Should a Mental Health Exam be required before Physician-assisted Suicide?

When I read the October 27, 2018 MedPage news article titled “Assessing Competency in Aid-in-Dying Patients (aka physician-assisted Suicide)-Should a Competency Exam by an Outside Doctor be Required?”, I was struck by one case cited by psychiatrist Richard Martinez, MD, professor of psychiatry and law at the University of Colorado Denver who opposes mandatory mental health exams as “an invasion of privacy ” …”(t)o mandate an interaction with a stranger”. Dr. Martinez also contends that “Depression should not be an exclusionary decision.” (Emphasis added)

Dr. Martinez cited the case of a young man who had a severe spinal cord injury after a fall and was on a ventilator to breathe. Doctors took him off sedation and asked if he wanted to live. He said no so the ventilator was removed and he died.

Although Dr. Martinez acknowledged that “people who work with people with spinal cord injuries have argued for a waiting period” and that this was a very difficult case in bioethics, he still maintained that, in the end, the issue is really about choice. (Emphasis added)

When I read this, I remembered when “Aaron” (not his real name) was admitted to our intensive care unit with a severe spinal cord injury after a car accident. This was in the early 1970s, long before the “right to die”/physician-assisted suicide movement became known to the public.

I was there when the doctors told Aaron that his legs were permanently paralyzed and he would never walk again. Naturally, this 18 year old young man was devastated. It didn’t take long before he told us he wanted to die. We were not surprised by this  normal reaction and the doctors wanted to stabilize him medically before ordering a psychiatric consult if he persisted in wanting to die.

One day while I was bathing Aaron, I asked him if many people complimented him on his legs. Aaron was puzzled but answered “No”. Then I asked him if his legs were the most important part of him. After a pause, he smiled a little and said probably not.

Then I talked with him about what he would still be able to do once he was medically stable and what he might be able to do in the future with rehabilitation and medical advances. Aaron looked a little less forlorn. I reassured him that we doctors, nurses and his wonderful family would be there every step of the way and I predicted how much better he could feel with time and more information.

But what really made a difference was when Aaron’s parents told me how much he enjoyed poker. So one quiet night, I started a midnight poker game in Aaron’s ICU room with the nurses taking turns between caring for the patients and playing. It was great to see Aaron finally laughing and making fun of how badly we played.

Even though we were caught by an unexpected visit from administrators and I had to promise never to do this again, it was worth it. When I last visited Aaron after he left our unit, he was laughing and talking to his friends. And making plans.

Supporters of physician-assisted suicide claim that one of their strongest safeguards is, as the Oregon physician-assisted suicide law states, that “If, in the opinion of the attending physician or the consulting physician, a patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, either physician shall refer the patient for counseling.” (Emphasis added) But only the evaluation of a patient’s competence to make such a decision- not the diagnosable mental disorders that afflict more than 90 percent of people who die by suicide- is required .

However, now that supposed “safeguard” is being questioned by some psychiatrists in this new MedPage article reporting on a panel discussion during the 49th annual American Academy of Psychiatry and the Law (AAPL) meeting.

In the article, psychiatrists like Anna Glezer, MD, an associate professor of psychiatry and of ob/gyn at the University of California San Francisco (UCSF) who supports requiring a mental health exam stated:

“A psychiatrist can help identify potentially treatable psychiatric symptoms that may relieve elements of patient suffering, and detect family agreement versus family conflict that may require further intervention and counseling,”

and

‘”I’ve done a case where I didn’t say ‘This person meets the criteria or doesn’t,’ but [instead said] ‘These are my concerns,'” she said. In this case, the patient had lost her husband within the past year “and I thought grief might be compounding her decision-making capacity.” (Emphasis added)

Dr. Ariana Nesbit, a psychiatrist at the San Diego Central Jail says PAD (physician-assisted death aka physician-assisted suicide) is a complicated issue, stating that:

Our goal is often thought to be to prevent suicide, and we still conceptualize suicidal ideation as a symptom and pathological. As someone who just recently finished training in three very liberal states, I can tell you that at no point during my training was I ever taught how to figure out whether someone’s suicidal ideation, or their suicide attempt, was rational, so we don’t have any widely accepted method for determining this.” (Emphasis added)

Dr. Nesbit also cited a study titled “Prevalence of depression and anxiety in patients requesting physician’s aid in dying: cross sectional survey” that found 26% of patients requesting physician-assisted suicide did meet depressive disorder criteria but three of them were approved for physician-assisted suicide anyway. The authors concluded that “Although most terminally ill Oregonians who receive aid in dying do not have depressive disorders, the current practice of the Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug.” (Emphasis added)

During a question and answer session, Annette Hanson, MD, adjunct assistant professor of psychiatry at the University of Maryland in Baltimore, questioned whether PAD itself was a good idea. “We’re not just consulting psychiatrists — we’re members of a profession,” she said. “We’re shapers of healthcare policy that will affect everyone in the country … including people who are institutionalized, including people who don’t have physical illnesses.” (Emphasis added)

Dr. Hanson told how she was contacted by a colleague who asked her how to do such an mental health exam on a patient seeking assisted suicide in Switzerland. because of an “irreversible neurological condition”.  Dr. Hanson said, “It turned out the ‘irreversible neurologic condition’ was schizophrenia”. Dr. Hanson concluded that “So the publicity surrounding the right-to-die movement is hurting our psychiatric patients.” (Emphasis added) She also added that “the American Psychiatric Association also considers [PAD] to be unethical, and re-emphasized that in [amicus] briefs to the Supreme Court.”

