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Bioethikos: Bringing Life to Bioethics

Archive for the ‘end of life’ Category

 

New ‘Incentives’ to Choose Death

Wednesday, February 1st, 2017 by Dr. Dennis Sullivan

As we have commented in this blog recently, the American Medical Association (AMA) is thinking of reversing its opposition to physician-assisted suicide (PAS). Canada and five U.S. states have made this practice legal, and “aid in dying” is now a part of everyday medical discussions. Here are a few more reasons to worry about all this:

In January, the Canadian Medical Association Journal published a “Cost Analysis of Medical Assistance in Dying in Canada.” Their conclusion: patients that choose PAS could save the national healthcare system millions of dollars over more expensive palliative care. My colleague Phillip Thompson discusses this issue in his blog here.

 

More grease for this slippery slope comes from the prestigious Journal of Medical Ethics. The December issue features an article entitled, “Organ Donation after Medical Assistance in Dying” (link). PAS may become more attractive for some terminally-ill patients if they could donate their organs. So add the subtle social coercion of doing a “noble” act as another reason to choose PAS. John Holmlund reacts to the trend here.

 

Those who endorse these ideas are acting compassionately, to be sure, but with individual radical autonomy as the underlying principle, rather than an absolute commitment to the sanctity of human life. May God have mercy on all of us as we struggle to find our way in the modern context of managed health care.

The New Push for Assisted Suicide

Tuesday, December 6th, 2016 by Dr. Dennis Sullivan

Mortar 

There is a growing movement within the American Medical Association (AMA) to legalize “aid in dying,” otherwise known as physician-assisted suicide. The current ethics statement of the AMA, with roots going back thousands of years, states the following:

It is the policy of the AMA that:
1.Physician assisted suicide is fundamentally inconsistent with the physician’s professional role.
2.It is critical that the medical profession redouble its efforts to ensure that dying patients are provided optimal treatment for their pain and other discomfort.
3.Physicians must resist the natural tendency to withdraw physically and emotionally from their terminally ill patients.
4.Requests for physician assisted suicide should be a signal to the physician that the patient’s needs are unmet . . .

 

Now this commonsense, compassionate standard is giving way to something more radical. At its meeting last June, the AMA’s Council for Ethical and Judicial Affairs approved the study of “aid in dying,” prior to its next annual meeting in 2017. The stated goal is to consider going “neutral” on assisted suicide. This would be an historical departure for the AMA.

There are many reasons this is a bad idea. It impairs the trust relationship between a doctor and her patients. It would detract from modern efforts to improve  palliative care and hospice. And given our utilitarian society that so devalues the sanctity of life, a “right to die” could easily morph into a “duty to die.”

All of this is bad medicine, and we should oppose it.

Current AMA Ethics Statement

New Challenges to Brain Death

Wednesday, February 10th, 2016 by Dr. Dennis Sullivan

heart-beat

Since 1969, the Harvard Criteria on Brain Death have provided guidelines for declaring a patient dead, even if the heart is still beating. This has allowed for a significant expansion of organ transplants. Donation occurs while the organ is still viable, resulting in better outcomes for recipients. As a legal, ethical determinant of the end of life, brain death is enshrined as firm doctrine in all 50 states.

Two recent cases in the news, however, have called brain death into question. In Oakland, California, 13 year-old Jahi McMath suffered a catastrophic complication of an operation to treat her sleep apnea. In Forth Worth, Texas, Marlese Munoz, 14 weeks pregnant, suffered a massive pulmonary embolism. In both cases, the patient was declared brain dead. In the case of Jahi, her parents insisted that life support be maintained, in the vain hope that she might improve and survive. With Marlese, her parents wanted to have life support discontinued, but the state intervened to keep her on the ventilator because of the pregnancy.

There are separate ethical issues in the Munoz case, but one thing should be clear: neither parents nor the state should have the power to determine when a patient has died. That is a clinical determination, and brain death is well established in ethics and law. Now, it is certainly reasonable for doctors to permit families to “say goodbye” to a loved one before turning off life support, but that does not change the facts. It is not a matter for debate: both California and Texas law permit doctors to end treatments under such circumstances, even over family objections, and protect physicians against liability for doing so.

Please note: Brain death is not an assault on the sanctity of human life. Religious voices that object to brain death often assert a sort of “Christian vitalism,” that claims physical life should trump everything, perhaps even God’s sovereignty. Modern medical ethics is complicated enough without adding this confusion.

