My Book Review on “Nurses and Midwives in Nazi Germany: The ‘Euthanasia Programs’”

“Nurses and Midwives in Nazi Germany-The ‘Euthanasia Programs’”
Edited by Susan Benedict and Linda Shields
Routledge Studies in Modern European History. London: Routledge 2014

My book review (abstract) was just published in the Linacre Quarterly journal. Here are some excerpts from my review with all emphasis added only for this blog.

In my nursing education during the 1960s, the Nazi euthanasia program was covered during a class but mainly as a ghastly aberration that was unthinkable today with our now strong ethical principles. As students, we were shocked and horrified by the revelation that nurses were integral to Nazi killing programs. We had little knowledge of the mechanisms that existed to encourage nurses to kill those patients whose lives were deemed “not worth living.”

Unfortunately, it is difficult these days to find information about nurses during the Nazi regime, even on the American Nurses Association website. Thus, the editors of this book do nurses and the public a great service by examining the little-known but crucial role of nurses in the Nazi euthanasia programs. Knowing this history is more important than ever as efforts to legalize assisted suicide and euthanasia continue to grow.

The authors explain the history, education, propaganda, and pressures that led so many nurses to participate in the killing of hundreds of thousands of helpless men, women, and children in the 1930s and 1940s; they also propose a model for teaching nursing ethics using the Nazi euthanasia program to encourage nursing students to examine ethical principles and their own values as a nurse in today’s health-care system.

……

The authors start with the rise of the influential eugenics movement in the early twentieth century in countries like the United States where the American Eugenics Society even held conferences on eugenics, such as the 1937 one which included the topic “The Relation of Eugenics to the Field of Nursing.” Eventually, the US eugenics movement fell out of favor after the Nazi euthanasia programs were discovered in World War II.

Even prior to World War II, German professional nursing publications discussed eugenics as “providing a scientific basis for the positive eugenics promoting reproduction among the healthy (often of northern European descent) middle to upper classes and negative eugenics encouraging limited reproduction and forced sterilization of the ‘unfit’ (who were often poor, uneducated, and more recent immigrants) as reasonable”.  Eugenic language was most prevalent in public health and psychiatric nursing texts and in discussions of poverty, immigrants, cleanliness, and social problems.

The editors also point to the influence on Adolf Hitler of the 1920 book titled Approval of the Extermination of Worthless Human Lives by Germans Karl Binding, a jurist, and Alfred Hoche, a psychiatrist. Binding and Hoche noted that there were no legal arguments preventing legalizing the killing of those whose lives were considered not worth living. (Emphasis added)

There was extensive propaganda aimed at increasing the acceptance of euthanasia by the public and health-care providers. Only a few months after Hitler seized power, the first law, affecting people diagnosed with psychiatric conditions, was passed. It mandated sterilization for people with hereditary disorders including alcoholism and epilepsy. Propaganda emphasized wastefulness of providing health care to the chronically mentally ill and the hereditary nature of undesirable physical, mental, and social traits.

Hitler did not propose the systematic killing of psychiatric patients during peacetime because he anticipated the opposition of the churches and the German people. The beginning of World War II muted moral objections and distracted the populace with concerns of conserving resources for the war effort and was the start of state-sponsored euthanasia. The first documented killing occurred in 1939 when Hitler granted the euthanasia request of a father whose son was born blind, missing a leg and part of an arm and who “seemed to be an idiot” .

In 1939, the German Ministry of Justice proposed two new clauses:

1.“Whoever is suffering from an incurable or terminal illness which is a major burden to himself or others can request mercy killing by a doctor, provided it is his express wish and has the approval of a specially empowered doctor.”

2. “The life of a person who, because of incurable mental illness, requires permanent institutionalization and is not able to sustain an independent existence may be prematurely terminated by medical measures in a painless and covert manner” . (Emphasis added)

The program started targeting those in asylums and the disabled in nursing homes for death by lethal gas, starvation, drugs, and neglect. The Jewish population was especially targeted regardless of health.

………

 

In 1933, Adolf Bartels, the deputy leader of the Reich’s medical profession, provided a blueprint of the future of nursing under the Nazis. He emphasized that German nurses in social and medical service had to meet standards in the new Reich that were very different from before. The new Reich not only wanted to look after the sick and weak but also wanted to secure a healthy development of all Germans “if their inherited biological predisposition allows for it” (p. 38). Above all, the new state wanted to secure and promote a genetically sound, valuable race, and, in contrast to the past, “not to expend an exaggerated effort on the care of genetically or racially inferior people”. (Emphasis added)

As a Nazi politician stated, “a nurse is the one who should carry out the will of the State in the health education of the people”. It was not necessary for the majority of nurses to become ardent supporters of the Nazi regime for them to do the will of the Reich. One source noted that the majority of nurses who participated in a secret euthanasia program known as T4 tried to remain good nurses; an estimated 10 percent or fewer were enthusiastic supporters of Nazi practice. But, as in other areas of public life, the Reich absorbed professional nursing organizations, leaving the nursing profession with no means of expressing opposing or dissenting views as well as no organizational support for refusing to participate. (Emphasis added)

……

 

Using midwives, the Reich took various measures both to prevent those regarded as having a “hereditary disease” or who were “racially inferior” from reproducing while increasing the birth rate of those considered valuable and healthy. Thus, the traditional midwife focus on the mother and child was changed to focus on the nation as a whole.

Midwives could initiate proceedings for forced sterilization, and it was now a duty for midwives to report to public health officers “deformed” births and small children with disabilities before their third birthday. Reports received from doctors and midwives were reviewed by medical examiners, and based solely on the reports, the examiners decided whether the child was to be killed or spared.

Parents with such children were told about institutions for children who needed special care that were being established through the country. They were persuaded to admit these children and were assured that the children would receive the best possible care. Parents could refuse but had to sign forms stating their responsibility to supervise and care for their children. The identified children in these institutions were killed by starvation or lethal injection. Parents were told that their children had died from natural causes.