Another MD talked about self-care for doctors after making mental health exams for physician-assisted suicide, saying that she deliberately tried “not to find out what happened to the patient” but still often found out what happened to the patients she evaluated when she would see an announcement about a memorial service

CONCLUSION

I am glad that I became a nurse decades before state legalized physician-assisted suicide. Back then, I saw what happened with patients like Aaron when we didn’t have the assisted suicide “option”: Patients received a chance for the best life possible and we received a chance to show how much we cared.

 

 

 

 

My Review of “Gosnell: The Trial of America’s Biggest Serial Killer”

I just saw the movie “Gosnell: The Trial of America’s Biggest Serial Killer” and was moved to tears even though I already knew much of the story about the notorious Philadelphia abortionist who ran an outrageously filthy clinic where he executed late-term babies who survived abortion by callously cutting their spinal cords. I also knew that some of the women died, suffered serious complications or contracted diseases from dirty instruments during the 30 years Dr. Kermit Gosnell ran his politically protected clinic.

This PG 13 movie scrupulously avoids sensationalism but through great acting, writing and accurate depictions of the clinic and Gosnell himself (actual pictures were shown at the end of the movie), the enormity of the evil cannot be ignored.

The movie starts much like an episode of “Law and Order” portraying a drug bust but then expands as police raid Gosnell’s abortion clinic for evidence of illegal prescription drug sales and find even greater problems. After the initial reluctance to prosecute by the District Attorney because the case involves abortion, a courageous assistant district attorney puts her job on the line to prosecute Gosnell.

The trial of Gosnell is riveting, especially when an expert witness abortionist describes how to correctly perform a late-term abortion that is unnervingly similar in callousness to Gosnell’s. The testimony of girls as young as 15 when they were trained by Dr. Gosnell to be his unlicensed assistants is also devastating as they describe an aborted baby swimming in a toilet or another struggling to keep breathing. The trial is very contentious but a stunning development late in the trial determines the result.

I highly recommend seeing this movie that even opened the eyes of people like Ann McElhinney who was neutral on abortion until she worked on this film.

CONCLUSION

Although one of the most shocking aspects of the Gosnell trial was his cutting the spinal cords of babies who survived abortion, Kermit Gosnell was not the first known abortionist to deliberately end the lives of babies who survived abortions.

In 1999, nurse Jill Stanek was shocked to discover a live baby boy left to die after an induced-labor abortion  and found this was a common practice in her hospital. Her courageous testimony led to the 2002 “Born-Alive Infants Protection Act” which extended legal protection to infants born alive after an abortion.

However, the lack of legal enforcement power in this Act led to the current “Born-Alive Abortion Survivors Protection Act that not only requires physicians and abortion facilities to afford “the same degree” of care to a baby born alive during an abortion that would apply “to any other child born alive at the same gestational age,” including transportation to a hospital, but also mandates fines and the possibility of imprisonment for medical professionals found to be noncompliant.

This bill was passed in the US House of Representatives this year and sent to the Senate where (because of procedural hurdles), it might need 60 votes to pass and be signed into law by President Trump.

Although it might be difficult to pass the Act now because of the political entrenchment of abortion supporters in the Senate, passing this law would provide at least one fitting endnote to the horrors of Dr. Kermit Gosnell’s clinic.

American Academy of Family Physicians Urges the American Medical Association to Drop Opposition to Physician-assisted Suicide

Compassion and Choices, the former Hemlock Society and now well-funded promoter of assisted suicide and other death “choices”, is celebrating the new resolution by the American Academy of Family Physicians (AAFP) to oppose the American Medical Association’s (AMA) long-standing opposition to assisted suicide.

The AFFP, the second largest component society of the AMA with over 131,000 members, just approved a new resolution adopting a position of  “engaged neutrality toward medical-aid-in-dying (aka physician-assisted suicide) as a personal end-of-life decision in the context of the physician-patient relationship.” (Emphasis added)

But as Dr. Rebecca Thoman, campaign manager for Doctors for Dignity for Compassion and Choices explained when the Massachusetts Medical Society adopted the same policy in 2017:

A “‘neutral engagement’ position is even better than a simply neutral position. It means if Massachusetts enacts a medical aid-in-dying law, the medical society will offer education and guidance to physicians who want to incorporate medical aid in dying into their practices.” (Emphasis added)

Now, yet another physician-assisted suicide bill is expected to be introduced next year in the Massachusetts legislature.

The AAFP resolution also stated that:

“By supporting the AMA’s opposition to medical aid in dying, some members feel the AAFP is telling them that they are unethical

and that

“the American Academy of Family Physicians reject(s) the use of the phrase ‘assisted suicide’ or ‘physician-assisted suicide’ in formal statements or documents and direct(s) the AAFP’s American Medical Association (AMA) delegation to promote the same in the AMA House of Delegates.” (Emphasis added)

CONCLUSION

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 a physician-assisted suicide law after the California Medical Association changed its opposition to neutrality.

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

Still, it was a surprise that in June 2018, the American Medical Association House of Delegates rejected the AMA’s Council on Ethical and Judicial Affairs (CEJA) strong report recommending that the AMA continue its long standing policy opposing physician assisted suicide. Instead the delegates “voted 314-243 to refer the matter back to the trustees for further deliberation”.

