About Medicine & Morality
AUGUST 2000
BIOETHICS WATCH
By Nancy Valko, RN
Topics in this issue:
Euthanasia and Death Ethics
(Includes a link to Archbishop Rigali's Statement on Assisted Nutrition and Hydration)
Less Aggressive Treatment Urged for Alzheimer's Patients
Euthanasia for Minors in Holland
Suicide Not a Religious Right, Court Says
Doctors Who Kill
Contraception: 40th Anniversary of Pill
EUTHANASIA AND DEATH ETHICSby Nancy Valko, RN
1. Catholic Hospital Ethics Committee Supports Starvation and Dehydration of Disabled Man; Archbishop Rigali Speaks Out On Principles of Providing Food and Water
Many were shocked when a front page article in the June 2, 2000 St. Louis Post-Dispatch revealed that Steven Becker, a 28-year old man said to be in a vegetative state after brain surgery two months before, was scheduled to have his life supports defined as food, water and even antibiotics withdrawn at St. John's Mercy Medical Center, a Catholic institution.
According to the article, Mr. Becker's wife reluctantly agreed to the recommendation of the hospital's ethics committee to end her husband's life, but Mr. Becker's mother obtained a court injunction to stop the removal of the feeding tube. A judge granted a temporary injunction and later appointed a state guardian who will determine if Mr. Becker has an opportunity for a meaningful life.
Weekly pickets protesting the anticipated starvation and dehydration of Mr. Becker have been taking place at the hospital and have even included Mr. Becker's aunts, according to sources.
(Source: "Mother, wife of man in coma differ over removing life support devices,"by William Lhotka, St. Louis Post-Dispatch, 6/2/00. "Comatose man's wife, mother agree to appointment of lawyer as guardian," by William Lhotka, St. Louis Post-Dispatch, 6/20/00).
On July 3, 2000, Archbishop Rigali sent the following release to St. John's Mercy Medical Center and other Catholic health facilities in the St. Louis area. To date, the hospital has not changed its position on discontinuing Mr. Becker's tube feedings.Archdiocese of St. Louis Office of Communications Statement July 3, 2000
On Friday, June 30, Archbishop Justin Rigali sent the following Statement of Principles for Health Care Decisions Concerning Assisted Nutrition and Hydration and Related Issues to a number of local healthcare providers:
Recently there has been some public discussion regarding the Catholic Church's teaching pertaining to end-of-life issues particularly to the issue of Assisted Nutrition and Hydration. The Archbishop believes now is an important moment to clarify general Catholic principles related to the subject of Assisted Nutrition and Hydration. The Statement emphasizes that while there are limited circumstances in which medical personnel may discontinue providing nutrition and hydration to those who are ill, there should be a presumption in favor of providing nutrition and hydration to all patients.2. Terminal Sedation / Dehydration for Conscious People Called Legal "Alternative" to Assisted Suicide
In a June, 2000 article in The Medical Ethics Advisor titled "Responding to Intractable Terminal suffering: The Role Of Terminal Sedation And Voluntary Refusal of Food And Fluids discusses a position paper from the American College of Physicians-American Society of Internal Medicine's end-of-life-care consensus panel.
Dr. Timothy Quill and Dr. Ira Byock, the authors of the article, state that the use of terminal sedation and withholding of food and water are both ethically and legally sound 'last resorts' that allow patients to exercise control over their deaths while avoiding the problems with more active euthanasia.
Dr. Quill is a supporter of euthanasia and was the plaintiff in the landmark US Supreme Court decision Quill vs. Vacco which found no constitutional right to assisted suicide. Dr. Byock has been an outspoken opponent of assisted suicide but states that terminal sedation/dehydration is an option because (o)ur courts have held that people have a right to refuse any treatment.
Quill and Byock cite a successful case where a man with an incurable brain tumor developed weakness, seizures and mental confusion and stated he wanted to hasten his death because he feared becoming a burden to his family and the developing loss of mental capacity.
