How to Protect Your Loved Ones From Pain
HOW TO PROTECT YOUR LOVED ONES FROM PAIN by Robert Sassone
CHAPTER 1
HOW TO PROTECT YOUR LOVED ONES FROM PHYSICAL PAIN
1-1 What is pain?
1-2 Is some pain valuable?
1-3 What is the process by which we feel pain?
1-4 How should the physicians analyze the patient's pain?
1-5 What pain relieving tools are available?
1-6 How are pain relieving drugs used?
1-7 Do pain relieving drugs even more effective than morphine exist?
1-8 Without using injections, how can we relieve the pain of patients who cannot swallow?
1-9 How are pain relieving drugs misused?
1-10 How do pain relievers protect us from feeling pain?
1-11 What are some possible ways to stop the mechanism by which nerve pain sensing cells sense pain?
1-12 How can we interfere with the transmission of the pain signal from the cell to the brain?
1-13 Are we discovering more effective pain relievers?
1-14 How do aspirin and similar drugs work?
1-15 How do nerve blocks and local anesthesia control pain?
1-16 How do narcotics (opiates or opioids) like morphine stop pain?
1-17 How do epidurals control pain?
1-18 How are patients given more control over their pain medication?
1-19 How does Patient Controlled Anesthesia (PCA) control pain, promote healing and reduce medical bills?
1-20 How do methods like natural childbirth techniques control pain?
1-21 What can be done if the pain signal reaches the inner part of the brain?
1-22 Is severe physical pain the only major pain problem?
1-23 How good is pain management at preventing and stopping pain that could be prevented and stopped?
1-24 Why does the pain relief system break down for so many patients?
1-25 Why do physicians fail to relieve cancer pain?
1-26 Is relieving pain simply a matter of giving the patient enough of a sufficiently strong pain reliever such as morphine?
1-27 Is it necessary for sleep to be interrupted so the patient can be given pain relievers during the night hours?
1-28 Can we soon expect significant improvements in pain relief?
1-29 Can severe bone pain be controlled?
1-30 Can relatives of patients help hospitals prevent pain?
1-31 What is the best way to protect your loved ones from physical pain when they are injured, seriously ill or require surgery?
1-32 How does it feel when pain is controlled?
1-33 How many people must suffer unbearable pain before death?
1-34 Why do people put up with all this unnecessary pain?
1-35 How serious is pain?
1-36 Do animal studies give evidence that pain in and of itself needlessly causes harm to patients?
1-37 How does unnecessary pain kill by aggravating other problems?
1-38 Why does "as needed" prescribing cause unnecessary pain?
1-39 Is anything being done to remedy the situation where many patients needlessly suffer pain?
1-40 What are the most important AHCPR guidelines for pain control?
1-41 Is the last year of life usually so painful that dying earlier and quickly would be preferable?
1-1 What is pain?
"Pain is a feeling of being hurt; suffering". (DF) "A more or less localized sensation of discomfort, distress, or agony, resulting from the stimulation of specialized nerve endings." (DO)
1-2 Is some pain valuable?
Yes. Pain can be a warning that the body is in danger of injury. It can signal a person to react promptly to remove a body part from a source of injury. Pain can also discourage movements that could otherwise injure the body.
1-3 What is the process by which we feel pain?
Specialized nerve cells sense pain and transmit a pain signal along nerves to the spinal column. The spinal column then transmits the signal to the thalamus, the brain's pain sensing center, which then transmits pain signal to other parts of the brain.
1-4 How should the physician analyze the patient's pain?
There is no instrument that measures pain. The physician observes and listens to the patient, (masculine includes both sexes) examining him and reviewing the patient's records as appropriate.
The physician may order appropriate tests such as urine, blood and other body fluid tests, X-rays or other scans, etc. The physician may consult literature or a specialist, etc. In appropriate cases, the physician should ask appropriate questions such as:
(a) Is the pain due to invasion of the soft tissues?
(b) Is the pain due to nerve compression?
(c) Is the pain due to distension of the liver by multiple secondaries?
(d) Is the pain due to involvement of the bones, with an actual or threatened pathological fracture?
(e) Is the pain due to some non-malignant complication of disease, such as abscess formation or some other infection?
(f) Is the pain due to some complication of therapy, such as pain in a surgical incision, pain following radio-therapy, or gastric irritation caused by aspirin? In addition, the physician may ask questions of the patient such as:
(g) Where does it hurt?
(h) When did it start hurting?
(i) Under what circumstances did it start hurting?
(j) How has the pain changed?
(k) How intense is the pain in the various places that hurt?
(l) What type of pain is it?
(m) Is the pain chronic or varying?
(n) If the pain varies, how does it vary with time, change of conditions or location? (o) Does the pain radiate?
(p) If the pain radiates, how does it radiate?
(q) What makes the pain worse?
(r) What relieves the pain?
(s) What were the relevant circumstances which might have been related to the start or change of the pain?
(t) How have relevant circumstances changed since the pain began?
In response to appropriate answers, the physician may ask more specific questions in an effort to focus in as exactly as possible on the necessary details relating to the pain. If the pain persists and the physician has not explored the areas covered by the preceding questions, it may be evidence that the physician has not done all that he should have done to control the patient's pain.
1-5 What pain relieving tools are available?
There are six primary tools for controlling pain:
(a) Prevention, such as draining an area where the accumulation of fluid might otherwise cause pain, or removing an allergy causing substance, etc.;
(b) non-medicine treatments such as change of diet;
(c) mild pain relief medicines such as aspirin;
(d) pain relief medicines stronger than aspirin but weaker than the morphine class, such as codeine;
(e) the morphine class or even more effective pain relievers such as fentenyl; and
(f) other techniques such as physical therapy, surgery, nerve blocks, electricity, etc., for control of certain pains.
Sometimes combinations of pain relievers are more effective.
1-6 How are pain relieving drugs used?
"A wide range of pain relieving drugs is available. It is appropriate to begin with well known mild analgesics such as aspirin or acetaminophen. There is an ever increasing number of other drugs which act in the same way as aspirin. These include indomethacin, ibuprofen, naproxen, and sulindac. They differ in duration of action and side effects, but basically all can provide effective relief of mild-to-moderate pain and are especially effective in providing relief of pain arising from bone and joint.