With the crucial help of a supportive media, Compassion and Choices started this momentum towards acceptance of physician-assisted suicide and other death choices like VSED (voluntary stopping of eating and drinking), terminal sedation and withdrawal of even spoon-feeding, affecting not just doctors but also nurses and other health care professionals and institutions.

In addition, Compassion and Choices also opposes conscience rights, even stating that  the new Federal Conscience and Religious Freedom Division:

“is not about freedom; it’s about denying patient autonomy. Under their proposed rules, providers are encouraged to impose their own religious beliefs on their patients and withhold vital information about treatment options from their patients — up to, and including, the option of medical aid in dying. And your federal tax dollars will be used to protect physicians who make the unconscionable decision to willfully withhold crucial information regarding their care from a patient and abandon them when they are most vulnerable.” (Emphasis added)

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

When the most basic medical ethic of not killing patients or helping them to kill themselves can be discarded in favor of “choice” or “quality of life”,  none of us of us can afford to be neutral- or silent-on this life or death issue.

No Suicide Discrimination!

When I was asked by my late daughter Marie’s best friend to join her on a family and friends fundraising walk for suicide prevention last Sunday, I hesitated.

I was in the process of reading yet another disturbing article about assisted suicide, this time a Journal of Clinical Psychiatry article titled “Working with Decisionally Capable Patients Who Are Determined to End Their Own Lives”  and I found it outrageous that the suicide prevention groups I know exclude potential physician-assisted suicide victims.

As a nurse, I have personally and professionally cared for many suicidal people over decades including some who were terminally ill. To my knowledge, none of these people went on to die by suicide except one-my own daughter.

Almost nine years ago, my 30 year old daughter Marie died by suicide using an assisted suicide technique she found after searching suicide and assisted suicide websites and reading assisted suicide supporter Derek Humphry’s book “Final Exit”.

Marie was a wonderful woman who achieved a degree in engineering despite struggling off and on with substance abuse and thoughts of suicide for 16 years. She was in an outpatient behavioral health program at the time of her suicide. Her suicide was my worst fear and it devastated all of us in the family as well as her friends. Two people close to Marie also became suicidal after her death but were fortunately saved.

For years before and after Marie’s death, I have written and spoken to groups around the country about the legal and ethical problems with assisted suicide as well as suicide contagion  and media reporting guidelines for suicide.

So it was with mixed feelings that I participated in the suicide prevention walk but now I am glad I did.

“WORKING WITH DECISIONALLY CAPABLE PATIENTS WHO ARE DETERMINED TO END THEIR OWN LIVES”

I finally finished reading this article after the walk and found that while the authors of this Journal of Clinical Psychiatry article insist that they are only discussing “decisionally capable” people with “advanced medical illness”, they write:

The 24% increase in US suicide rates from 1999 to 2014 has led to greater efforts to identify, prevent, and intervene in situations associated with suicidality. While the desire to kill oneself is not synonymous with a mental illness, 80%–90% of completed suicides are associated with a mental disorder, most commonly depression. Understandably, psychiatrists and other clinicians face strong moral, cultural, and professional pressures to do everything possible to avert suicide. Hidden within these statistics are unknown numbers of individuals determined to end their lives, often in the context of a life-limiting physical illness, who have no mental disorder or who, despite having a mental disorder, were nevertheless seemingly rational and decisionally capable and in whom the mental disorder did not seem to influence the desire to hasten death.”

Tragically, the authors also state:

“In reviewing the either sparse or dated literature in this field, surveys from the United States and Canada support that most psychiatrists believe that PAD (physician aid in dying, a euphemism for assisted suicide) should be legal and is ethical in some cases and that they might want the option for themselves.”

And

“Although we see ‘assisted death’ as an option of last resort, we instead ask whether on certain occasions psychiatrists might appropriately not seek to prevent selected decisionally capable individuals from ending their own lives.” (All emphasis added)

This flies in the face of long-standing professional suicide prevention and treatment principles.

Notably, the article ends with an addendum, the 2017 Statement of the American Association of Suicidology (AAS): “Suicide is not the same as ‘Physician Aid in Dying’

That concludes:

“In general, suicide and physician aid in dying are conceptually, medically, and legally different phenomena, with an undetermined amount of overlap between these two categories” but “Such deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.” (Emphasis added)

WHY I AM GLAD I WENT ON THE SUICIDE PREVENTION WALK

The Sunday walk was sponsored by the American Foundation for Suicide Prevention (AFSP), a group that I discovered states it is trying to “Develop an updated AFSP policy position on assisted death (other common terms include physician assisted suicide or Death with Dignity Laws)

The next day, I was able to contact a policy person at their Washington, DC office and, unlike other suicide prevention group representatives I have contacted in the past, I found this woman surprisingly interested and receptive to the idea that we should not discriminate against certain people when it comes to suicide prevention and treatment. She even asked for my contact information.

Of course, the AFSP may decide to exclude potential assisted suicide victims like other organizations have done but at least I tried and that’s the best tribute I can give to my daughter now.

 

How the New “Palliative Care and Hospice Education and Training Act” Could Threaten Conscience Rights.