……..

The world was riveted by the 1945 Hadamar trial, the first mass atrocity trial after the Nazi regime was defeated in World War II. This trial came before the infamous Nuremburg trials that included doctors. Hadamar was covered extensively by American media but ignored by the American Journal of Nursing even though nurses were charged.

The trial involved one of the largest and most important killing centers, Hadamar Psychiatric Hospital, one of the six institutions in Germany designated for killing the mentally ill. In 1943, a ward (called an “educational home”) was set up for mixed-race children with Jewish heritage within Hadamar. Completely healthy children were killed with lethal injections. The actual numbers are not known because employees were required to take an oath of secrecy. It is estimated that more than 13,000 patients were killed in 1941 and 1942, even before the ward was set up.

 

In the first Hadamar trial, Head Nurse Irmgard Huber was tried with six others for killing over 400 men, women, and children. Nurse Huber was charged with “obtaining the lethal drugs, being present when some of the fatal injections were given, and being present when the false death certificates were made out”. Two male nurses were charged with administering the lethal injections. All pleaded not guilty. Their defense was that they were powerless and had inadequate knowledge to judge the morality of their actions. All denied accountability. (Emphasis added)

Trial testimony confirmed that the nurses prepared patients for their deaths, directed the entire nursing staff of the institution, and were present at the daily conferences where the falsified death certificates were completed. Duties to patients were limited to so-called kindnesses that consisted of bringing small gifts to pediatric patients and taking care to prevent patients from knowing that they would soon be killed. Head Nurse Huber insisted that she wished to render a last service to these patients and did not want to do them any harm and that she had a clear conscience.

…….

The second Hadamar trial in 1947 did not receive the same attention as the first. Twenty-five members of the Hadamar staff were charged. At this trial, Head Nurse Huber was charged with killing 15,000 German mental patients. All but one of the defendants were found guilty and served sentences ranging from two and a half to five years. The one nurse found not guilty claimed she had feigned pregnancy in order to achieve release from the killing center. (Emphasis added)

In the end, Head Nurse Huber was released from prison in 1952; the others by 1954.

………

The book presents a model used for two innovative teaching programs about this subject, one in Israel and one in Australia, perhaps the most important contribution of this book. The editors believe that the Nazi era should be taught to students, “highlighting the danger of failing to see each individual as a valuable member of human society. And while the heart of nursing and midwifery continues to be care and caring practices, it is fundamental for students to confront this history to develop insights into the causes and social constructs that enabled nurses and midwives to distort the goal of nursing practice and theory to harm and murder patients.”

The results of these programs and the responses by students appear encouraging. The editors hope that by raising these issues, students will be forced to confront their own values and beliefs, sometimes an intensely uncomfortable experience. They also believe students who are exposed to this “dark element of nursing and midwifery history” will be better prepared to face pressure or to report and oppose violations of the trust that is central to any relationship between nurses and patients

 

CONCLUSION

Decades after the Nazi atrocities, we are seeing a resurgence of the same “life unworthy of life” justification that drove Nazi eugenics. We see how this perspective increasingly approves the deliberate termination of some lives as “merciful” and “humane.” There is an emerging, shocking consensus that we can—or perhaps even should—choose to have our own lives terminated when our lives are considered not worth living either by ourselves or by others if we cannot speak for ourselves.

The authors of this book make it clear: we all need to know and understand the past in order not to repeat it. Hopefully, it is not too late to turn the tide of history back toward respect for all life.

 

 

What You Need to Know About Medical Abortion and Abortion Reversal

This month Governor Butch Otter signed a law making Idaho the fifth state to mandate that women getting a medical (drug-induced) abortion be told that the abortion may possibly be stopped after the first dose if the woman changes her mind about having the abortion. This abortion reversal process  involves taking the hormone progesterone to counteract the first abortion drug mifepristone and before taking the second drug misoprostol 36-72 hours later that causes expulsion of the unborn baby. There is now a website at www.abortionpillreversal.com for information on abortion reversal that includes a hotline phone number at 1-877-558-0333.

The first abortion reversal  was performed by Dr. Matthew Harrison in 2007 and by 2015, he claimed that more than 213 babies had been saved. Although not always successful, abortion reversal has resulted in hundreds more babies alive today. Last December, the California Board of Registered Nursing finally notified Heartbeat International that it can now grant continuing education units (CEUs) to nurses who study the life-saving process known as Abortion Pill Reversal.

Planned Parenthood and other abortion groups are not pleased.

As I wrote in my February 16, 2017 blog “Are Mail Order Abortions Coming?” , medical abortions rates now rival surgical abortion rates while abortion clinics are closing at a record pace because of factors like “economic difficulties”, “a generally hostile atmosphere and declining demand”. Thus, the medical abortion procedure has become more appealing to groups like Planned Parenthood and now there are even efforts to provide more medical abortions by telemedicine even though a 2014 study found more complications with medical abortions than surgical ones.

THE PROMOTION AND CHANGING CRITERIA FOR MEDICAL ABORTION

In a disturbing March 27, 2018 Medscape article Medical Abortion in Very Early Pregnancy” (password protected),  Peter Kovacs, MD, PhD touts a study that allegedly shows medical abortion is now safe even “as soon as early pregnancy is diagnosed” and even before an ultrasound can show if the unborn baby is developing outside the womb. This abnormality is called an ectopic pregnancy and, if not detected early, can result in life-threatening complications and surgery.  Ectopic pregnancy occurs in 1-2% of  all pregnancies.

But as even Dr. Kovacs admits:

“Under well-controlled conditions using sedation and appropriate pain control, surgical termination of pregnancy is associated with minimal bleeding or pain. However, it can be associated with surgical complications (trauma, heavier bleeding, infection), which can lead to further interventions.