"A more potent analgesic is represented by codeine, an opiate derivative. People often unnecessarily fear codeine because of its minimal ability to cause addiction. Its main problem, like all opiates, is that it may cause constipation. Often combined with acetaminophen it is an effective analgesic of moderate strength.
"If more powerful analgesia is needed, and if it has been determined that the pain is likely to be responsive to opiates, there should be no hesitation in prescribing morphine. For relief of severe pain, morphine remains unexcelled although it is shrouded in myths which the medical profession embraces all too often. For example, 'I don't want to start you on morphine now, because if I do, when we really need it, it will have lost its effect;' or 'I'm afraid if I start you on morphine I may turn you into a drug addict.'
"The fear of drug addiction in terminally ill patients would be laughable if it had not caused so many patients to endure needless pain. It is well documented that if morphine is taken for the relief of pain, habituation does not occur. Unless the disease advances, dosage requirements usually remain remarkably stable for many months, and if some other pain relieving procedure is initiated, such as a nerve block, morphine can be quite rapidly withdrawn without provoking the type of severe withdrawal seen in a true addict.
"For patients able to take morphine by mouth, the best approach is to establish the dose which the patient needs to get relief by giving it either as an elixir or as tablets. The drug is of fairly brief duration and so should be given every four hours. It is wrong to give the drug only when the pain has broken through the effect of the previous dose. Once the total daily requirement has been established, the morphine can then be given in the same amount, using sustained release morphine tablets such as MS Contin. This controlled release preparation allows the patient to be dosed only twice a day instead of every four hours. This is major a boon, and if it did no more than allow undisturbed nights it would be an invaluable preparation.
"In terms of dose, morphine is a very flexible drug. The rule is that as long as side effects allow it, the dose should be increased until pain relief is achieved. Pain in some way acts as a physiological antagonist to morphine so that respiratory depression does not occur even at very high doses.
"For the patients who cannot take morphine by mouth, there are two alternatives. The first is to use a constant infusion syringe which pumps a morphine solution either into a vein or under the skin. Alternatively, in centers where the necessary skill exists to set it up, morphine can be infused into the space between the membranes surrounding the spinal cord, the epidural space, or directly into the cerebrospinal fluid around the spinal cord. Unusual activities, such as lying with the patch on a heating pad, may change the rate at which medicine passes into the body. Passing too much medicine too quickly could be dangerous". (PM)
1-7 Do pain relieving drugs more effective than morphine exist?
Yes. For example, Dilaudid (hydromorphone), a semi-synthetic drug, which is usually given every four hours, and levorphamol are each about five times more effective than morphine as pain relievers. Fentenyl, a synthetic pain reliever, is about one hundred times more powerful in relieving pain than morphine and may be administered via an adhesive patch that is effective for three days. These new pain relievers are so strong that they should be used only under appropriate conditions.
1-8 Without using injections, how can we relieve the pain of patients who cannot swallow?
Oral suppositories are very effective in certain cases. It is possible to place a small amount of pain relieving drug in the mouth, from where it can be absorbed into the body. Commercially available patches with fentenyl or similar pain relievers can be attached to the patient's skin. The pain reliever is released through a permeable membrane and absorbed through the patient's skin. One patch lasts about three days. The patient can shower or soak in a hot tub without effect on the patch.
1-9 How are pain relieving drugs misused?
Most pain caused by misuse of pain relieving drugs involves administering too small a dose, by waiting until the patient is in severe pain before administering the pain relief drugs, or by failure to move on to the next more potent level of pain reliever. For example, aspirin is not sufficient for a codeine level pain, nor is codeine sufficient for a morphine level pain. The dosage instruction "as needed" also known as "when necessary" or "P.R.N." frequently fails to relieve pain. (LA106)
Pain relief drugs can also be administered under inappropriate conditions, such as when powerful drugs are given for minor pains that could be controlled by weaker drugs, especially when the patient cannot be monitored, such as on an outpatient basis.
1-10 How do pain relievers protect us from feeling pain?
Pain relieving drugs either stop the cause of the pain, such as swelling, or they interfere with the transmission of the pain signal from the nerve cell to the brain's pain sensing center.
1-11 What are some possible ways to stop the mechanism by which nerve pain sensing cells sense pain?
One simple way is removal of the cause of pain. When you touch something hot, you feel pain, which prompts a reflex by which you immediately remove your hand from the hot object. If you feel pain because of an infected tooth, the tooth can be removed or filled. If you feel pain due to an infection, clearing up the infection removes the pain. If you feel pain caused by fluid build up, removal of the excess fluid often relieves the pain. When tension causes pain, it helps to remove the tension. Other examples are equally obvious.
Another way is to interfere with the ability of the nerve pain sensing cell to detect pain stimuli or to transmit the signal indicating pain stimuli. A complex series of thousands of separate actions may be necessary for a cell to detect pain stimuli and transmit a signal. The cell may have to absorb at least one particular element such as calcium or emit or transmit something or move something from one part of the cell to another. We are now discovering these thousands of secrets of cells and putting them to use. For example, a substance derived from spider venom permits us to close the calcium channel into a cell which will help us improve pain control. (DI)
1-12 How can we interfere with the transmission of the pain signal from the cell to the brain?
Think of pain as having to go through a series of gates before the brain feels it. If any of these gates can be closed, the pain will not get through.
1-13 Are we discovering more effective pain relievers?
Yes. As our understanding of cells increases, we are finding and we will continue to find more and better ways to stop pain. For example, "Biochemists have isolated a pain killer from the skin of a poisonous frog from Equador that is 200 times stronger than morphine. An article in the British magazine New Scientist reported that the extract is from the frog Epipedobates Tricolor, traditionally used for poison arrows. Epibatin, as the drug is called, is dramatically different from other frog extracts, and researchers in Bethesda, MD., think it affects the nervous system in a way not yet understood." (RE)
Additionally, the receptors and the binding brain molecules for both opium and marijuana have recently been discovered, promising vast improvements in pain control. (LT/SC)
1-14 How do aspirin and similar drugs work?