Two weeks ago, I wrote about the new Senate Bill 693 titled the “Palliative Care and Hospice Education and Training Act” (now referred to the Committee on Health, Education, Labor, and Pensions) and warned about the current and future involvement of Compassion and Choices (the former Hemlock Society now pushing for legalizing physician-assisted suicide throughout the US) in “end of life” education for healthcare professionals. But Compassion and Choices is not the only organization supporting practices that, until the last few decades, were universally condemned.  For example, last year the American Nurses Association took a position approving VSED (voluntary stopping of eating and drinking) to hasten death  and that those decisions “will be honored” by nurses.

In addition, this year the American Medical Association House of Delegates rejected the AMA’s Council on Ethical and Judicial Affairs (CEJA) report recommending that the AMA continue its long standing policy opposing physician assisted suicide. Instead the delegates “voted 314-243 to refer the matter back to the trustees for further deliberation”.

Unfortunately, Senate Bill 693 does not contain any requirement of conscience rights protection in allocating grants to groups proposing to expand hospice and palliative care education programs for healthcare professionals.

BIOETHICS AND CONSCIENCE RIGHTS

According to Dr. Edmund Pellegrino, writing on the origin and evolution of ethics in 1999 for the Kennedy Institute of Ethics :

“In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics.”

Instead of the old Hippocratic Oath principles requiring high ethical and moral standards for doctors including prohibitions against actions such as assisting a suicide, bioethics has evolved into essentially four principles: Respect for autonomy (the patient’s right to choose or refuse treatment), Beneficence (acting in the best interest of the patient), Non-maleficence (not causing harm) and Justice (fairness, equality and distributive justice “so that the needs of the entire population are taken into account.” ) which often compete in actual medical situations.

Unfortunately, the principles of the new bioethics do not address the issue of conscience, which has now become a contentious issue in bioethics.

For example at the 2018 AMA meeting where the House of Delegates voted not to accept the Committee on Ethical and Judicial Affairs report’s recommendation to continue the AMA’s opposition to physician-assisted suicide, one doctor responded:

“We feel the AMA abandoned all physicians who, through conscience beliefs, want to support patients with this in states where it’s legal,” said Lynn Parry, MD, a Colorado delegate, on behalf of the PacWest group, which includes AMA delegates from six Western states that have legalized physician aid-in-dying. “I personally think we need to protect physicians in those states and would ask for referral back.” (Emphasis added)

Dr. Ezekiel J Emanuel, MD, PhD, an influential physician who was one of the architects of Obama care and a formerly strong opponent of assisted suicide, wrote in a 2017 New England Journal of Medicine article “Physicians, Not Conscripts — Conscientious Objection in Health Care” that:

“ Conscientious  objection  still  requires  conveying  accurate  information  and  providing  timely  referrals to ensure patients receive care.

……

“Health care professionals who are unwilling to accept these limits (on conscience rights) have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession.

……

“Laws may allow physicians, nurses, pharmacists, and other health care workers to deny patients treatment or to refuse to care for particular populations, but professional medical associations should insist that doing so is unethical.” (All emphasis added)

CONCLUSION

When it comes to issues like withdrawing feeding tubes from so-called “vegetative”  patients, terminal sedation to hasten death and physician-assisted suicide, this last point from Dr. Emanuel leaves those of us physicians and nurses who refuse to kill our patients or help them kill themselves with few options to continue in our professions.

Years ago when I was threatened with firing for refusing to increase a morphine drip on a comatose man who was removed from a ventilator but still continued breathing, I was told that this was acceptable “end of life” care to “prevent pain”.  I know one nurse who was fired for refusing to give morphine every hour to a dying patient in no distress and barely breathing because the family demanded it. I’ve heard from families who were automatically offered hospice instead of rehab when their loved one was elderly and injured.

When such outrages occur even outside of formal hospice or palliative care programs and considered “normal” end of life care, ethical healthcare professionals find no recourse through their professional organizations or the law to protect their patients from premature death.

Thus when healthcare legislation like SB 693 promotes giving grants to organizations who support or might support VSED, assisted suicide, etc. to train healthcare professionals in hospice and palliative care without clear conscience rights protection, both healthcare professionals and the public are at risk of a normalized culture of premature death.

 

Beware the New “Palliative Care and Hospice Education and Training Act”

Right now, there is a Senate Bill 693 titled “The Palliative Care and Hospice Education and Training Act” to authorize more and better training in palliative and hospice care. Although a provision (SEC. 6. Clarification) was recently added to explicitly forbid federal funding for any health care furnished for the purpose of causing or assisting the death of any individual by assisted suicide, euthanasia or mercy killing, many of us have serious concerns. (The similar House Bill 1676 has already passed and sent to the Senate.)

As an RN with decades of nursing experience in hospice, oncology (cancer) and critical care, I have been involved with many end-of-life situations. I am an enthusiastic supporter of ethical palliative and hospice care which is indeed wonderful for patients of any age and their families.

Unfortunately, there is a growing trend towards calling unethical practices “palliative” or “hospice” care.