Medical abortion can be more painful because the products of conception have to be expelled from the uterus, and it is accompanied by prolonged bleeding. Still, medical abortion obviates surgical complications and is significantly cheaper.” (Emphasis added)

He recommends  “(A)propriate patient selection (no increased risk for or symptoms of ectopic pregnancy, appropriate follow-up to confirm successful abortion, patient compliance)” as obviously important. (Emphasis added)

CONCLUSION

Planned Parenthood tells women that having a medical abortion (at home, of course) is just “kind of like having a really heavy, crampy period” with large clots and that “(a)ny chills, fevers, or nausea you have should go away pretty quickly”.

And that:

“People can have a range of emotions after having an abortion. Most people feel relief, but sometimes people feel sad or regretful. This is totally normal. If your mood keeps you from doing the things you usually do each day, call your doctor or nurse for help” along with numbers to call for “free, confidential, and non-judgmental emotional support after an abortion.” (Emphasis added)

But two things Planned Parenthood does not tell women about is medical abortion reversal and the availability of real assistance with a problematic pregnancy including crisis pregnancy centers that now outnumber abortion clinics in the US.

Women need-and have a right-to know about both these alternatives.  It’s up to all of us to make sure as many women as possible know this.

Should Nurses or Other Non-Physicians Be Allowed to Perform Abortions?

When abortion was legalized in the 1973 Roe v Wade decision, we were told that abortion should be a private decision between a woman and her doctor.

Now there is a lawsuit by Planned Parenthood and the American Civil Liberties Union to force the state of Maine to allow abortions by non-physicians such as nurses and midwives.

Why? Although Planned Parenthood and the ACLU claim that this is about the safety of first-trimester abortion and the lack of enough accessible abortion clinics as well as “threats of violence”, the truth is that it is getting harder and harder to find doctors willing to do abortions.

This new expansion of abortion is part of a larger movement to remove restrictions on abortion. According to the liberal Public Leadership Institute, already “California, Montana, New Hampshire, Oregon and Vermont allow trained and licensed APCs (advance practice clinicians like nurses and physician assistants) to perform aspiration abortions.”

The Institute even provides model legislation for states called the ““Qualified Providers of Abortion Act” and cites the American College of Obstetricians and Gynecologists as recommending “expanding the pool of non-obstetrician/gynecologist abortion providers by training advanced-practice clinicians (APCs)—nurse practitioners, certified nurse-midwives and physician assistants—to perform aspiration (aka suction or vacuum) abortions.”

 ABORTION AND SAFETY

The source cited for the claim of safety for non-physician abortions is a new National Academies of Sciences, Engineering and Medicine report, “The Safety and Quality of Abortion Care in the United States.”

This report cites a 2013 study “Safety of Aspiration Abortion Performed by Nurse Practitioners, Certified Nurse Midwifes, and Physician Assistants Under a California Legal Waiver”  that dismissed the result of twice the number of complications for the non-physicians vs physicians as not “clinically relevant”.

But finding any true statistics on complications of abortion (including death) is already virtually impossible because according to the national Centers for Disease Control (CDC)  “states and areas voluntarily report data to CDC for inclusion in its annual Abortion Surveillance Report. CDC’s Division of Reproductive Health prepares surveillance reports as data become available. There is no national requirement for data submission or reporting.” (Emphasis added)

In addition, abortion clinic health inspections are often lax or ignored. As the Washington Free Beacon reported last October, according to the 2016 “Unsafe-How the Public Health Crisis in America’s Abortion Clinics Endangers Women report from the pro-life advocacy group Americans United for Life, “between 2008 and 2016, 227 abortion clinics were cited for over 1,400 health and safety deficiencies.”

According to Arina Grossu, a bioethicist and the director of the Center for Human Dignity at the Family Research Council, “Restaurants and tanning salons and vet clinics, they’re all more closely regulated than the abortion industry.”

This, of course, does not take into account the physical, spiritual and emotional toll of abortion on women that I have seen both personally and professionally.

CONCLUSION

In the 2016 US Supreme Court’s Whole Women’s Health v. Hellerstadt at decision held that:

“Two provisions in a Texas law – requiring physicians who perform abortions to have admitting privileges at a nearby hospital and requiring abortion clinics in the state to have facilities comparable to an ambulatory surgical center – place a substantial obstacle in the path of women seeking an abortion, constitute an undue burden on abortion access, and therefore violate the Constitution.”

Abortion supporters cheered and are now emboldened to go farther in their quest for tax-payer funded abortion on demand without restrictions.

But all is not lost.

The number of abortions is declining and there are now more crisis pregnancy centers than abortion clinics.  and more lives are being saved. Programs like Project Rachel are helping even more women and men suffering from the tremendous psychological damage caused by abortion.

Most women are choosing life after viewing an ultrasound of their baby and more  people are opposing taxpayer funding of groups like Planned Parenthood, especially after the scandal of selling aborted babies’ body parts.

But most importantly, we must keep working towards a society that once again views abortion as unthinkable.

Legal Safeguards, Burdensome Obstacles and Conscience Rights

After I wrote last week’s blog “The New Federal Conscience and Religious Freedom Division” , I was surprised by this criticism: “arguing conscience can make doctors (and others) look whiney, as opposed to heroic” and give assisted suicide supporters “an easy platform to describe them as selfish and out of touch ideologues who want to make their parents suffer.” But this comment did make me think.

Actually, I felt horror, intense sadness and fear when, as I wrote in the blog, I was “threatened with termination (after the fact) for refusing to participate in an unethical health care decision years ago.” I was trying to save my patient from being deliberately terminated with an overdose of morphine that neither he nor his family requested but I found no support in the “chain of command” at my hospital. I could not pass this patient to another nurse so I basically stopped the morphine drip myself, technically following the order “titrate morphine for comfort, no limit”.

Especially as the sole support of three children with no family support, I feared losing my job but I could not participate in good conscience for my patient’s sake. I did not feel either heroic or whiney.