After 10 days without food and water but medication to control the pain, the man became confused, agitated, and distressed, and was given increasing doses of a sedating medication until he was unconscious. He died 24 hours after the terminal sedation was started. Both Quill and Byock agreed that terminal sedation / dehyration "constitutes excellence in palliative care for patients suffering at the end of life" and would recommend doctors who refuse to dehydrate their patients to death to transfer these patients to a doctor who will.
The article also includes this trenchant analysis of terminal sedation/dehydration from the another doctor:
'Those of us who have a principle-based ethic feel that this is demeaning the life of the patient, devaluing the patient and it is also devaluing the importance of the physician's role in caring for the patients,' state Gregory Hamilton, MD, a Portland, OR, psychiatrist and president of Physicians for Compassionate Care, an advocacy group opposed to the legalization of physician-assisted suicide. The only appropriate use of terminal sedation would be to 'interrupt the pain cycle' with the intention of waking the patient at at later time, he says.
"Even if the sedation would allow the patient to continue with a previous intention to refuse food and hydration, it would require the doctors to perform out side their role," he says. 'If you are doing it with the intention of dehydrating them to death it is just a form of slow euthanasia. It should not be allowed. It doesn't give the patient control, it gives the doctor control. It relieves the doctor's dilemma, and we should not allow it.'(Source: "What to Do When Patients Refuse Food and Water," Medical Ethics Advisor, June, 2000)
Comment: The debate about withholding tube feedings from so-called vegetative patients was never really about just allowing the most severely brain-injured patients to die. Rather, it was about crossing the ethical and legal line to intentionally cause death.
Now we have doctors defending suicide by starvation and dehydration for perfectly conscious people. And although the article only discusses terminal sedation / dehyration for terminally ill people, other doctors and ethicists defend this procedure for the elderly and disabled also.
In this article, the same assisted suicide / euthanasia arguments are now being used for terminal sedation/dehydration: "hard" cases where there is supposedly no alternative, relieving suffering rather than causing death, "safeguards" to make sure the patient is rational, etc.
But rather than pushing for a change in the law, Quill and Byock just want more education for doctors so that this euthanasia option is more available. This is obviously easier to do and allows terminal sedation/dehydration to just slip into common medical practice.
Ironically, the case study of a man with the brain tumor sounds exactly like the cases cited for assisted suicide and, indeed if the man had lived in Oregon, a lethal overdose could have been provided legally. Note, however, the length of time and suffering caused by the terminal sedation / dehydration. Indeed, a case could be easily made that a lethal overdose would have been more humane. (I wonder if Dr. Byock will continue to oppose assisted suicide as this sinks in.)
Conscience rights for health care providers are mentioned at the end of the article, but if terminal sedation / dehydration is accepted, there will be few places where a pro-life doctor or nurse can get a job since they won't participate in "all options" or refuse to refer to others willing to hasten death. Conscience rights must include a right to refuse to refer and protection against job discrimination or termination. NV3. Less Aggressive Treatment Urged for Advanced Alzheimer's Patients
A study in the July 5, 2000 Journal of the American Medical Association recommends that people with advanced Alzheimer's disease be categorized as having a terminal illness and not necessarily receive surgery or antibiotics for hip fractures or pneumonia, the usual standard of care.
Dr. R. Sean Morrison and Dr. Albert L. Siu, of the Mount Sinai School of Medicine in New York, the authors of the study done at only one hospital, say such patients have a higher probability (53-55%) of dying within six months even with standard treatment and it is more important to keep them comfortable rather than try to cure their infections or injuries.
Dr. Morrison cited the fact that such routine measures as blood tests and urinary catheters can be more frightening to such patients and that most of them did not receive pain medication.