"Aspirin, for example, acts to block pain at its origin, the specialized nerve cells in the skin and organs that sense pressure, injury, cold, heat and disease." (GH)
1-15 How do nerve blocks and local anesthesia control pain?
"Local anesthesia, also called nerve blocks, quell pain signals along nerves running from the pain receptor cells to the spinal cord." (GH)
1-16 How do narcotics (opiates or opioids) like morphine stop pain?
"Narcotics, like morphine, stop pain signals from running up the spinal cord and slam the door on them in the thalamus, the center that refers pain information to other parts of the brain where pain perception occurs. (GH)
1-17 How do epidurals control pain?
"EPIDURAL ANESTHESIA, in which a small amount of morphine is infused around the spinal cord, has been a boon to patients because it blocks pain from racing up to the brain. And because there is no memory of pain, patients can move around earlier and avoid the debilitation associated with pain- induced immobility. Permanent epidural pumps are now being worn by patients with certain types of agonizing pain that does not respond to other treatment." (GH)
1-18 How are patients given more control over their pain medication?
The first step is for doctors to be more sensitive to how their patients feel and to more effectively interview patients. A competent physician must know if the drug he is prescribing is failing to relieve the pain. He must not continue an ineffective pain relief treatment when better pain relief tools are available. In some cases, it is wise to give the patient near total control over the fine adjustment of pain killing medicine. After all, the patient knows best how the patient feels. If necessary, PCA (Patient Controlled Anesthesia) should be utilized.
1-19 How does Patient Controlled Anesthesia (PCA) control pain, promote healing and reduce medical bills?
"PCA machines were set up throughout the (University of Chicago) hospital, enabling patients to push a button to give themselves doses of opiates whenever they wanted to subdue or avoid pain. Two out of three post-surgery patients now administer pain killers to themselves.
"PCAs not only control pain, they promote faster recovery. One study showed that PCA patients were discharged 4.6 days earlier than patients receiving standard injections of pain killers administered by nurses. PCA patients saved an average of $1,735 on their hospital bills." (GH)
1-20 How do methods like natural childbirth techniques control pain?
Emotional factors may aggravate suffering caused by pain. Concentrating on the pain, rather than on something else, increases pain intensity. A wounded soldier or an injured athlete may not feel much pain initially because he is concentrating on something else. Another factor that aggravates suffering from pain is the expectation that the pain will never end or will not end soon. Natural childbirth techniques diminish the suffering that childbirth would otherwise cause by focusing the mother's attention away from her pain. They give her duties to perform which distract her from concentrating on the pain and remind her that the pain is temporary and has a purpose. Additionally, the relaxation techniques of natural childbirth ease pain by reducing physical tension. This method is similar to the use of a hot water bottle to ease a stomach ache; the body concentrates on the warmth rather than the pain.
1-21 What can be done if the pain signal reaches the inner part of the brain?
"Even these deep areas of the brain, where pain is finally felt, are no longer off limits to scientists intent upon subduing the ancient enemy. Some patients with severe, intractable pain are having tiny electrodes implanted into the pain reception areas of the brain. Another experimental approach uses an implantable pump to infuse small amounts of morphine into the brain." (GH)
It should soon be possible to protect the brain from pain signals by taking advantage of the recently discovered opiate receptor in brain cells. (LT/SC)
1-22 Is severe physical pain the only major pain problem?
Nonphysical pain is more subtle than physical pain and cannot be controlled by merely giving the patient the proper dose of the proper medicine. Seriously ill patients frequently need emotional support such as love, someone to converse with, or someone to talk to them even if they are unable to talk back. Please see chapter 2 for a discussion of nonphysical pain control.
1-23 How good is pain management at preventing and stopping pain that could be prevented and stopped?
Pain relief is effective when the physician does his job well. Unfortunately, when the patient is in severe pain, the physician frequently does a poor job of pain relief. For example: "There is widespread recognition that patients with cancer frequently receive insufficient treatment for their pain." (JP)
1-24 Why does the pain relief system break down for so many patients?
A physician must know how to treat various types of pain and he must know the types and intensities of pain afflicting his patient. Many physicians are deficient in either or both areas.
Surveys have shown that there is often a great discrepancy between the intensity of pain the patient is feeling and the intensity of pain the care giver believes the patient is feeling. (PM)
Because the patient too frequently is in greater pain than the care giver believes, the patient too frequently is given insufficient pain relief. This is the fault of the physician who does not take the time to become familiar with the patient's subjective symptoms and/or who does not take the time to become familiar with modern methods of pain treatment.
1-25 Why do physicians fail to relieve cancer pain?
"Some of the most common reasons include failure to assess properly the etiology of cancer pain, under utilization of existing pain management techniques, and excessive fear of tolerance and addiction to the narcotic analgesics....Inadequate communication between health care providers and their patients about pain intensity could represent another major factor interfering with the provision of adequate pain control....Failure to appreciate the magnitude of the patient's pain is likely to result in inappropriate analgesic prescribing and administration." (PM)
Many physicians do not take the necessary time to determine the cause and intensity of the pain with sufficient precision, and consequently fail to give the patient the medicine which would relieve the pain.
1-26 Is relieving pain simply a matter of giving the patient enough of a sufficiently strong pain reliever such as morphine?
Generally, pain can be treated more effectively if the cause is first determined, because different medicines are effective in different ways. Most pain relief is not a complex problem. However, a patient can suffer from many different pains which each have different causes. For this reason, pain relief can be complex. Although morphine is a much stronger pain reliever than aspirin for many purposes, the way morphine works prevents it from stopping certain types of pain such as bone pain. Thus morphine alone might provide negligible pain relief for some pains that can be controlled effectively by a generally milder medicine such as aspirin plus morphine.
1-27 Is it necessary for sleep to be interrupted so the patient can be given pain relievers during the night hours?