Understanding Brain Death
Controversies about Brain Death
Arthur Caplan on Brain Death

Looking for Hope: Suicide Prevention

Tuesday, August 18th, 2015 by Dr. Heather Kuruvilla

Hold_my_handImage courtesy of Wikimedia Commons

by Dr. Heather Kuruvilla

Suicide is the 10th leading cause of death in the US, and is the most common cause of death after cancer and heart disease. The most recent statistics for suicide compiled by the American Foundation for Suicide Prevention show a yearly increase in the number of suicides every year since 2000.  In 2013, someone in the US died from suicide every 12.8 minutes.

Suicide is always tragic, and is also preventable.  It is estimated that over 90% of people who commit suicide were suffering from mental illness at the time of their death.  Depression is the mental illness most often correlated with suicide, though bipolar disorder and other personality disorders may also play a role.

Underdiagnosis of mental illness likely plays a key role in suicides, which means that health care professionals can help prevent this tragedy.  Treating persons holistically, recognizing the interdependence of physical and mental well-being, is of crucial importance.

As Christians, we recognize the impact that the Fall and the Curse have on all of creation.  Certainly the whole person is subject to disease, both physical and mental.  Genetic and epigenetic mutations, biochemical disorders, and anatomical dysfunctions will plague mankind until the Lord’s return.  If we wish to alleviate suffering, we need to wisely steward all of the tools at our disposal, including counseling, pharmaceuticals, and human interaction.

For too long, sufferers of mental illness have felt stigmatized, often not reaching out for needed treatments.  This needs to stop.  A holistic view of personhood can truly make a difference.

 

Balancing Faith and Science at the End of Life

Tuesday, July 7th, 2015 by Dr. Dennis Sullivan

caduce

(by guest blogger Sam Franklin)

My mother, luckily, died in the presence of six of her closest relatives — all of whom were born-again believers. Other patients aren’t as lucky.

Consider “Ms. Ellen,” who spent her last days surrounded only by medical professionals — none of whom affirmed her Christian faith:

Ms. Ellen felt the lack of sensitivity and respect for her faith, but she wanted the entire medical team to know that she knew she would not be living much longer. Why? Because hope for her at this critical moment was not rooted in anticipating a miraculous healing of her body, but in a need for spiritual peace and physical comfort as she approached the end of her life . . .

Unfortunately, Ms. Ellen would be robbed of this opportunity as she quietly lay in her bed, now questioning those more than 21,800 hours of hope-filled moments that she had tucked away over the many years of her life for a time such as this.

 

In my mother’s case, every decision she made reflected her beliefs. Unfortunately, Ms. Ellen’s beliefs influenced none of her medical team’s decisions. Nonetheless, even when patients tragically die alone, a Christian healthcare professional can help final decisions affirm deeply-held beliefs, regardless of their religious background.

Let’s take time to ask patients about their faith and how it impacts their last few days. We shouldn’t force our faith on them, but hopefully, we may have an opportunity to share the gospel. Together, patients and healthcare providers can agree upon appropriate treatment, and in doing so, we address an oft-neglected aspect of patient care: the soul.

NY Times Opinion Piece

Remembering Spring in the Midst of Winter

Monday, March 9th, 2015 by Dr. Heather Kuruvilla

1280px-Colorful_spring_gardenPhoto Courtesy  of Wikimedia Commons

by Dr. Heather Kuruvilla

Just days ago, much of the nation was facing wind chill advisories and subzero temperatures.  But walking around my neighborhood yesterday, I heard the sounds of rushing water as the snow melted, the song of birds, and the honking of geese.  The sun was shining, and the smell of spring was in the air.  We knew it was coming.  For weeks now, folks I’ve encountered, whether in line at the post office or ringing up my groceries at Wal-Mart, have been encouraging each other with the hope that “spring is on its way”.

Even on the coldest day, no one doubted that spring was coming.  We’ve seen the seasons change again and again. The pattern of resurrection is woven throughout the fabric of nature.  For every winter, there is a spring.

The fact that we’re still talking about Brittany Maynard proves that the “winter” of our lives is often difficult.  Brittany  Maynard, diagnosed with terminal cancer, chose to end her life last November rather than face the certain pain that lay ahead of her.  I think any of us who has seen the ravages of cancer can empathize with what must have been an agonizing decision.