Dr. Ladislav Volicer, the director of geriatric research at the E. N. Rogers Memorial Veterans Hospital in Bedford, Mass., said the best solution to the problems described by Dr. Morrison might be to keep patients with dementia out of acute-care hospitals and let them stay in their homes or nursing homes, even with a broken hip or pneumonia.
Dr. Stephen McConnell, a spokesman for the Alzheimer's Association, said Dr. Morrison's recommendations were consistent with those of the association. He also said that "(p)eople with advanced dementia are near death. Good palliative care is probably going to be much more important than the standard medical treatments designed to fix people."(Source: "Less Aggressive Treatment Urged in Severe Alzheimer's," by Denise Grady. New York Times, July 5, 2000.)
Comment: Since last December, there have been articles in the Journal of the AMA and the New England Journal of Medicine the two top medical journals in the world saying that feeding tubes do not even prolong life when used in patients who have severe dementia such as Alzheimer's. Now we are being told that surgery, antibiotics, etc. are also futile and harmful. Instead of treatment and more sensitive care in hospitals, the authors recommend even around-the-clock pain medication that, although necessary when the patient is having pain, may instead make the patient too sleepy to eat or interact.
And even though almost 50% of advanced Alzheimer's patients in the study lived more than 6 months with standard care, the authors now want advanced Alzheimer's patients classified as terminal. And, of course, they will die within 6 months if they are not fed or their pneumonia or hip fractures are left untreated.
t seems like there is great momentum to find a cure for Alzheimer's while, at the same time, there is a concerted effort to get rid of people in the advanced stages as soon as possible. NV3. Colorado Court Rejects Claim that Assisted Suicide is Religious Right
The Colorado Court of Appeals rejected an 81-year-old former judge's claim that a state law criminalizing assisted suicide violates his constitutional right to the free exercise of religion. Former District Judge Robert Sanderson wanted his durable power of attorney for health care, a kind of living will, to allow his wife to authorize his death by euthanasia as long as two doctors agreed his medical condition was hopeless.
Sanderson is in good health now, but wanted assisted-suicide as an option if his condition deteriorated. Sanderson contended that that Colorado's assisted-suicide law interferes with his religious belief that God or nature gave human beings free will and intended that they use it.(Source: "Court Rejects Right-to-die Claim," by Steve Gutterman,Washington Post, 6/8/2000)
4. British Medical Association Calls for Greater Freedom to End Lives of PVS Patients (From SPUC the Society to Protect Unborn Children, UK):
A spokesperson for the British Medical Association has called for greater freedom to be given to doctors to end the lives of patients in so-called persistent vegetative states (PVS's). At the moment an individual high court order must be obtained in each case, but the spokeswoman said: "There are a lot of patients in conditions with no hope of recovery, which places doctors in a difficult ethical dilemma. I don't think it would be right for every difficult case to go to court." The comments came after a London hospital was given permission yesterday to withdraw hydration and nutrition from a lady who has been in a PVS since giving birth in 1978. Doctors in England were first given permission to dehydrate PVS patients to death in 1993 following the Tony Bland case, and since then the legal precedent has been used to issue court orders for between 18 and 20 other patients. [Source: The Guardian, 17/14/00)Comment: It is very disturbing to see the UK start to dismantle even its limited legal protections for severely brain-injured people. In the US, we have seen the privatization of such decisions spawn the expansion of the pool of vulnerable people to the elderly, less severely brain-injured, etc.; the expansion of treatment withdrawal decisions to include antibiotics, insulin, heart medications, etc.; and the increasing acceptance of more active measures to cause death such as morphine drips for stroke patients; terminal sedation/dehydration for the disabled, frail elderly and terminally ill; and terminal weaning from ventilators using medications to prevent breathing.