It is usually better to give a patient a long lasting pain reliever so he can sleep undisturbed all night long. For example, Naproxyn (Naprosyn) is an aspirin-like medicine that provides pain relief for 12 hours. Fentenyl can be given by a commercially available patch which lasts three days (72 hours).
1-28 Can we soon expect significant improvements in pain relief?
Yes. Progress is being made faster than ever before in medicine. Until recently, morphine was the strongest pain reliever. Now we have drugs like fentenyl, which is about a hundred times more effective at relieving pain than morphine. This is just the beginning. The 1992 discoveries of the long sought opiate receptor in the brain and the natural brain molecule that binds to the marijuana receptor are major steps along the road to vastly improved pain control. (SC)
We can expect substantial additional improvements in pain relief in the near future.
1-29 Can severe bone pain be controlled?
Yes. Bone related and similar pains, for example, do not respond well to morphine. However, those pains which do not respond to morphine are controlled by other pain relief methods. Bone related pains are controlled by a combination of medicines and physical relief techniques. While the medicines that are used control pain in a manner analogous to aspirin, the physical techniques are designed to relieve the cause of the pain. A case of severe bone pain might be controlled by a combination of physical therapy, aspirin or hormonal type medicines, massage, etc., which might be used to partially relieve pain by removing part of its cause. Pain relief medicines such as morphine would then be given in sufficient quantity to control whatever pain remained.
1-30 Can relatives of patients help hospitals prevent pain?
Yes. First make certain the patient is admitted to the best available hospital for treating his specific illnesses or injuries. A doctor who is not treating the patient, especially a doctor with a specialty near the type required for treating the patient, or some nurses, will be able to advise as to hospital reputations. A hospital possession of advanced equipment, such as MRI, may indicate a proficiency at treating a certain type of injury or illness. Even in more effective hospitals, information is not always communicated. Especially when a patient is transferred or patient's condition changes, the new shift of medical personnel may not be aware of relevant facts. Relatives can communicate these facts. For example, the medical staff may believe a patient cannot eat, but relatives can devote more time than the staff to assist the patient. Relatives can perhaps feed the patient and lovingly pause when the patient needs to rest during the meal, so that a patient apparently unable to eat can be fed. Nursing care is rationed in hospitals. Because there are too few nurses to assign one per patient, relatives who may be constantly beside the patient can immediately respond to his requests or pass them on to the nurses and, if appropriate, demand that they be fulfilled. Sometimes action must be taken promptly to increase its chances to be effective. The hospital schedule may preclude treating a patient at the optimum time. By demanding treatment or volunteering to assist, an attending relative may persuade the hospital to shift its schedule to benefit the patient without harming others.
1-31 What is the best way to protect your loved ones from physical pain when they are injured, seriously ill or require surgery?
In most cases, the best way to protect your loved ones from physical pain when they are receiving medical care is to understand why experts tell us that all physical pain can be controlled and to follow the suggestions in this chapter.
There are three levels of pain:
(1) mild to medium pain; (2) serious pain; and (3) very severe pain. You can control mild to medium pain yourself with aspirin, acetominophen (tylenol), ibuprofen, etc. Your physician can frequently control serious pain with codein related pain relievers.
For very severe pain, you may need a pain specialist in addition to your treating physician or even a group of pain specialists and special treatments or medicines such as fentenyl.
Most people who suffer very severe pain have not yet consulted a pain specialist. Those suffering very severe pain have not received the medicines or treatment they need to control their pain and as a result have needlessly suffered very severe pain even though all physical pain can be controlled.
Many people settle for inadequate pain relief because of unfounded or emotional fears. They may fear opiates because of incorrect information. Sometimes people postpone using the best pain relief medicines because they fear that the pain may become more intense later. Some want to show total faith in their non-pain specialist physician by denying even to themselves that they are sick enough to have severe pain. Physicians may also have emotional reasons for their unwillingness to consult with specialists. Again, all pain can be controlled. While many physicians control less severe pain fairly well, many do not take proper actions to control conditions causing very severe pain.
The solution is to seek out a physician who will take reasonable steps to control your pain. This chapter will help you to select such a physician and to know when, how, and why to seek his assistance.
1-32 How does it feel when pain is controlled?
"If pain is properly controlled, the patient will never feel it again. He will ask if the medicines are really necessary any more, because the pain has gone." (SA) (LA106)
1-33 How many people must suffer unbearable pain before death?
None receiving good medical care! For more than 20 years, it has not been necessary to suffer unbearable pain before death. As pain comes and goes, it may take a short time before the pain is controlled. Knowledgeable doctors claim that all physical pain can be controlled. "A number of studies have shown, and this corresponds to my experience, that the majority of critically or terminally ill patients do not have pain and that those who do can be controlled by the judicious use of pain-killing medicines." (FO) In support of this testimony are statements of numerous doctors, including the founder of the modern hospice movement, Cicily Saunders, M.D. (SA), Richard Lammerton M.D., who assisted Saunders in founding the modern hospice movement (LA106), and many articles in medical journals such as The Journal of Pain and Symptom Management, Cancer, Pain, etc. (AN, JA, JP, PA, PS) The author believes that those who disagree are not well informed.
1-34 Why do people put up with all this unnecessary pain?
People may not respect physicians in general, but they respect their own particular physician. Sometimes, they wrongly assume that he knows what he is doing in areas outside his specialty. The treatment of very severe pain has frequently been beyond the average physician's expertise and so has been treated very poorly. Most physicians were not properly taught pain management in medical school and experience frequently reinforces this deficiency. Patients who know someone who died painfully may believe their own pain cannot be controlled.
1-35 How serious is pain?
Pain kills. Pain disables. "The dramatic difference pain control can make in preventing death and unnecessary illness was shown in two recent studies.
"In one, scientists from the Massachusetts General Hospital reported in the January issue of the New England Journal of Medicine that of 30 infants given deep anesthesia (greater than average pain relief) during open heart surgery and post operative pain relief, none died. Among 15 other infants given routine analgesia (average pain relief) during the same type of surgery, four died. "Stress hormones released in response to pain damaged the infants' hearts, depleted their immunity and caused other deleterious changes, says Dr. K.J.S. Anand, who headed the MGH research team. 'Deep anesthesia continued post-operatively may reduce the vulnerability of these neonates to complications and may reduce mortality.' he concluded.