Her decision illustrates our very basic, human need for hope; the hope that winter will give way to spring.

As Christians, we hold to the hope of resurrection, knowing that the darkness of Good Friday gave way to the triumph of Easter Sunday.  Christ, then, is our ultimate hope.

 

But a terminal patient needs “short-term” hope, too.  What are some ways we can help suffering persons to embrace hope?  According to Cancer Research UK:

Everyone needs to have some sense of hope for their future. When you are dying, this hope may be that you can visit a place that you love. Or you may hope that you can enjoy being with your family and friends for a time. Some people believe that there is life after death and find that this gives them hope…many people hope for comfort, dignity, friendship and love to surround them in their final days.

 

That means every one of us has the potential to be a hope-giver.  For more information on helping the terminally ill, check out these resources:

Hospice Foundation of America

Get Palliative Care

 

Asking the wrong question?

Monday, February 2nd, 2015 by Dr. Heather Kuruvilla

health-care-md

 

(by guest blogger: Erica Graham)

How do we, as a society, decide when someone is mature enough to make their own healthcare decisions?  Recently, the Connecticut Supreme Court ruled that 17 year old Cassandra C. must undergo chemotherapy to treat her Hodgkin’s lymphoma, even though she does not wish to receive treatment.  While waiting for the court’s decision, Cassandra was taken into state custody, and confined to a room at Connecticut Children’s Medical center with a guard posted outside her door to prevent her from leaving.  This clear violation of Cassandra’s autonomy has sparked dialogue about when a teen is mature enough to make end of life health care decisions. Currently, teens can legally make some healthcare decisions, like whether or not to get an abortion, without parental consent.  Most of the discussion surrounding Erica’s case has focused on her age and maturity level. Personally, I know 17 year olds who are mature enough to make this decision, as well as some who are not mature enough. Maturity is not simply a matter of age.

So how should maturity be determined in cases like these? I propose an analysis of her reasoning, not her age, should be used to determine her level of maturity. Cassandra’s main reason for not wanting to receive chemotherapy, even though the odds of successful treatment in her case are high, was because she didn’t want to put poisons in her body. Her reasoning, not her age, shows her lack of maturity to make this decision. Her reasoning is not founded on carefully considered risks and benefits like that of a mature adult. It appears her reasons are built on fear and her lack of understanding of a treatment that will most likely save her life. While not every adult is mature enough to consider risks and benefits carefully, the law has the ability, in the case of a teenager, to prevent them from making poor decisions that they may not fully understand.

Certainly some adults refuse chemotherapy, but Cassandra’s case is a different set of circumstances. By undergoing chemotherapy she has an 85% chance of living for many more decades. Basic logic dictates that this benefit overrules the pain and inconvenience of chemotherapy treatments. Despite the fact that this decision violates Cassandra’s autonomy, I am glad the court can intervene when a lack of mature reasoning and logic is evident in a teen. I agree with the court’s decision on the grounds that Cassandra didn’t demonstrate mature moral reasoning.

CNN Article

NBC News Article

Ezekiel Emanuel is Wrong

Monday, October 6th, 2014 by Dr. Dennis Sullivan

Physician-ethicist Ezekiel Emanuel seems to love being at the center of controversy. One of the architects of Affordable Care Act, he is director of Clinical Bioethics at the NIH and chairs the Department of Medical Ethics & Health Policy at U Penn. He has frequently (and often unfairly) been criticized for pointing out the flaws in our current health care system, which he describes as  “truly dysfunctional” (Wash. Post). Worse of all, many think of him as a real utilitarian pragmatist, and have accused him of trying to ration health care. He has denied this.

So it comes as a bit of a shock to see Emanuel’s latest article in the Atlantic, “Why I Hope to Die at 75.” He claims that he will stop using the health care system at age 75. He puts it this way:

[H]ere is a simple truth that many of us seem to resist: living too long . . . renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic (source below).

Emanuel goes on to say that this is no death wish, but he feels that he may no longer be productive and enjoy things at age 75. So he hopes that will be the end. If he has cancer or develops pneumonia, he will refuse chemotherapy or antibiotics. His last colonoscopy will be at age 65. And when he hits 75, no flu shot.