Once the medical firewall of not intentionally causing death was breached, there has been little to slow the slide down the slippery slope. Note the next story. NV5. Jail for Family Charged with Assault After Saving Disabled Boy
When David Glass, a 12 year old with disabilities resulting from hydrocephalus (more commonly known as water on the brain), was hospitalized with a chest infection, relatives were alarmed when the doctors told them he was close to death, stopped feeding David and started administering diamorphone, a kind of morphine. An uncle and two aunts fought to stop the doctors and physically removed the boy from the hospital. David, now 14, is alive and doing well and his mother credits the aunts and uncle with saving the boy's life.
However, a judge has now sentenced the relatives to 9 to 12 months in jail for violent disorder and assault, dismissing the mother's plea that the relatives are helping to supply around the clock care for David.(Source: "Jail for relatives in hospital fight over boy," by David Graves, The Telegraph (UK), 7/15/00. http://www.telegraph.co.uk:80/et?ac=002875421417162&rtmo=aq49XJJJ&atmo=99999999&pg=/et/00/7/15/ngla15.html)
6. Dutch Reject Euthanasia for Minors?
With Holland ready to formally legalize the openly tolerated practice of euthanasia, the Dutch government withdrew its proposal that would allow physicians the possibility, in exceptional cases, of allowing a request for euthanasia by a minor between 12 and 16 against the wishes of their parents." The withdrawal of the proposal is widely expected to speed the passage of a broader bill to legalize euthanasia.(Source: "Dutch Reject Legal Euthanasia for Minors," Associated Press, New York Times,
7/14/00http://www.nytimes.com/yr/mo/day/news/world/dutch-euthanasia-ap.html)Comment: The title of the article says euthanasia is rejected for minors under 16 , but the operative phrase is "without parental consent." Children in Holland are already euthanized with the parents consent. One Dutch doctor said in a recent article that he considered children as young as 7 capable of giving consent to euthanasia.
Several years ago, there was a TV show discussing euthanasia in which a Dutch doctor who headed a neonatal unit told how he never considered euthanasia until a family asked if they had to keep their baby with Down Syndrome alive. He said that he lethally injected that baby, then routinely dispatched such children unless the family was very religious and insisted that the child live.
The doctor then told how he euthanized a baby boy who had a non-fatal, deformed penis because he felt that this deformity would give the boy a terrible quality of life. Amazingly, however, he said that he had overruled a family who wanted their newborn with some missing limbs euthanized because he felt that medical technology could help such a child. (Makes you wonder what "limb" is the most important!)
He also said decisions for euthanasia were primarily up to the doctor, not the family.Comment: When principle is abandoned for "feelings", life itself becomes an arbitrary "privilege" rather than a right even for the young. NV
7. Chicago MD's License Revoked after Lethal Injection
Dr. Robert Lance Wilson, a 44 year old cardiologist, had his medical license revoked by the Illinois Department of Professional Regulation after being after an investigation into allegations that he injected 69 year old Henry Taylor with a fatal dose of morphine and potassium chloride. The department accused Dr Wilson of "gross negligence and unethical conduct" and his license will be suspended for 5 years after which time Wilson may petition for reinstatement.
Mr. Taylor was dying of a terminal kidney condition and Dr. Wilson contended that Taylor was suffocating to death...and I was just trying to make him feel comfortable."
The Cook County medical examiner's office ruled the death a homicide, but the state's attorney's office decided not to bring criminal charges, saying it could not prove that the injection killed Taylor.
In 1998, Henry Taylor's brother filed a lawsuit against the hospital and Wilson, which is pending.(Source: "Doctor's License Revoked Over 1998 Injection," by Noah Isackson. Chicago Tribune, 6/27/00. http://www.chicagotribune.com/news/metro/southwest/article/0,2669,SAV-0006270244,FF.html)
Comment: Some doctors and nurses feel that the dying process is "taking too long" in some cases and that the process should be speeded up. This case is a chilling reminder to such doctors and nurses that misplaced "compassion" can have dire results legally as well as ethically. NV
7. Utah Psychiatrist Convicted in Deaths of 5 Patients
44-year-old Robert Allen Weitzel, a Utah psychiatrist, was found guilty of manslaughter and negligent homicide when 5 of his patients were given overdoses of morphine.