"In the second study, patients with sickle-cell disease, who are frequently hospitalized for pain, were switched from narcotic injections and fast acting pain pills to long lasting controlled-release morphine capsules.
"One year after the switch, admissions for sickle-cell pain decreased 44%, hospital days dropped by 57% and emergency room visits fell by 67%, Dr. Daniel Brookoff of the University of Pennsylvania reported in the Annals of Internal Medicine." (2GH)
1-36 Do animal studies give evidence that pain in and of itself needlessly causes harm to patients?
"Research in animals has convinced psychologist John Liebeskind of UCLA that patients pay a penalty for not having their pain stopped. Rats given standard anesthesia during a surgical procedure similar to an appendectomy had pain-related impaired-immune function and a rapid growth of transplanted tumors, he says. "Similar rats given adequate medication but who woke up pain-free after surgery did not experience a drop in their immune function nor an acceleration of tumor growth.
"'The message is clear,' Liebeskind says. 'Pain can kill. It's not just some inconvenient thing...'" (2GH)
1-37 How does unnecessary pain kill by aggravating other problems?
A human being needs to eat and needs reasonable amounts of exercise. Pain can make a person unable to eat, exercise, or effectively perform other necessary functions. Failure to perform these functions causes the body to deteriorate and risks causing death by some factor that would not occur if the person had not been weakened by pain.
1-38 Why does "as needed" prescribing cause unnecessary pain?
"What must be avoided is the giving of analgesics 'when necessary'." (LA106)
Lammerton describes how delays, giving of too little pain reliever and other problems cause many patients to suffer greatly when the "when necessary" or "as needed" pain relief concept is used or, as is inevitable, misused. (LA106)
"Over the years, clinical surveys have continued to show that routine orders for intra-muscular injections of opioid 'as needed'-the standard of care in nearly all clinical settings-result in unrelieved pain in nearly half of the 23 million patients who have surgery each year. For example, in a 1987 study, 203 of 353 medical-surgical patients reported experiencing severe pain during their hospitalization (PA). Fewer than half of the patients with pain had a member of the health care team ask them about their pain or note it in the patient's medical record. The dose of analgesic administered over a 24-hour period was judged to be inadequate, and total pain relief was only reported by 35% of the patients. In 1969, Oden concluded that 'while traditional intra-muscular dosing of analgesics as necessary is simple and inexpensive, it falls short of the mark in effectively achieving control of acute pain'" (AN).
"Studies reveal that traditional treatment will leave the patient in pain more often than not and may lead to shallow breathing and cough suppression in an attempt to 'splint' the injured site. Retained pulmonary secretions and pneumonia may follow. Unreleaved pain may also delay the return of normal gastric and bowel function in post-operative patients." (JA)
1-39 Is anything being done to remedy the situation where many patients needlessly suffer pain?
"The (U.S. Government) Agency for Health Care Policy and Research (AHCPR) recently released a clinical practice guideline that provides recommendations for physicians, other health care providers, and consumers on appropriate and effective management of acute pain in adult and pediatric patients and in patients with special needs." (GH)
1-40 What are the most important AHCPR guidelines for pain control?
"After an exhaustive review of the scientific evidence, a public forum, and consultations with relevant organizations and experts in clinical practice, a guideline for acute pain management was developed, peer reviewed, and tested in practice settings. While not all acute pain can or should be eliminated, the panel found that several alternative approaches, when appropriately and attentively applied, adequately prevent or relieve pain. These alternative approaches are incorporated in the guideline.
"The guideline also recognizes that patients have variable medical and surgical conditions, responses to pain and interventions, and personal preferences. It offers clinicians, therefore, a flexible approach to acute pain management. The guideline recommends a collaborative, interdisciplinary approach to pain control that includes all members of the health care team and input from the patient and the patient's family when appropriate. Whenever possible (ie., for scheduled operations and procedures), an individualized pain control plan should be developed and agreed on pre-operatively by patients and practitioners. Assessment and frequent reassessment are critical to successful management of acute pain, and the patient's self-report should be the principal barometer of pain intensity and relief. Special efforts should be made to elicit accurate pain reports from children, non-English speaking patients, and others who may have difficulty communicating their pain.
"The guideline also includes the following recommendations:
"* Early intervention to control pain before it becomes established, including treatment before, during, and after surgery;
"* Aggressive use of both pharmacologic and non-pharmacologic therapies to control and/or prevent pain;
"* Use of non-pharmacologic interventions, including education, relaxation, distraction, imagery, massage, application of heat or cold packs, electro- analgesia, and other means that can reduce the need for drugs for mild pain and enhance pharmacologic treatment of moderate to severe pain;
"* Pharmacologic treatment administered around the clock, rather than as needed;
"* Careful monitoring (patient self-reports, behavioral, and physiological evaluations) every 2 hours while awake for 24 hours after surgery;
"* Patient-controlled analgesia, when available and judged appropriate by the clinician;
"* Use of non-opioids (acetaminophen and non-steroidal anti-inflammatory drugs), either alone or with opioids, to control mild to moderate pain;
"* Use of opioids (eg., morphine, codeine) for moderate to severe pain;
"* Intravenous administration of opioids when oral intake is problematic;
"* Spinal analgesia (epidural opioid and/or local anesthesia);
"* Neural blockage with regional (injected and topical) anesthetics;
"* Other agents, such as nitrous oxide and ketamine hydrochloride, when trained personnel and appropriate monitoring are available;
"* Development of an institutional quality assurance/education program to monitor the provision of effective pain relief. "The guideline includes recommendations for infants, children, and adolescents; elderly patients; patients with alcohol or other drug abuse problems; and other patients with special needs (including obstetric patients and those who have procedures outside of the operating room). It also includes procedures for site-specific pain control, analgesic dosage tables for adults and children, sample pain assessment tools, examples of non-pharmacologic interventions, and pre-operative and post-operative pain management flow charts." (GH)
1-41 Is the last year of life usually so painful that dying earlier and quickly would be preferable?