Ironically, a later autopsy requested by the family showed no lethal condition or brain injury as suspected when the patient had a crisis after routine surgery.

I’ve known other doctors, nurses and therapists who have similarly put their jobs on the line for the real reason for conscience rights: protection of patients. We are a thinning white line in the face of expanding demands for deliberate death as a civil right while our US and other countries’ professional organizations are changing or considering changing their positions against medically assisted suicide and euthanasia.

If we who refuse to terminate our patients are harassed or eliminated from our professions and future potential students discouraged from choosing such a profession, patients will be denied the choice of such medical professionals and a final barrier will be broken in the lethal flood to follow.

WHEN “LEGAL SAFEGUARDS” BECOME “BURDENSOME OBSTACLES”

Already there are impatient calls to expand medically assisted suicide and euthanasia.

Thaddeus Pope, JD, PhD, the influential Director of the Health Law Institute and Professor of Law at the Mitchell Hamline School of Law in Saint Paul, Minnesota and writer of the Medical Futility Blog, wrote an article last December titled “Medical Aid in Dying: When Legal Safeguards Become Burdensome Obstacles” for the American Society of Clinical Oncology Post. (According to ASCO, it “has taken no official position on medical aid in dying”.)

Mr. Pope notes the “uniformity and similarity” of the six current medically assisted suicide statutes but brings up four so-called “safeguards” affecting the “next-generation issues: the justifiability of prevailing eligibility criteria and procedural requirements” that will allegedly need to be addressed. (Emphasis added)

The first is “Expanding From Adults to Mature Minors” which Mr. Pope characterizes as “unduly restrictive” in part because “Many states already allow terminally ill mature minors to withhold or withdraw life-sustaining treatment”. (Emphasis added)

Mr. Pope’s second issue is “Expanding From Contemporaneous Capacity to Advance Directives”, stating that “All six statutes require that the patient concurrently have both a terminal illness and decision-making capacity. But this dual mandate excludes many patients who have no other exit options” such as those with “advanced dementia”. (Emphasis added)

The third issue he cites is “Expanding From Terminal Illness to ‘Reasonably Predictable’” because:

“(T)his rigid time frame excludes patients with grievous and irremediable conditions that cause suffering intolerable to the individual. Some medical conditions may cause individuals to irreversibly decline and suffer for a long period before dying. Instead of demanding a strict temporal relationship between a medical condition and death, these statutes might be more flexible and instead require that death be ‘reasonably predictable’.” (Emphasis added)

Mr. Pope’s final issue is “Expanding From Self-Ingestion to Physician Administration”:

“First, it excludes patients who lose the ability to self-administer before they otherwise become eligible. Second, self-ingestion is associated with complications. For example, around 3% of these patients had difficulty ingesting or regurgitated the medication. Other patients regained consciousness after ingestion.” (Emphasis added)

And, as in most of the previous issues, Mr. Pope approvingly cites the rapidly expanding assisted suicide situation in Canada:

“Canadian patients avoid all these problems (with self-ingestion), because physicians usually administer the medication. As a result, only 5 of more than 2,000 Canadian patients who used medical aid in dying self-ingested the lethal medication.” (Emphasis added)

Ironically, there is one so-called “safeguard” that Mr. Pope would like to see tightened:

“that the prescribing or consulting physician refer the patient “for a mental health specialist assessment” if “there are -indications of a mental disorder.” Yet prescribing and consulting physicians have referred only 5% of medical aid in patients who are dying. Leading experts argue that this rate is probably too low relative to the expected rate of impaired judgment. Others are “surprised by how rarely the prescribing or consulting physicians refer patients for a psychiatric consultation.” (Emphasis added)

This discrimination in suicide assessment is not acceptable for any suicidal person-except now, of course, for a person requesting medically assisted suicide.

CONCLUSION

Without a strong resistance movement, these proposals are only just the next step in the death agenda. So far, much of the public, government officials and medical professionals have been shielded from the real truth by euphemisms and false reassurances from assisted suicide supporters, a mostly sympathetic mainstream media and often spineless professional and health care organizations. We all must educate ourselves to speak out before it is too late.

Defending Physician-assisted Suicide

In a recent letter to the editor in the Wall Street Journal,  Dr. David Grube, national medical director of Compassion and Choices, defended physician-assisted suicide by stating:

“I knew that the people who requested it didn’t want to end their life. They loved life but realized they had an incurable, terminal disease and didn’t want to suffer needlessly as the inevitable end of life approached.

The proof is that more than one-third of terminally ill Oregonians who obtain the medication never take it, but they get great comfort in knowing they have access to it if they need it, which helps them suffer less.” (Emphasis added)

Is this really the crucial argument to upend our medical and legal ethics to legalize physician-assisted suicide?

Especially when more than 33% of people approved for assisted suicide don’t use the lethal overdose prescriptions, this should be a wake-up call for assisted suicide activists as well as suicide prevention groups and the rest of society.

As a former oncology (cancer) and hospice nurse who cared for many terminally ill patients including relatives over decades, I encouraged my patients and family members to talk about all their concerns. I found very few who wanted to end their lives out of fear of future suffering. I  reassured my patients and relatives that we would make them as comfortable as possible and support them until their natural death. Not one died by suicide and all died with true dignity.

But this was before physician-assisted suicide began to be legalized, glamorized and  promoted by activists, especially through sympathetic media outlets.

WHERE IS THE FOLLOW UP ON THE PATIENTS WHO DON’T TAKE THE LETHAL OVERDOSE?

What happened to these patients who decided not to take the lethal overdose? Did they unexpectedly improve or find their symptoms adequately treated? Was the terminal diagnosis wrong? Did they find the physical, emotional and spiritual support to continue living?

Unfortunately, those writing state assisted suicide reports are apparently not interested in this important information that could help save other lives.