For example and just a few years ago in a Catholic hospital, I saw a nurse/friend’s life deliberately ended due to so-called palliative and hospice care labeled “comfort care.” She had recently suffered a serious brain injury and was declared hopeless after a couple of weeks. The family was strongly pushed to switch to “comfort care”.  She was taken off a ventilator, had her feeding tube removed (against her adult son’s wishes), and continued to receive the sedation medications used when she was on the ventilator, even receiving an increase in those medications when she continued to breathe on her own. Despite my friend’s son insisting that he wanted the feeding tube replaced and that he wanted to eventually care for his mother at home whatever her level of functioning was, he was told to wait until a doctor could order the feeding tube replaced. The hospital waited until he went home to sleep, transferred her to the hospice unit without his permission and she was dead by morning.

Unfortunately, similar stories have become increasingly more common since the 1970s when the Euthanasia Society of America changed its name to the Society for the Right to Die and promoted the new “living wills”. Now we have well-funded groups like Compassion and Choices (the former Hemlock Society) not only promoting physician-assisted suicide but also trying to change medical ethics from never deliberately causing or hastening death to merely a “choice” about when and how to die.

Two years ago in my blog “Is Compassion and Choices aiming to become the “Planned Parenthood” of Euthanasia?, I warned about the current and future involvement of Compassion and Choices in “end of life” education.

Here are some excerpts:

With over $22 million in 2015 net assets,  a 4 star rating from Charity Navigator, enthusiastic media coverage and a new  Federal Policy Agenda for 2016 and Beyond” , Compassion and Choices increasingly appears to be following in the 4 star, politically and media supported, $1.3 billion dollar revenue ($528 million in government taxpayer funding) steps of the Planned Parenthood Federation of America.

While Compassion and Choices claims that it just “works to improve care and expand choice at the end of life”, it also admits that “We employ  educational training programs, media outreach and online and print publications to change healthcare practice, inform policy-makers, influence public opinion and empower individuals.” (Emphasis added)

……….

THE PALLIATIVE AND HOSPICE CONNECTION

Compassion and Choices has worked for decades not only to legalize physician-assisted suicide in every state but also to normalize and integrate physician-assisted suicide into medical practice and reaches out to established medical groups like the American Academy of Palliative and Hospice Medicine (AAPHM.

………..

Now, Compassion & Choices’ website has a video presentation based on this article  titled  “Understand the Clinical Practice of Aid in Dying” for doctors and other clinicians. The presentation even offers continuing medical education credits.

This would not be possible if the AAPHM had not changed its position on assisted suicide from opposition to “studied neutrality”, a position that the American Medical Association itself is now considering.

………….

Compassion and Choices also supports two other “legal” options for assisted suicide in states that haven’t passed physician-assisted suicide laws. One is “voluntary stopping of eating and drinking (VSED)” and the other is “palliative sedation-Sometimes called terminal sedation”. Significantly, the recommendations include the admission that “VSED includes pain and symptom management” and “Palliative sedation must be medically managed by a healthcare provider”. Thus the need to influence and train hospice and palliative care providers.

………..

WHERE THE MONEY AND POWER IS

Compassion and Choices now has its “Federal Policy Agenda / 2016 & Beyond”.

The priorities on its agenda include:

Establish federal payment for palliative care consultations provided by trained palliative care professionals who will advocate for and support the values and choices of the patient….”  (Emphasis added)

Also included are

Professional Education and Development” training programs for doctors and other providers “in discussing terminal prognoses and death” and  “Policies and Payment Systems” to change medical policies and payments to a “a value-based healthcare payment system” that will “(e)ncourage Congress to direct CMS (the Centers for Medicare and Medicaid Services) and other federal agencies” to withhold   “appropriations or other funds”  for treatment that was “provided but (deemed) unwanted”.

This last provision reinforces the fear many healthcare providers already have that, if in doubt, it is safer not to treat a person rather than treat him or her in hope of a good result because of potential lawsuits or reimbursement problems.

………

In the meantime, if the Compassion and Choices federal policy agenda is successful, they stand to benefit from a potential windfall of government taxpayer funding to provide their currently  “free consultation, planning resources, referrals and guidance”.

CONCLUSION

I have already contacted my state senator to express my concerns and urged him to vote “no” on SB 693.

As Nancy Elliot, chair of the Euthanasia Prevention Council USA, ended in a great letter to Senators opposing the Palliative Care and Hospice Education and Training  Act :

“instead of creating a rival form of palliative care…Wouldn’t it be better to educate/update all physicians and nurses about pain and symptom management?”

Journal of the American Medical Association Article Calls Crisis Pregnancy Centers “Legal but Unethical”

When I first started nursing school, abortion was illegal in all 50 states and the American Medical Association (AMA) was influential and widely admired.

But, as cited and influential in the Roe v Wade decision in 1973, the AMA dropped its’ opposition to abortion in 1970  after a few states legalized abortion with resolutions  that stated:

“abortion is a medical procedure that should be performed by a licensed physician in an accredited hospital only after consultation with two other physicians and in conformity with state law, and that no party to the procedure should be required to violate personally held moral principles”.

I remember how upset many doctors were with the AMA after Roe v Wade and many dropped out of the AMA.

Now, there are over one million MDs in the US  but less than 25% of practicing doctors are members of the AMA, down from 75% in the 1950s. (This is not just because of abortion but also the politics of the AMA.)

The AMA today now stands firmly for abortion rights and even against common sense conscience rights protection.

“AT ‘CRISIS PREGNANCY CENTERS’, CRITICS SAY, IDEOLOGY TRUMPS EVIDENCE”

This is the title of a July 18, 2018 article in the Journal of the American Medical Association by Rita Rubin, MA excoriating crisis pregnancy centers (CPCs) as “legal but unethical”.