Not according to the only two studies the author has been able to find. "In one study, researchers at the Philadelphia Geriatric Center analyzed the last year of life of 200 elderly persons living outside nursing homes. They found that 82% had a majority of 'high-quality' months, one in four never or seldom experienced pain, and two out of three were mentally alert most or all of the time. In the other study, the Federal National Institute on Aging studied the cases of more than 1,200 elderly persons who died in Fairfield County, Conn. in 1984-1985. They found that 80% had 'no difficulty with orientation or recognizing family as late as one month before death', more than half died in their sleep, almost a quarter were in good or excellent health a month before death-52% could breathe freely, 61% had no pain and 69% were not taking pain medication." (CO)
REFERENCES
(AN) Anesthesiol Clin. North Am. 1989; 1-15
(CO) Columbia Magazine Jan. 1992, p5
(DF) World Book Dictionary (1987) Definition of pain, p1495
(DI) Discovery Magazine 6/91, p52
(DO) Dorland's Illustrated Medical Dictionary 23rd edition
(FO) Lawrence V. Foye, MD, Director of Education Services of Veterans Administration, formerly with National Cancer Institute, testimony before U.S. Senate Special Committee on Aging, 7 Aug. 1972
(GH) The Good Health Magazine 26 Apr. 1992, p12 et seq. "The Big Hurt" by Ronald Kotulak
(JA) Journal of Am. Med. Association 20 May 1992 V267 #19 p2580
(JP) "Correlation of Patient and Care Giver Ratings of Cancer Pain" Vol. 6 No. 2 Journal of Pain and Symptom Management, Feb. 1991 p53
(LA) Care of the Dying Richard Lammerton, M.D. (1975) reprinted with permission of U.K. publisher by LIFE 900 N Broadway, #725, Santa Ana, CA 92701 p106
(PM) "Pain Management" by Matthew E Conolly, MD, Associate Professor of Medicine and Pharmocology, UCLA, Issues in Law & Medicine, Vol 4 No. 4, p500 (1989)
(PA) Pain 1987; 30:69-78
(PS) "Correlation of Patient and Care Giver Ratings of Cancer Pain" Journal of Pain and Symptom Management, Feb. 1991, Vol. 6 No.2 p53
(RE) Orange County, CA Register 18 June 1992 pB6
(SA Sanders, C.M. "Treatment of Intractable Pain in Terminal Cancer" Proceedings of Royal Society of Medicine, 1963, vol. 56, p191
(SC) "Cloning of a Delta Opioid Receptor by Functional Expression" Evans, et al. Science 12/18/92, p1952-1955, related articles 1882-1884, 1946-1948
Chapter 2
HOW TO PROTECT YOUR LOVED ONES FROM NONPHYSICAL PAIN
2-1 What is depression?
2-2 What causes depression?
2-3 What is the solution for depression?
2-4 What are the major anti-depressant medications?
2-5 Why are ill and terminally ill patients more prone to depression?
2-6 What is the leading cause of depression in terminally ill patients?
2-7 How is depression in an ill or terminal patient best controlled?
2-8 How are chemically caused depressions controlled?
2-9 How many American adults suffer from depression?
2-10 Do many terminally ill patients become depressed?
2-11 When are terminally ill patients most likely to be depressed?
2-12 What percentage of depressed terminally ill patients could have their depression relieved by appropriate treatment?
2-13 What percentage of depressed terminally ill patients actually are treated by measures designed to control their depression?
2-14 What should we do to relieve the depression of terminally ill loved ones?
2-1. What is depression?
The term "depression" has two related meanings. A normal healthy person is subject to mood swings and becomes depressed at times, but this is not the type of depression psychiatrists discuss and treat. A person is said to be depressed when the depth or duration of the depressed condition exceeds that experienced by healthy people. Psychiatrists define depression as a mental disorder characterized by prolonged feelings of despair and dejection, often accompanied by fatigue, headaches, and other physical symptoms. (DF)
Symptoms of depression include: "* Persistent sad, anxious, or 'empty' mood * Feelings of hopelessness, pessimism * Feelings of guilt, worthlessness, helplessness * Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex * Insomnia, early-morning awakening, or oversleeping * Appetite and/or weight loss or overeating and weight gain * Decreased energy, fatigue, being 'slowed down' * Thoughts of death or suicide; suicide attempts * Restlessness, irritability * Difficulty concentrating, remembering, making decisions * Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain". (NI)
2-2. What causes depression?
Depression can result from physical, chemical, medical, emotional, or other causes, such as depressing events, or from any combination of causes.
Depression can be caused by a body chemical imbalance. An imbalance can make a patient more susceptible to depression so that physical or emotional stress can trigger the onset of depression.
Depression can also be caused by physical events, such as use of illegal drugs or severe or long-lasting pain. (Most patients do not know that most deaths are painless, and where there is pain, experts tell us it can always be controlled.)
Depression can be caused by emotional events or by fear. Fear of one's now evident mortality can be significant during terminal illnesses.
Depression can be caused by symptoms such as sleeplessness or inability to eat.
"Some types of depression run in families, indicating that a biological vulnerability can be inherited....However it can also occur in people who have no family history of depression.
Whether inherited or not, major depressive disorder is often associated with having too little or too much of certain neurochemicals.
"Psychological makeup also plays a role in vulnerability to depression. People who have low self esteem, who consistently view themselves and the world with pessimism, or who are readily overwhelmed by stress are prone to depression.
"A serious loss, chronic illness, difficult relationship, financial problem, or any unwelcome change in life patterns can also trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder." (NI)
Causes of depression can add up. For example, a patient might be able to handle fear of disease, then lose control because of fear of abandonment. This makes loving compassionate medical care critically important, because it leaves fewer potential causes of depression to be born by the patient. It is the duty of a care giver to attempt to remove enough causes of depression so that the patient can handle what remains. Some diseases such as lyme disease which can be caused by a tick bite can cause depression.
2-3. What is the solution for depression?