WHAT HAPPENS TO THE UNUSED LETHAL OVERDOSE?

Another concern is what happens to the lethal overdose that the patient does not take?

In any home health situation, every unused dose of a controlled medication must be accounted for and disposed of carefully. We know how important it is to keep such medication out of a child’s reach or from misuse by a family member or friend. Keeping overdoses for possible future ingestion is obviously dangerous, especially when our nation is in the middle of an opioid crisis that now kills almost 100 Americans every day.

However when it comes to unused lethal overdoses in assisted suicide, Death with Dignity’s advice is that:

“Anyone who chooses not to ingest a prescribed dose or anyone in possession of any portion of the unused dose must dispose of the dose in a legal manner as determined by the federal Drug Enforcement Agency or their state laws, if any.”

CONCLUSION

When even assisted suicide supporters admit data suggests that the “distress prompting patients to request these lethal medications primarily stems from their fear over losing control at the end of life” but claim that the more than 33% who don’t take the prescribed lethal overdose should still have it to supposedly “get great comfort in knowing they have access to it if they need it”,  physician-assisted suicide is further exposed as a terrible response to human fear and despair.

As our National Association of Pro-life Nurses states, patients need us to take their hands, not their lives.

 

Another Threat to Conscience Rights for Medical Professionals

2012 New York Times:  “Instead of attempting to legalize physician-assisted suicide, we should focus our energies on what really matters: improving care for the dying — ensuring that all patients can openly talk with their physicians and families about their wishes and have access to high-quality palliative or hospice care before they suffer needless medical procedures. The appeal of physician-assisted suicide is based on a fantasy. The real goal should be a good death for all dying patients.” (Emphasis added)

2016, Journal of the American Medical Association: “CONCLUSIONS AND RELEVANCE Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices. (Emphasis added)

The writer of these conflicting views on assisted suicide is Ezekiel J. Emanuel, M.D., PhD., a very influential doctor who is Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania and one of the architects of Obamacare. He is considered an expert on medical ethics who speaks and writes prolifically for both medical journals and general media outlets.

NO CONSCIENCE RIGHTS?

Unfortunately, Dr. Emmanuel is now opposing conscience rights for those of us who object to participating in deliberate death decisions like abortion and assisted suicide.

In his April, 2017 New England Journal of Medicine article “Physicians, Not Conscripts — Conscientious Objection in Health Care” , Dr. Emanuel writes:

“Health care professionals who conscientiously object to professionally  contested  interventions  may  avoid  participating  in them directly, but, as with military conscientious objectors, who are required to perform alternative service, they cannot completely absent themselves from providing  these  servicesConscientious  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 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. “

……

Although the political process may continue unabated, and courts may deem conscience clauses to be legal, it is incumbent on professional societies to affirm professional role morality and authoritatively articulate the professional ethical standards to which all licensed health care professionals must adhere. 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

Please reread that last sentence “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.

Some may think this cannot happen in the U.S. or that actions like assisted suicide only occur privately in a patient’s home but, as I wrote in my last blog “Outrage: The American Nurses Association Approves Physician Assisted Starvation Suicide”, the American Nurses Association recently published a position statement “Nutrition and Hydration at the End of Life” that states:

” Decisions about accepting or forgoing nutrition and hydration will be honored, including those decisions about artificially delivered nutrition as well as VSED.”

and

“People with decision-making capacity have the right to stop eating and drinking as a means of hastening death.”

(All emphasis added)

In reality, nurses face an even greater risk than doctors who refuse to participate or refer patients making death decisions.

After assisted suicide was legalized in Oregon, the Oregon Nurses Association quickly issued guidelines for nurses that included these two points for “Nurses Who Choose Not to Be Involved”: “You may not:”

  • Subject your patients or their families to unwarranted, judgmental comments or actions because of their decision to continue to provide care to a patient who has chosen assisted suicide.

  • Abandon or refuse to provide comfort and safety measures to the patient.”  (All emphasis added)

Abandonment is a very big deal in nursing. To be accused of abandoning a patient can result in termination, loss of license or even a lawsuit.

But even if you are not a health care professional, you should be concerned about ethical health care professionals being forced out of health care by taking Dr. Emmanuel’s advice that there are only “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. ”

Can any of us really trust a health care system that only accepts medical professionals who are just as willing to help end our lives as they are to  care for us?

Outrage: The American Nurses Association Approves Physician Assisted Starvation Suicide

“People with decision-making capacity have the right to stop eating and drinking as a means of hastening death.”

and

“There is an extensive knowledge base to help manage the burden of most physical symptoms (of voluntary stopping of eating and drinking). Symptom control is imperative.”

With these quotes from its’ recent position statement “Nutrition and Hydration at the End of Life”, the American Nurses Association (ANA) effectively gives up the principle of opposing physician assisted suicide.

Last November, I wrote a blog when I was alerted off that the ANA  was drafting a new position statement on food and water. The nurse who alerted me included a site for public comment and I urged others to participate as I did.

Now I am saddened but not really surprised to find that final result was the endorsement of decisions withdrawing food and water, even by mouth, and even if the patient is not imminently dying. The statement also explicitly included people with “severe neurological conditions” and dementia.

As the ANA statement makes clear “Decisions about accepting or forgoing nutrition and hydration will be honored, including those decisions about artificially delivered nutrition as well as VSED.” (Emphasis added) VSED stands for voluntary stopping of eating and drinking and is promoted by Compassion and Choices, the former Hemlock Society, as a legal alternative in states without assisted suicide laws.

Here are the ANA’s recommendations on food and water in its’ entirety from the document:

“ANA Recommends that:

  • Nurses recognize those situations when nutrition and hydration can no longer benefit a patient, and adhere to clinical standards that include providing nutrition and hydration only to patients for whom it is indicated.

  • Patients with decision-making capacity—or their surrogates, who are relying on the patients’ preference or have knowledge of the person’s values and beliefs—will be supported in decision-making about accepting or refusing clinically appropriate nutrition and hydration at the end of life.