Weitzel's lawyers contended that he prescribed the morphine as "comfort care" to ease the pain of patients who were dying from complications of old age and that he was immune to criminal charges under Utah's Personal Choice and Living Will Act, which gives immunity to doctors who, in good faith, administer pain medication to terminally ill patients. The lawyers also contended that the families of the patients agreed to this comfort care although members of the families expressed outrage at the doctor's actions at the trial.
All five patients died during 16 days on Weitzel's geriatric/psychiatric unit at the Davis Hospital and Medical Center. The patients were being treated for loud and combative behavior stemming from senile dementia and were not in severe pain.
Weitzel is also still facing 22 federal counts alleging that he wrote fraudulent prescriptions to obtain morphine for himself and his Utah medical license has been suspended.
(Source: Salt Lake Tribune, 7/11/00.)Comment: In my experience and that of other nurses, excessive morphine or other drugs can be easily disguised as "comfort care" when the real goal is to hasten or cause death. This may be one more reason why so many euthanasia supporters fight so hard against the Pain Relief Promotion Act now pending in Congress. Are they perhaps just as afraid that cases like this psychiatrist's will become public as well as stopping the use of controlled substances for assisted suicide in Oregon?
These cases are often portrayed in the media as "complex" and "witch - hunts" against caring doctors. It's really not that hard in most cases.The principles of pain management are simple: When a patient does not have pain, pain relievers should not be given. (Long-acting pain relievers like MS Contin are wonderful in preventing pain in people with chronic or terminal pain, but the point is that they had pain to begin with.) When a patient reports or shows pain by grimacing or other bodily manifestations, pain medication should be started in low to moderate doses and the increased only if there is evidence which should be documented that the patient continues to have or show pain. Sometimes a patient has severe pain which needs aggressive use of pain medication but once relief is established, the dosage is assessed and often decreased so that the lowest amount needed is found. Many times, chronic pain is better managed with non-narcotic pain relievers than narcotic pain relievers because medications like ibuprofen (Motrin, Advil), etc. are more helpful because they help relieve inflammation. Narcotics should be used only if necessary and stopped as soon as possible because of the side effects of drowsiness, etc.
In testimony before a congressional committee on the Pain Relief Promotion Act this year, representatives of the AMA and pain relief organizations said that the principle of double effect (medication intended to relieve pain but which may hasten death) is largely a myth when pain is appropriately controlled. However, this double effect principle was successfully used as a defense in the first cases involving Jack Kevorkian as well in other cases where doctors were accused of euthanasia. NV8. Ex-doctor Charged with Killing 3 Patients
Since Michael J. Swango graduated from medical school, many of the 45-year-old's patients patient mysteriously died; but he always managed to find a new job even after he was convicted of trying to poison co-workers.
Finally, federal investigators say they have enough evidence to convict Swango with the 1993 murders of 3 patients who he cared for at a Veterans Affairs hospital in New York.
"Instead of using his medical license to become a healer, Swango embarked upon a career as a killer," said Loretta E. Lynch, the United States attorney for the Eastern District of New York. "Through a web of lies and deception, Swango inveigled his way into the confidence of hospital administrators across the country and the world. Once in their trust and in their employ, he utilized his skills to search for victims and take their lives."
Swango was the subject of a 1999 book, Blind Eye: The Terrifying Story of a Doctor who Got Away with Murder , by James B. Stewart, who says that the Swango case highlights the reluctance of the medical profession to screen or sanction its own members.