The solution for most serious depression is proper care. It involves finding the causes of the depression, whether medical, emotional, life style, or other causes, and then applying the appropriate known measures to prevent depression from continuing. In the same way, the depression of most ill people and most terminal patients can be controlled. Some hospice experts such as Lammerton have stated that the depression of all terminally ill patients can be controlled so that there need never be a request for euthanasia. (LA)
2-4 What are the major anti-depressant medications? Three groups of anti-depressant medications are most often used to treat depressive disorders:
tricyclics, monoamine oxidase inhibitors (MAOIs), and lithium (manic depressive syndrome). (NI)
Recent years have seen a vast increase in the number of available anti-depressant drugs, with many new drugs discovered that act on the brain to increase chemicals that otherwise are reduced during depressed episodes.
2-5 Why are ill and terminally ill patients more prone to depression?
Since we would rather be healthy, illnesses and terminal conditions are depressing events. Physical changes such as weakness, chemical, medical and other changes associated with illness or a terminal condition can cause depression.
2-6 What is the leading cause of depression in terminally ill patients?
The leading cause of depression in terminally ill patients is uncontrolled or improperly controlled pain. (LA) People can tolerate a substantial level of pain when they believe that the pain will be relieved, but if a patient loses hope that the pain will be controlled and believes, however wrongly, that the pain will never end, he may become severely depressed. This is unfortunate, especially since all physical pain can be controlled. (See chapter 1 for physical pain control.)
Learning of a serious disease is the second leading cause of depression in terminal patients. The sudden replacement of the prospect of a healthy future with the expectation of imminent death accompanied by unknown complications from the terminal illness can result in an immediate intense depression. This depression is caused by inevitable comparisons such as: "I was healthy, but now I will never be healthy again. I have been relatively pain free, but now I may be facing increasing pain. I was free, but now I am going to be increasingly limited." While it is normal for a patient to be temporarily depressed when he learns he has a terminal illness, most patients adjust to the bad news and come out of the depression by focusing on the necessary things to be done and the remaining life to be lived.
According to Richard Lammerton, M.D., who assisted Dr. Saunders in developing the modern hospice, a patient will always come out of the depression caused by learning he has a terminal condition, provided his pain is controlled and he receives reasonable emotional support. (LA) 2-7 How is depression in an ill or terminal patient best controlled?
Depression in ill or terminal patients can best be controlled by determining the causes of the depression, and then eliminating or controlling them as much as possible. To control depression, hospice organizations have used the following strategy:
(a) control the patient's pain;
(b) provide the patient with loving emotional support, since troubles can be borne more easily if we feel loved; and
(c) attempt to relieve any depression caused by chemical or medical problems by controlling those problems. (LA)
2-8 How are chemically caused depressions controlled?
A number of drugs are now used to neutralize chemical imbalances that would otherwise cause depression. (NI)
2-9 How many American adults suffer from depression?
"During any 6-month period, 9 million American adults suffer from a depressive illness." (NI)
2-10 Do many terminally ill patients become depressed?
Most patients suffering a long terminal illness at some time may also suffer from at least mild depression. Sadly, depression in terminally ill patients is too seldom adequately diagnosed and treated.
2-11 When are terminally ill patients most likely to be depressed?
Patients are most likely to be depressed shortly after first learning or suspecting that they have a terminal illness. In most cases, after a transition time, this initial depression diminishes or disappears.
2-12 What percentage of depressed terminally ill patients could have their depression relieved by appropriate treatment?
Substantially all depressed terminally ill patients could receive substantial relief for their depression. (LA)
2-13 What percentage of depressed terminally ill patients actually are treated by measures designed to control their depression?
Sadly, only a tiny percentage of depressed terminally ill patients receive care designed to relieve their depression.
2-14 What should we do to relieve the depression of terminally ill loved ones?
First, do not place too heavy a burden on the physician. Many physicians do not perform well outside their specialty, especially when venturing into such areas as pain and depression. Second, understand that the depression of your loved one is normal to his condition. Make him feel loved and cared for by doing nice things and acting pleasantly. Make certain he knows he will never be abandoned physically, emotionally or otherwise. Third, observe your loved one for signs of a depression requiring professional help. Fourth, if appropriate, discuss your loved one's situation with nurses who spend time with him and have seen many similar patients. Their experience may help you decide if additional action is warranted. Fifth, when necessary, ask for a consultation with a physician especially trained in the diagnosis and treatment of depression. Sixth, seek additional information, if needed. Seventh, seek a sympathetic religious counselor.
REFERENCES
(DF) World Book Dictionary (1987) p562
(LA) Care of the Dying, Richard Lammerton, MD of St Joseph's Hospice, The Care and Welfare Library, outlines proper care of the dying, which includes control of depression.
Lammerton was one of the first two doctors to specialize in hospice care. Pages 114-140 are perhaps the best, but other parts of the book may also be helpful. (NI)
"Plain Talk About Depression" (1992) U.S. National Institute of Mental Health Office of Scientific Information
CHAPTER 3
ADVANCE DIRECTIVES FOR HEALTH CARE, INCLUDING LIVING WILLS AND DURABLE POWERS OF ATTORNEY
3-1 What is an advance directive for health care?
3-2 Should most people sign an advance directive for health care?
3-3 Are advance directives for health care legally enforceable?
3-4 What are the main types of advance directives?
3-5 Must advance directives for health care be written?
3-6 What experience shows that advance directives for health care should be in writing rather than oral?
3-7 Does the Federal Patient Self Determination Act require you to sign an advance directive for health care?
3-8 Why are advance directives for health care important?
3-9 What does the durable power of attorney for health care do?
3-10 Are there any limitations on the power of the "attorney in fact"?
3-11 What is the disadvantage of having a durable power of attorney for health care?
3-12 What is the advantage of a durable power of attorney for health care?
3-13 What does the advance directive relating to future medical care do?
3-14 Does the author recommend that patients sign an advance directive relating to future medical care?
3-15 What are the apparent advantages of advance directives relating to future medical care?
3-16 What are the disadvantages of advance directives relating to future medical care?
3-17 How many have signed advance directives of any kind for future medical care?
3-18 What is a living will?
3-19 Can living wills improve medical care?