Among the allegedly “unethical” practices the article cites are that CPCs “don’t prescribe or provide birth control” and “dispense misleading information-sometimes mandated by the state-about disproved or exaggerated harms associated with abortion, including increased risk of breast cancer, depression and infertility”. The article also criticizes the free ultrasounds as “medically unnecessary” and “emotional manipulation”.

But, according to the article, the biggest ethical problem seems to be “withholding information” about obtaining abortions.

The article cites California as the first state to pass a crisis pregnancy mandatory disclosure law that mandates CPCs to “post or distribute a notice about California’s public programs that provide free or low-cost contraception, prenatal care, and abortion“.(Emphasis added)

The article criticizes the June 26, 2018, the US Supreme Court’s National Institute of Family and Life Advocates v. Becerra decision that struck down the California law as likely unconstitutional.

The JAMA article also decries a recent Health and Human Services’ announcement that Title X family planning services grants includes “natural family planning methods” and that faith-based organizations are eligible to apply for such grants.

THE REAL FACTS ABOUT CRISIS PREGNANCY CENTERS

As even the JAMA article admits, there are more than 3500 CPCs in the US, more than twice the number of US institutions that performed at least 1 abortion in 2014 according to the pro-abortion Guttmacher Institute. That is a decline of 3% between 2011 and 2014.

Obviously, crisis pregnancy centers are seen as threatening to the pro-abortion movement.

As CPC volunteer Patty Knap observed in her blog The Real Reason Crisis Pregnancy Centers Must Always be Free”,  “The difference between an abortion center and a pro-life pregnancy center is like day and night. Or life and death.”

Ms. Knap observes that, unlike an abortion clinic that charges for everything, CPCs don’t charge for anything-including pregnancy tests. Instead, Ms. Knap says, “Every pregnancy center in the country is constantly fundraising”.

Ms. Knap says offering their services without charge is necessary because the trust factor is so important. When their clients understand the motivation of someone who isn’t profiting from the decision they are making, they are more likely to accept the truth and real help.

CONCLUSION

Just as outrageous as California’s attempt to compel crisis pregnancy centers to advertise abortion is that so many mainstream media outlets continue to ignore or disparage the ongoing efforts of the pro-life movement to offer desperate women a loving opportunity for them and their unborn babies.

We may sometimes wonder if attending fundraising baby showers in our churches, picketing abortion clinics with telephone numbers for help, donating to Birthright, etc.  is really accomplishing much. But, as the successes of CPCs show, even the smallest effort by a great number of people can produce the awesome result of helping distressed mothers and saving their babies’ lives.

Medical Experts Now Agree that Severely Brain-injured Patients are Often Misdiagnosed and May Recover

People with severe brain injuries from accidents, strokes, illness, etc. are often in comas at first. If they don’t die or spontaneously wake up, they can progress to a “persistent vegetative state” (PVS) described as “awake but unaware” and/or a “minimally conscious state” (MCS) described as definite, but extremely limited, awareness of self or environment, and limited means of communication. People with these conditions have had court battles over removing their feeding tubes such as the 1988 Nancy Cruzan (PVS) and the 2001 Robert Wendland (MCS) right to die” cases.

Now, an August 9, 2018 Medscape article “New Guideline for Minimally Conscious, Vegetative States Released”  reveals that 3 specialty societies including the American Academy of Neurology have just published a new guideline with 15 recommendations for “accurate diagnosis, prognosis and treatment for these conditions”.

The reason for the new guidelines, according to Dr. Joseph Giacino, who was one of the authors of the study, is because:

“Misdiagnosis of  DoC (“disorders of consciousness”) is common because underlying impairments can mask awareness — in fact, there is a 40% rate of misdiagnosis, leading to inappropriate care decisions as well as poor health outcomes.” (Emphasis added)

The 223 page new guideline titled Practice guideline update: Disorders of consciousness” states that:

 “Clinicians should refer patients with DoC (disorders of consciousness) who have achieved medical stability to settings staffed by multidisciplinary rehabilitation teams with specialized training to optimize diagnostic evaluation, prognostication, and subsequent management, including effective medical monitoring and rehabilitative care.”

and

When discussing prognosis with caregivers of patients with DoC (disorders of consciousness) during the first 28 days after injury, avoid statements suggesting that these patents “have a universally poor prognosis”. (All emphasis added)

According to Dr. Giacino, “Approximately 20% of individuals who have disturbance in consciousness from trauma regain functional independence between 2 and 5 years post-injury, even though they may not return to work or pretrauma functioning.” (Emphasis added)

The study also cites the drug amantadine and brain imaging showing that the brain can still respond normally to stimulus even though the person seems unaware as potentially helpful.

What about the “right to die” for these people? Ominously, the guideline does mention 1 study found that hospital mortality was 31.7%, with 70.2% of those deaths associated with the withdrawal of life-sustaining therapy”. (Emphasis added)

IS THE “40% MISDIAGNOSIS” RATE REALLY NEWS?

Doctors like Dr. Keith Andrews of the UK and US doctor Mihai Dimancescu published  medical journal articles  in the 1990s showing that around 40% of patients in a so-called “persistent vegetative state” were misdiagnosed.  And in 1987, the Royal Hospital for Neuro-Disability in the UK opened a “vegetative state” unit and later developed the “Sensory Modality Assessment and Rehabilitation Technique (SMART)” as a clinical tool for the assessment and rehabilitation of people with disorders of consciousness following severe brain injury.