(Source: "Ex-Doctor Charged With the Killing of 3 Patients on Long Island," by Michael Cooper, New York Times, 7/12/00. http://www.nytimes.com/library/national/regional/071200ny-doctor.html)Comment: At least this time, no one is saying that this MD is a compassionate physician just trying to do his best and being unfairly charged. But should being perceived as a caring doctor make a difference when patients are terminated? And can even such "caring" doctors stop at just one patient? NV
8. Oregon Suicides Hit Record High in 1998
The state of Oregon reported 569 suicides in 1998, the highest number ever reported as well as the first year that Oregon's assisted suicide law was implemented. The 569 suicides do not include physician-assisted suicides, which are counted separately. The report also showed there were 761 suicide attempts in 1998 among children and teen-agers ages 6 to 17.
"Suicide is a serious public health problem," said Lisa Millet, injury prevention manager for the Oregon Health Division. "It's the ninth-leading cause of death among Oegonians and the second leading cause of death among youth ages 10 through 24."(Source: "Oregon Suicides Hit Record High in 1998," by the Associated Press. The Oregonian, 6/28/00.)
Comment: As the article notes, these suicide statistics do not include assisted suicides. The article does not speculate on the connection between a legal acceptance of assisted suicide and "regular" suicide but, as euthanasia opponents long pointed out, assisted suicide as an acceptable option would most probably lead to an increase of suicides among other vulnerable groups like teens. NV
CONTRACEPTION
1. Fabricated Research, Death and Disability, and Politics Involved in the Pill's Invention.
In an amazing article in the New York Times, Barbara Seaman chronicles the invention of the birth control pill 40 years ago when Margaret Sanger, the founder of Planned Parenthood, funded the initial research. While Ms. Seaman does not condemn the Pill, she is concerned about its safety for women and the politics surrounding the even the first experiments designed to test the Pill's safety and effectiveness.
Seaman accuses Gregory Pincus, the scientist who invented Enovid, one of the first birth control pills, with fabricating research on the experiments of his Pill on Puerto Rican women. She calls Enovid a "chemical swamp"that was changed "(o)nly after millions of women had taken Enovid -- and thousands had died or had been disabled by blood clots." The amount of hormones in the birth control pill was eventually decreased, but Ms. Seaman says that even today's Pills raise concerns about the relationship of the Pill to breast cancer, infertility and high blood pressure."Source: "The Pill and I: 40 Years On, the Relationship Remains Wary," by Barbara Seaman. New York Times, 6/25/2000. http://www.nytimes.com/library/national/science/health/062500hth-women-pill.html)
Comment: The moral concerns about the Pill are just now beginning to be recognized by the secular world 40 years after the invention of the Pill, but the medical dangers of the Pill have remained relatively hidden. This article should raise skepticism among everyone especially women when medicine with a political agenda is called "safe". NV
2. Medical Journal Reports Pill Risks as "Insignificant"
A report in the July 5th edition of the Journal of the American Medical Association suggests that while women taking birth control pills-even the newer, low-dose forms-face an almost threefold greater risk of stroke than non-users, that risk is outweighed by the contraceptive benefits of the Pill.
"The key is about whether this risk matters," given how effective the pill is at preventing pregnancy, said Dr. S. Claiborne Johnston, a co-author of the report and assistant professor of neurology at the University of California at San Francisco.
If oral contraceptives were replaced by condoms, about 687,000 additional unintended pregnancies would result each year, the study authors said. Some of those women would have abortions, and others would face health risks associated with pregnancy plus "major psychological and economic consequences" of unintended children, Dr. Johnston said.(Source: "Report Weighs Benefits and Risks of Pill," by the Associated Press. New York Times, 7/5/2000)
Comment: Is it really better to be dead or disabled than pregnant? Do the authors really consider pregnancy to be a physical and emotional threat to women?
Never mentioned by the authors is the potential abortifacient aspect of the pill or the increased risks of breast cancer, etc. The authors, of course, do not tout the benefits of Natural Family Planning, which has no physical risks, but instead conjecture about the use of condoms. It seems as if the authors are more concerned about population control than women's real health. NV
Related Statement
Taking a stand against causing death, March 2,2005
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