Why this somber navel-gazing with 18 years to go?  What is Emanuel trying to prove? He is implying, I think, that there is no more to life than our contributions to society. He is subtly saying that older patients are selfish to use so many health care resources, and that we should all just forget about living long lives. Ah, but that of course is the ultimate lie that so many functionalists would have you believe. We are valuable because of what we do, not for who we are.

On the other hand, the Christian view of the human person teaches that we are valuable for our own right. Each of us was made “a little lower than God,” and our Creator has crowned us “with glory and majesty” (Psalm 8:5, NASB). The elderly deserve honor; they have the right to enjoy the fruit of their labor. Our value is intrinsic, and does not depend on our age or our abilities.

Don’t let a pontificating utilitarian make you feel guilty for living out the full lifespan that God has allotted you.

Article in The Atlantic

Death Panels Redux?

Tuesday, September 30th, 2014 by Dr. Dennis Sullivan

A recent report by the Institute of Medicine is entitled: Dying in America. Among other things, it documents how poorly Americans understand their options at the end of life. The IoM recommends that doctors get paid for having end-of-life discussions with their patients. This idea was unpopular back in 2009, and led some to accuse the government of trying to establish “death panels,” designed to limit treatment options and to ration health care.

But this is a distortion. According to the IoM report:

The [2009] provision would have reimbursed clinicians for the time spent in advance care planning with patients. Such conversations would have included discussion of the documents that can help ensure that patients’ wishes regarding care are followed in the event they become unable to express them (source listed below).

Recent polls have show that the majority of Americans strongly support such discussions, and a growing number have established advance directives for themselves and their loved ones. Nonetheless, a recent Forbes article makes the alarming claim that death panels are “on the rebound.” Why all this suspicion?

The main reason may be that advance directives (e.g., living wills or durable powers of attorney for health care) are not perfect, and they are not always honored. A patient’s prognosis is not always easy to predict. And families are sometimes reluctant to go along with their loved ones’ wishes, even when they are clearly stated.

Yet for all of these concerns, greater clarity in the face of serious illness is not a bad thing. In our technologically-advanced society, we are often able to keep the bodily shell alive, which merely prolongs the dying process. For people of faith, this is unnecessary, for a better life awaits us.

We should all have advance directives – and doctors should be paid for advising us about them.

Dying in America

Forbes Online Article

Physicians and Lethal Injection

Tuesday, June 24th, 2014 by Dr. Dennis Sullivan

Our justice system is embroiled in controversy in recent years, over a procedure that a majority of Americans support: the death penalty. Older methods, including firing squad, electric chair, or gas chamber, have been supplanted by lethal injection. This is thought to be more humane, and therefore less in conflict with the Eighth Amendment proscription of “cruel and unusual punishment.”

But the use of lethal injection has brought with it a whole new set of issues, as revealed by several “botched executions” in recent months. In Ohio last January, Dennis McGuire’s execution took 25 minutes, called by one defense attorney “a failed, agonizing experiment.” In April, Clayton Lockett’s lethal injection procedure by Oklahoma officials lasted 43 minutes, and only ended when the condemned suffered a massive heart attack.

Most Americans support the death penalty in the United States, though the margin has become much smaller in recent years. In 1996, 78% were pro-death penalty; in 2013, that had dropped to 55% (Washington Post). This is a huge shift in public opinion, and these recent events may have a further impact.

In response, there has been a renewed call for physicians to get involved. After all, properly applied professional medical judgment could ensure that the condemned prisoner is truly unconscious before injecting agents to stop the heart or suppress respirations. This would greatly reduce fears of violating Eight Amendment safeguards. A recent legal committee on death penalty reform has recommended that “Jurisdictions should ensure that qualified medical personnel are present at executions and responsible for all medically-related elements of executions” (source).

But this is a truly dangerous recommendation. For over 2400 years, the Hippocratic tradition in medicine has expressly forbidden participation in killing, and this violates the codes of ethics of both the American Medical Association and the American Nurses Association. Even the practice of assisted suicide is forbidden in both codes, and at least that has the goal of relieving suffering.

No, healthcare professionals should strongly resist this idea, and refuse to have anything to do with state-sanctioned killing. Regardless of concerns about the comfort of the procedure, the death penalty is not intended to be therapeutic. For all of the recent controversy, this is not a problem that doctors or nurses can solve.