Despite this, most media stories about cases like Terri Schiavo’s and “right to die”/assisted suicide groups continued to insist that “PVS” is a hopeless condition for which everyone should sign a “living will” to ensure that food and water is withheld or withdrawn to “allow” death.

This happened despite articles like the New York Times’ 1982 article “Coming Out of Coma”.  about the unexpected return of consciousness of Sgt. David Mack over a year after the famous “right to die” neurologist Dr. Ron Cranford  predicted ”He will never be aware of his condition nor resume any degree of meaningful voluntary conscious interaction with his family or friends” before. (Emphasis added)

There have also been articles about people like Terry Wallis who in 2003 regained consciousness after 19 years in a “minimally conscious” state. Unfortunately, such cases were often explained away as just “misdiagnosis” or a “miracle”.

MY EXPERIENCE

Just before Drs. Jennet and Plum invented the term “persistent vegetative state” in 1972,  I started working with these many comatose patients as a young ICU nurse. Despite the skepticism of my colleagues, I talked to these patients as if they were awake because I believed it was worth doing it for the patient if hearing is truly the last sense to go. Because of this, I unexpectedly saw some amazing recoveries and one patient later  told me that he would only respond to me at first and refused to respond to the doctor because he was angry when heard the doctor call him a “vegetable” when the doctor assumed the patient was comatose.

Over the years, I’ve written about several other patients like “Jack”, “Katie” and “Chris” in comas or “persistent vegetative states” who regained full or limited consciousness with verbal and physical stimulation. I also recommended Jane Hoyt’s wonderful 1994 pamphlet “A Gentle Approach-Interacting with a Person who is Semi-Conscious  or Presumed in Coma” to help families and others stimulate healing of the brain. Personally, I have only seen one person who did not improve from the so-called “vegetative” state during the approximately two years I saw him.

CONCLUSION

It is good news that the American Academy of Neurology and other groups are finally rethinking their approach to people with severe brain injuries, especially the recommendation to start rehabilitation therapies as soon as the person is medically stable and the recommendation for  periodic and thorough testing over time.

This is crucial because the often quick prognosis of “hopeless” attached to people with severe brain injuries can-and has-led to early withdrawal of feeding tubes and ventilators as well as DCD (donation after cardiac/circulatory death) for these non-brain dead people.

Dr. Joseph Fins MD and chief of Medical Ethics at Weill Cornell Medical College perhaps says it best when he praises the new guideline as “a real step forward for this population that has historically been marginalized and remains vulnerable” and “suggests that brain states are not static, but dynamic, and that people can improve over time”. (Emphasis added)

 

 

 

 

 

Caught in Social Media Bias

I have been hearing about Facebook blocking or restricting “conservative” content on the internet. Recently, there was a National Right to Life News story about a Republican judge from my state of Missouri who could not “boost”  (pay for reaching a wider audience) a pro-life video of his nephew overcoming a life-threatening birth defect detected prenatally. Facebook’s stunning rationale?

“Your Ad wasn’t approved because it doesn’t follow our Advertising Policies. We don’t allow ads that contain shocking, disrespectful or sensational content, including ads that depict violence or threats of violence.” (Emphasis added)

A short time ago, I saw that a shared written item from #NoAbortionCoercion on protecting conscience rights for healthcare providers on our National Association of Prolife Nurses (NAPN) Facebook page  was not allowed to be “boosted” because it also conflicted with Facebook’s advertising policies.

The item read:

“Conscience rights of healthcare providers must always be protected. As nurses, the government is constantly telling us what we must and mustn’t do when caring for our patients. There can be no coercion to act against our consciences. Compassion and love is and will always be at the center of what we do. #NoAbortionCoercion”

Our NAPN media nurse says that this has happened before and he has been told that some ads are considered “political”.

However, NAPN is a 501C3 educational organization, not a political one. We have only volunteers, not salaried employees. We do not endorse candidates.

I am a spokesperson for NAPN and as our NAPN website states :

“NAPN is a not-for-profit organization uniting nurses who seek excellence in nurturing for all, including the unborn, newborn, disabled, mentally and or/physically ill, the aged and the dying. Beginning in 1973, when abortion was accepted as a legal alternative to pregnancy, healthcare professionals have been confronted by an ever-increasing number of morally challenging life issues. The list of ethical dilemmas continues to grow: in vitro fertilization, cloning, fetal experimentation, organ donation and transplantation, nutrition and hydration, patient rights, certain sterilization practices, looming rationing of medical resources, assisted suicide and euthanasia, and stem cell research with its promise of advances in the treatment of disease. No one is more affected by these morally challenging issues than the nurse and the pressure to utilize unethical techniques and practices in the care of patients is increasing. Through a united, educational, professional organization such as NAPN, nurses can, in good conscience, deliver the best possible patient care while preserving, protecting and defending respect for human life.”

NAPN also helps to support nurses facing conscience rights legal battles and even offers a $1000 pro-life scholarship award each year to the school of the winning nursing student based on his or her essay, academic achievements, demonstration of leadership and participation in pro-life activities. Applications for the next 2018-2019 award will be posted soon on our website and Facebook page.

