nutrition and hydration artificially administer by  vein or gastric tube when the individual with Alzheimer’s or dementia is in the end stages of the disease and is no longer able to receive food and water by mouth

The presumption is that such a death is peaceful and painless when a person is assumed to be unaware in a “vegetative” or late Alzheimer’s state. However, Bobby Schindler has written an account of the reality  of a prolonged starvation/dehydration death on his sister Terri Schiavo that was hidden from the public.

“JOE’S” CASE

Several years ago, I cared for a man with early stage Alzheimer’s who had a serious pneumonia needing a ventilator for a couple of days. Afterwards, Joe (not his real name) was alert and cooperative but the ventilator tube unexpectedly affected his ability to swallow and speak easily. His family asked about a feeding tube and special swallow therapists to try to retrain his throat muscles so that he could eat and drink safely. That is how an even older friend of mine in the same situation but without Alzheimer’s was successfully treated recently.

However in Joe’s case, a neurologist was first called to evaluate Joe’s mental status. I was there as the doctor asked him questions like “How many fingers am I holding up?” The man answered the questions correctly but the neurologist immediately wrote for nothing by mouth including crucial blood pressure medications. He also then recommended no feeding tube to the family. No swallow therapy was ordered. Joe was never asked about this.

When I questioned the neurologist and pointed out that the man had given correct answers by nods and holding up the correct number of fingers when asked, the neurologist responded by saying that the man did not hold up his fingers “fast enough”!

This is the tragic reality when we judge some lives as not worth living.

UP CLOSE AND PERSONAL

One of my oldest friends, “Dr. Mary” (not her real name), is a pro-life doctor who asked me years ago to be her power of attorney for health care if she became incapacitated. She had never married and had no close relatives. She told me what she wanted, especially in light of the Nancy Cruzan case, and signed an advance directive available through our archdiocese.

My friend now has presumed Alzheimer’s dementia and she is now in the later stages. She can still feed herself, albeit somewhat messily. She no longer remembers my name or her friends’ names but she is delighted when we come.

At almost 90 and with inevitable death approaching, she now has a Do Not Resuscitate (DNR) order but her nursing home is well aware that this does not mean any reduction in care or attention.

Along with her other friends who visit and help, our goal now is to make Dr. Mary as happy and safe as possible. If she needs spoon-feeding, she will get it. All of us hope that Dr. Mary will never need a feeding tube but she will not be denied one if necessary.

But best of all, Dr. Mary will continue to receive our love until her Lord calls her home.