  • Nurses will have adequate and accurate information to understand patients’ cultural, ethnic, and religious beliefs and values regarding nutrition and hydration at the end of life. Patients’ views and beliefs should be respected.

  • Nurses will support patients and surrogates in the decision-making process by providing accurate, precise and understandable information about risks, benefits and alternatives.

  • Decisions about accepting or forgoing nutrition and hydration will be honored, including those decisions about artificially delivered nutrition as well as VSED.

  • People with decision-making capacity have the right to stop eating and drinking as a means of hastening death.” (All emphasis added)

The ANA position statement admits “There is some consensus (though not universal agreement) that VSED can be an ethical and legal decision”, but in regard to conscience rights, the document only states that  “Nurses who have an informed moral objection to either the initiation or withdrawal of nutrition or hydration should communicate their objections whenever possible, to provide safe alternative nursing care for patients and avoid concerns of patient abandonment.” (Emphasis added)

DOES THE ANA SPEAK FOR ALL NURSES?

The American Nurses Association claims it is the “voice of nursing” and “the nation’s only full-service professional organization that represents the interests of the nation’s 3.6 million registered nurses.”

However, the ANA does not give out its actual membership numbers and the vast majority of the nurses I have encountered over many decades do not belong to the ANA.

I used to belong to the ANA many years ago and was even active in my state’s chapter, hoping to get support for conscience rights after the Nancy Cruzan feeding tube case. But I  became disillusioned when the organization became more politically active and took controversial positions without notifying members. I eventually joined and became active in the National Association of Pro-Life Nurses.

Medical ethics and law has radically changed in just a few decades and now we are confronting physician assisted suicide and other deliberate death decisions.

At the very least, we health care professionals need our conscience rights honored and protected so that we can truly and ethically care for our patients. Unfortunately, the ANA is hurting rather than helping that objective when it comes to nurses refusing to participate in deliberate death decisions.

 

 

 

Baby Doe and Karen-35 Years Later

When I started nursing school 50 years ago, medical ethics was not a course but rather common sense principles incorporated into our education. There was no controversy about not harming patients, integrity, equality of treatment regardless of status, etc.

So, of course, abortion and euthanasia were unacceptable and even thinkable in those days.

I particularly remember one teacher who told us about the hypothetical situation of a child with Down Syndrome whose parents wanted to let their baby die and how we naturally had to put the interests of the child first. This kind of protection for patients was routine both ethically and legally in those days.

In 1982, I remembered that situation when Baby Doe,  a newborn baby boy with an easily correctable hole between his esophagus (food pipe) and trachea (windpipe), was denied this lifesaving surgery by his parents and a judge because he also had Down Syndrome. Six days later, Baby Doe starved and dehydrated to death while his case was being appealed to the Supreme Court after the Indiana Supreme Court ruled 3-1 against saving him.

My husband, a doctor, and I were appalled when we first read about Baby Doe in the newspaper and my husband suggested that we adopt the baby ourselves and pay for the surgery.

I said yes but with some reluctance since I was already pregnant with our third child and our other children were just 5 and 3. But who else was better situated than us to care for a child with a disability who needed surgery?

In the end, we were too late to save Baby Doe. We found out that Baby Doe’s parents had already rejected the many other families who tried to adopt him.

Five months later, I gave birth to my daughter Karen who also happened to have Down Syndrome and a life-threatening condition that needed surgery.  Karen was born with a complete endocardial cushion defect of the heart  that the cardiologist told us was inoperable. We were told to just take her home and our baby would die within 2 weeks to 2 months.

I was heartbroken and cried for 3 days in the hospital before I finally got mad. My obstetrician never came back to check on me in the hospital even though I had a C-section and I demanded a second opinion on her heart condition in case the cardiologist was biased against children with Down Syndrome.

I insisted on leaving the hospital early with my daughter because I wanted as much time as possible with her and especially because I realized that I needed to research Karen’s heart condition to effectively advocate for her.

I joined the St. Louis Down Syndrome Association which helped me enormously, especially with my research and emotional support. Fortunately, it turned out that the initial prognosis was wrong and the cardiologist told us that Karen’s heart could be fixed with just one open-heart operation at age 6 months.

I was elated until the cardiologist told me that he would support my decision to operate “either way”, meaning I could refuse surgery just like Baby Doe’s parents.

I was furious and told him that the issue of Down Syndrome was irrelevant to Karen’s heart condition and that my daughter must be treated the same as any other child with this condition. I also added that if he were biased against people with Down Syndrome, he could not touch my daughter.

To his credit, this doctor recognized the injustice and because of Karen, he eventually became one of the strongest advocates for babies with Down Syndrome.

Unfortunately, I ran into other medical professionals caring for Karen who were not so accepting. One doctor actually told us that “people like you shouldn’t be saddled with a child like this” and another doctor secretly wrote a DNR (do not resuscitate) order against my instructions at the time. It was then that I realized that my so-called “choice” to save my daughter was really a fight.

Tragically, Karen died of complications of pneumonia when she was just 5 ½ months old and just before her scheduled open-heart surgery. I will always miss her but I am so grateful that I was her mother. Karen changed many lives for the better, especially mine.

I became active in the Down Syndrome Association, promoted President Reagan’s “Baby Doe” rules ,  provided babysitting/respite for many children with various disabilities, and even got a chance to talk to then Surgeon General C. Everett Koop about setting up a national hotline for new parents of children with disabilities to find resources.

But most importantly, I was determined to find out what had happened to medical ethics  over the years since nursing school that resulted in the Baby Doe tragedy and hopefully help reverse the mindset that people with disabilities were “better off dead”.

What I discovered was a landmark 1979 book titled “Principles of Biomedical Ethics” written by Tom Beauchamp PhD, a professor of philosophy, and James Childress PhD, a theologian and also a professor of philosophy. Neither one had a medical degree.