CONCLUSION

Of course, NAPN is only one of many groups and individuals complaining about apparent bias against pro-life or conservative groups on social media.

Facebook founder Mark Zuckerberg testified in April before the US Congress that he had no knowledge of bias against conservatives but as Lifenews.com and other news sources have found, there is conservative speech being suppressed not only by Facebook but also Twitter, Google and YouTube. We need more than just reassurances that improvements will be made while the problems are still ongoing.

With so much of the mainstream media enthusiastically supporting abortion, assisted suicide and other deliberate death decisions while ignoring or negatively reporting on issues like conscience rights and alternatives like crisis pregnancy centers, it is especially important for the public to be able to access social media sites like NAPN’s for real facts.

In today’s volatile legal and cultural climate, we need all available information-not a double standard.

An “Acceptable” Prejudice

This week, Fox News had a story  about John Cronin, a young man with Down Syndrome who, with his father, founded and runs what is now a $4 million dollar company called Crazy Socks.

This story follows the February announcement that the new Gerber Spokesbaby is Lucas Warren who had Down Syndrome. The famous baby food company stated that Lucas “exemplifies Gerber’s longstanding heritage of recognizing that every baby is a Gerber baby.” (Emphasis added)

However, this past week, the influential ethicist Arthur L. Caplan, PhD wrote a commentary titled “Should It Be Harder to Get Abortions for Down Syndrome Babies?”
for Medscape, a password protected medical news website for health professionals.

In his commentary, ethicist Caplan recognizes the worries that “Down Syndrome is becoming increasingly rare in Europe and the United States” because of prenatal testing and abortion.

But he contends that because:

“In recent years, we have even seen kids with Down syndrome appearing on cheerleading squads, or being put into beauty pageants. It’s clear that there has been movement to not exile or isolate children in the United States with Down syndrome and to try and get them more mainstream.” (Emphasis added)

Nevertheless, ethicist Caplan accepts the ultimate “exile” of Down Syndrome by abortion because “After all, legally, you don’t have to have any reason to decide to end the pregnancy.” (Emphasis added) He additionally cites polls showing high public support for abortion for “genetic  or hereditary diseases”.

Therefore he also criticizes the few states that have passed laws to protect unborn babies testing positive for Down Syndrome from abortion. (Emphasis added)

Dr. Caplan says he is not against “offering information to parents” about Down Syndrome but he is against “mandating” that such information be given.

Perhaps Dr. Caplan has forgotten that in 2008, the Kennedy Brownback law “Prenatally and Postnatally Diagnosed Conditions Awareness Act” was overwhelmingly passed by both houses of Congress and signed into law “(t)o amend the Public Health Service Act to increase the provision of scientifically sound information and support services to patients receiving a positive test diagnosis for Down syndrome or other prenatally and postnatally diagnosed conditions.”

DOWN SYNDROME AND PREJUDICE

Unfortunately, prenatal discrimination naturally leads to postnatal discrimination as I personally discovered when my husband and I had our daughter Karen who had Down Syndrome and a heart defect. We were shocked when the cardiologist gave us the option of refusing cardiac surgery and letting her die despite the excellent chance for survival with surgery.

Although we chose life for our daughter, we later found that Karen was secretly made a “Do not Resuscitate” (DNR) during one hospitalization by our trusted pediatrician who said I was “too emotionally involved with that retarded baby”. Unfortunately, we eventually lost our Karen to complications from pneumonia before her planned surgery.

I’m sure Dr. Caplan would not be in favor of terminating anyone because of race, sex, etc. but he apparently has a “politically correct” blind spot when it comes to abortion.

Ironically, one of the state laws that ethicist Caplan objects to states:

“That Indiana does not allow a fetus to be aborted solely because of the fetus’s race, color, national origin, ancestry, sex or diagnosis or potential diagnosis of the fetus having Downs syndrome or any other disability.”  (Emphasis added)

Sadly, that Indiana law was ruled unconstitutional in 2018 because of the legal “right to abortion” for any or no reason at all.

CONCLUSION

There is no test that will prove that an unborn baby is “perfect”, either before or after birth. For example, many of us have had our so-called “normal” children unexpectedly die or become addicted to illegal drugs years after birth. It is a sad conceit to assume that we can ensure the happiness of ourselves and our families by testing and then controlling which of our unborn babies are allowed to live.

In reality, a 2016 study “Positive attitudes prevail within families of people with Down syndrome” showed that almost 90% of families with members having Down Syndrome reported pride, love and even feelings of enrichment.

And a 2011 study in the American Journal of Medical Genetics titled “Self-perceptions from People with Down Syndrome “ found that “99% of people with Down syndrome indicated that they were happy with their lives”.

Nevertheless, as those of us who have had children with Down Syndrome know, the negative stereotypes of people with Down Syndrome persist despite these studies and often affect the medical professionals and ethicists charged with giving women and families information and options (including adoption) for conditions like Down Syndrome. Incomplete or biased information can be deadly and result in the now up to 90% of mothers who abort their unborn babies after a diagnosis of Down Syndrome.

The world is so much poorer without people like my late daughter Karen who was greatly loved. Prejudice against Down Syndrome justified as the legal “right to abortion” is lethal, not “acceptable”.

Women and their families surely deserve both comprehensive information and support when a prenatal diagnosis like Down Syndrome is made.

And every child, born or unborn, deserves a chance for life.