They devised these four principles for medical ethics:

  • Autonomy – The right for an individual to make his or her own choice.
  • Beneficence – The principle of acting with the best interest of the other in mind.
  • Non-maleficence – The principle that “above all, do no harm,” as stated in the Hippocratic Oath.
  • Justice – A concept that emphasizes fairness and equality among individuals.

Although all these principles were considered equal, it wasn’t long before autonomy became the cornerstone principle in ethics and law, ultimately leading not only to Baby Doe but also to the legalization of assisted suicide/euthanasia.

Ironically, all these principles have been used to justify cases like Baby Doe’s as well as assisted suicide/euthanasia.

Beneficence and non-maleficence have become a ways to see death as an actual blessing to real, perceived or potential suffering. Ominously, the justice principle has become the rationale for rationing under the guise of supposedly not wasting scarce healthcare resources .

CONCLUSION

35 years after Baby Doe, some things like medical technologies and education for people with disabilities are better but many things like assisted suicide/euthanasia have pushed the ethics of death even farther and are a threat to all of us and our loved ones.

The Baby Doe tragedy should have been a fire alarm for the evils we see today but it is never too late or impossible to try to promote a culture of respect for all lives.

My Oral Submission to the New Zealand Health Committee Regarding Physician-assisted Suicide on March 5, 2017

As a nurse and legal consultant in the USA with 47 years of experience in the most challenging areas of medicine such as critical care, oncology, burn unit and hospice, I have seen many of the most challenging cases in medicine. I also have professional and personal experience with suicidal people, including my own 30 year old daughter Marie who died using an assisted suicide technique that she found searching the internet and after a 16 year struggle with drug addiction. I have worked with many suicidal people, including some with terminal illness. To my knowledge, my daughter was the only one lost to suicide.

I have previously submitted written testimony about physician-assisted suicide and I would like to follow up with two crucial issues that I feel must be addressed.

First I will discuss how physician-assisted suicide empowers doctors, not patients. Second, I’ll share a nurse’s perspective.

1. Physician-assisted suicide empowers doctors, not patients.

Society has long insisted that health care professionals adhere to the highest standards of ethics as a form of protection for society. The vulnerability of a sick person and the inability of society to monitor every health care decision or action are powerful motivators to enforce such standards.

However in physician-assisted suicide, unlike any other medical intervention, any licensed doctor of any experience or specialty is granted immunity from “civil or criminal liability or professional disciplinary action for participating in good faith compliance “with an assisted suicide law[1].  The doctor or doctors involved are the ones to decide whether or not the patient is eligible, not the patient.

All the doctor is required to do is fill out a prescription and state forms. The usual standards for caring for a suicidal person including  intensive management[2]  are changed in physician-assisted suicide to “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.”[3] (Emphasis added). Not surprisingly, only 3.8% of people using physician-assisted suicide in Oregon were referred for psychiatric evaluation in 2016[4].

This is dangerous medical discrimination in treatment standards for suicidal people.

In addition, since the doctor is not required to be present or examine the patient after death, any complications or other problems must be self-reported by the doctor to the state. Even the death certificate must be falsified to report the death as from natural causes rather than the lethal overdose.[5]  This violates the standards set by the Centers for Disease Control which require accuracy because, among other issues, “The death certificate is the source for State and national mortality and is used to determine which medical conditions receive research and development funding, to set public health goals, and to measure health status at local, State, national, and international levels.”[6]

The  immunity protections and the secrecy of even the minimal self-reporting standards in US assisted suicide laws eliminates the possibility of future potential lawsuits or prosecutions and keeps the myth of “no problems, no abuses” alive.

2. A Nurse’s Perspective

The dangers of the legalization of physician-assisted suicide are especially acute for us nurses. Unlike doctors, we nurses cannot refuse to care for a patient in a situation like assisted suicide unless another willing nurse can be found which can be impossible. If we do refuse, that is considered abandonment and cause for discipline and even termination. And we are necessarily involved when the assisted suicide act occurs in home health, hospice or health care facility even though the prescribing doctor is not required to be there.

And these deaths are not guaranteed quick, painless or even possible in some circumstances. As a new December 21, 2016 Kaiser Health News article revealed, doctors are trying new drugs because the old drugs are becoming too expensive and taking too long to work. Unfortunately, some new alternative drugs have “turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain”.[7]

Like most nurses, I have worked over the years with a variety of doctors who are at various points on the spectrum on competency and integrity.

Years ago, I was threatened with termination after I refused to increase a morphine drip “until he stops breathing” on a man who would not stop breathing after his ventilator was removed and no other nurse was available to take over the patient. The patient was presumed to have had a stroke when he did not wake up from sedation after 24 hours. I reported the situation up the chain of command at my hospital but no one supported me. I loved my profession and at that time, I was the sole support of three young children but I knew that nothing was worth betraying the trust of my patients.

I escaped termination that time but I refused to back down. Soon after, every nurse on a medical division of nurses refused to give an overdose to a patient and told the doctor that he would have to give it himself. The doctor cancelled the order.

Legalizing physician-assisted suicide can force nurses like us to leave healthcare, leaving no reliable safe haven for people who don’t want to end their lives.

Does anyone really want to entrust our healthcare system just to people who are comfortable with ending lives? I don’t.

FOOTNOTES

[1] “Oregon Revised Statute. 127.885s.01. Online at: https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx

2 “Evaluation and Treatment of the Suicidal Patient” . American Family Physician. Online at http://www.aafp.org/afp/2012/0315/p602.html

3 “Evaluation and Treatment of the Suicidal Patient” .American Family Physician. Online at http://www.aafp.org/afp/2012/0315/p602.html

4 “Oregon Death with Dignity Act Date Summary” .Online at https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf

5 : “Washington state “Death with Dignity Act”. Online at http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/DeathwithDignityAct/DeathCertificateInstructions

6 CDC Medical Examiners’ and Coroners’ Handbook on Death Registration and Fetal Death Reporting”. CDC. Online at https://www.cdc.gov/nchs/data/misc/hb_me.pdf

7 “Docs  In Northwest Tweak Aid-In-Dying Drugs To Prevent Prolonged Deaths” by JoNel Aleccia. Kaiser Health News. February 21, 2017. Online at http://khn.org/news/docs-in-northwest-tweak-aid-in-dying-drugs-to-prevent-prolonged-deaths/

My Submission to the AMA Opposing Neutrality on Physician-Assisted Suicide

Amid conflicting reports about whether or not the American Medical Association was going to consider a position of neutrality on physician assisted suicide, I was informed that the AMA’s Council on Ethical and Judicial Affairs was collecting data, position statements, etc. for consideration of assisted suicide and other topics before the June AMA Annual meeting. The deadline for submissions was February 15.

The following is my submission titled “Neutrality on physician assisted suicide also hurts nurses”

Dear AMA,

I have been a registered nurse since 1969. After working in critical care, hospice, home health, oncology, dialysis and other specialties for 45 years, I am currently working as a legal nurse consultant and volunteer as well as spokesperson for the National Association of Pro-Life Nurses. Over the years, I have cared for many suicidal people as well as people who attempt suicide.

I have served on medical and nursing ethics committees, served on disability and nursing boards. I have written and spoken on medical ethics-especially end of life issues-since 1984.

The dangers of the legalization of physician-assisted suicide are especially acute for us nurses. Unlike doctors, we nurses cannot refuse to care for a patient  in a situation like assisted suicide unless another willing nurse can be found which can be impossible. If we do refuse, that is considered abandonment and cause for discipline and even termination. And we are necessarily involved when the assisted suicide act occurs in home health, hospice or health care facility even though the doctor is not required to be there.

marievalko

Marievalko Picture of Marie Valko 1979-2009

As a nurse and the mother of a suicide victim (see picture above), I am alarmed by reports that the AMA is considering a position of neutrality on physician-assisted suicide. I beg you to uphold the legal and ethical standard that medical professionals must not kill their patients or help them kill themselves. Suicide is a tragedy to be prevented if possible, not a civil right.

MY DAUGHTER KILLED HERSELF USING AN ASSISTED SUICIDE TECHNIQUE

In 2009, I lost a beautiful, physically well 30-year-old daughter, Marie, to suicide after a 16-year battle with substance abuse and other issues. Her suicide was like an atom bomb dropped on our family, friends and even her therapists.

Despite all of our efforts to save her, my Marie told me that she learned how to kill herself from visiting suicide/assisted suicide websites and reading Derek Humphry’s book Final Exit. The medical examiner called Marie’s suicide technique “textbook final exit” but her death was neither dignified nor peaceful.

Marie was not mere collateral damage in the controversy over physician-assisted suicide. She was a victim of the physician-assisted suicide movement, seduced by the rhetoric of a painless exit from what she believed was a hopeless life of suffering.

SUICIDE CONTAGION

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, these two young people received help and were saved, but suicide contagion, better known as “copycat suicide”, is a well-documented phenomenon. Often media coverage or publicity around one death encourages other vulnerable people to commit suicide in the same way.

STUDY SHOWS LEGALIZING PHYSICIAN-ASSISTED SUICIDE IS ASSOCIATED WITH AN INCREASE RATE OF TOTAL SUICIDES

A 2015 article in the Southern Medical Journal titled “How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?” came to these conclusions:

“Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.”

THE HEALTH AND ECONOMIC COSTS OF SUICIDE

My Marie was one of the almost 37,000 reported US suicides in 2009. In contrast, only about 800 assisted-suicide deaths have been reported in the past 16 years in Oregon, the first state to legalize physician-assisted suicide. According to the Centers for Disease Control (CDC) suicide was the 10th leading cause of death for Americans in 2012, with “More than 1 million people reported making a suicide attempt in the past year” and “More than 2 million adults reported thinking about suicide in the past year.” The CDC estimates that suicide “costs society approximately $34.6 billion a year in combined medical and work loss costs”, not to mention the emotional toll on families.

Obviously our real health-care crisis here is a staggering and increasing rate of suicides, not the lack of enough assisted suicides.

BRITTANY MAYNARD

There was a media frenzy in October 2014 when Brittany Maynard, a young newlywed woman with a brain tumor, announced plans to commit physician-assisted suicide on November 1 and raise money to have physician-assisted suicide legalized in all US states. There was an immediate and unprecedented media frenzy surrounding Ms. Maynard’s tragic story that routinely portrayed her pending assisted suicide as “heroic” and even counting down the days to her suicide. Personally, I thought this looked like a crowd on the street shouting for a suicidal person on a window ledge to jump.

In the end, Brittany hesitated for a day before she went through with her pledge to take the lethal overdose.

Now, assisted suicide supporters even deny that physician-assisted suicide is suicide, insisting that media stories use euphemisms like “aid-in-dying” and “death with dignity” in cases like Ms. Maynard’s to make assisted suicide more palatable to the public. However, this defies common sense when the definition of suicide is the intentional taking of one’s own life.

PHYSICIAN-ASSISTED SUICIDE AND MEDICAL DISCRIMINATION

I have been a registered nurse for 47 years, working in intensive care, oncology, hospice and home health among other specialties. Personally and professionally, I have cared for many people who attempt or consider killing themselves.

Some of these people were old, chronically ill or had disabilities. Some were young and physically healthy. A few were terminally ill. I cared for all of them to the best of my ability without discrimination as to their condition, age, socioeconomic status, race or gender. I will do anything to help my patients — except kill them or help them kill themselves.

Suicide prevention and treatment works, and the standards must not be changed just because some people insist their desire for physician-assisted suicide is rational and even a civil right.