3-20 What does experience say about living wills?
3-21 What is the most important factor causing patients to choose euthanasia?
3-22 What are directives to kill?
3-23 Can an informal statement cause you to be starved to death?
3-24 What is it like to die of dehydration in a hospital setting?
3-25 What fundamental difference has modern medical technology caused which has made advance directives seem more important?
3-26 Why have advances in medical technology caused pressure for euthanasia?
3-27 What arguments related to improved medical care lead some to favor killing patients?
3-28 Does each person have the legal power to control his medical treatment?
3-29 Who controls medical treatment for people who are not able to control their own medical treatment?
3-30 What is "an informal statement not intended to control medical care"?
3-31 Did Nancy Cruzan, whose case reached the U.S. Supreme court in 1989, die because of an oral informal statement?
3-32 What is a patient protective document such as a "loving will" or "will to live statement"?
3-33 Have all states made at least some advance directives enforceable?
3-34 What is the advantage of a durable power of attorney?
3-35 What is the disadvantage of a durable power of attorney?
3-36 What is the best protection against too much or too little medical treatment when a patient is disabled and may be near death?
3-37 How can the defects of a durable power of attorney best be corrected?
3-38 How can you make a simple document best control each of the thousands of possible conditions which might occur if you become disabled?
3-39 How do I best protect myself from euthanasia and both too much or too little medical care if I become incompetent?
3-40 What type of advance directive is best?
3-1 What is an advance directive for health care?
An advance directive for health care is a statement made by a person which is meant to control a decision about his future medical treatment if he should become incompetent. An incompetent person is, because of illness, injury, or other condition, unable to control his medical care. Some state laws call advance directives for health care by other names.
3-2 Should most people sign an advance directive for health care?
No. It is preferable for the average person to do nothing, or just discuss his feelings about health care with one or more relatives, friends or doctors.
3-3 Are advance directives for health care legally enforceable?
All fifty states now make specified types of advance directives for health care enforceable. Either or both of the durable power of attorney for health care and advance directive relating to future medical care are enforceable in every state. Less radically worded living wills are enforceable. Federal law requires that patients be asked if they have signed an advance directive.
3-4 What are the main types of advance directives?
The six main types of advance directives are:
(a) durable powers of attorney for health care;
(b) advance directives relating to future medical care, legal pursuant to law;
(c) living wills which are pro euthanasia statements permitting killing by cutting off food and water or other care or by other means;
(d) directives to kill which permit active euthanasia or assisted suicide; they are usually known by misleading euphemisms such as "aid in dying" and are legally enforceable only in the Netherlands.
(e) informal statements which were not intended to control medical care but are later used by a court for that purpose; and
(f) protective advance directives which are designed to prevent a patient from being killed by the cutting off of care, food or water. An example is the Loving Will published by American Life League.
You never have to sign any advance directive.
3-5 Must advance directives for health care be written?
No. Oral advance directives for health care can be but need not be given legal effect. However, with oral advance directives witnesses may forget, lie, misinterpret or otherwise confuse or change what was said.
3-6 What experience shows that advance directives for health care should be in writing rather than oral?
Many courts have made decisions about medical care of incompetent patients. Many of these courts have decided to cut off food and water to the patient based on alleged oral statements made by the patient, thereby causing the patient's death.
3-7 Does the Federal Patient Self Determination Act require you to sign an advance directive for health care?
No. The Federal Patient Self Determination Act 42 USC1395 cc(f)(1), 1396a(a), requires that health care providers such as hospitals tell you that you can prepare an advance directive for health care. However, you are not required to sign an advance directive for health care. You cannot be discriminated against for failure to sign an advance directive.
3-8 Why are advance directives for health care important?
Advance directives for health care give other people instructions relating to the power of life or death over an incompetent patient. By selecting or rejecting medical or other care such as food or water, advance directives can either permit a patient to live or cause his death. Many incompetent patients have died after their water and other fluids were cut off because some judge ruled that death would be their wish if they could be asked.
DURABLE POWER OF ATTORNEY FOR HEALTH CARE
3-9 What does the durable power of attorney for health care do?
A durable power of attorney for health care names one or more adults who need not be lawyers as attorney in fact. The attorney in fact is given power to select, accept or reject future medical care if the patient is considered incompetent (unable to make these decisions). No one ever has to sign a durable power of attorney for health care.
3-10 Are there any limitations on the power of the attorney in fact?
While limitations can be placed on the power of an attorney in fact, the typical durable power of attorney for health care places few or no limitations. The attorney in fact usually should be given written instructions by the patient, such as are found in the American Life League Loving Will.
3-11 What is the disadvantage of having a durable power of attorney for health care?
Since the attorney in fact has power to accept, select or reject medical care, he has nearly total control over your body if you are incompetent. He could make a different decision than you would have made, a decision which might lead to your death. This is a heavy burden. No one ever has to sign a durable power of attorney.
3-12 What is the advantage of a durable power of attorney for health care?
By naming one or more people as attorneys in fact, you give them all power to control decisions related to your medical care, so other people cannot later claim to express your wishes. This can be important if you trust someone else more than your closest relatives, or if you want to give one relative preference over others. In the absence of a durable power of attorney for health care, your doctor will normally discuss life and death decisions with your closest relatives. You can then express your desires for care with your attorney in fact in as much detail as you feel appropriate. If you do sign a durable power of attorney for health care or any other advance directive related to medical care, the author suggests that the document should state:
"Euthanasia by act or omission is not among the powers granted by this document, nor is power to cut off food and water while my body can still benefit from them."
ADVANCE DIRECTIVE RELATING TO FUTURE MEDICAL CARE
3-13 What does the advance directive relating to future medical care do?
The advance directive relating to future medical care is the name given in this book to the documents, legally enforceable by various state laws, which a person may sign to control which forms of medical care may be cut off if he becomes incompetent. The name for the advance directive relating to future medical care and the types of patient care to be cut off under different conditions vary by state. Some states permit even food and water to be cut off.
The advance directive relating to future medical care states conditions under which stated types of medical or other care should or should not be given if the patient becomes incompetent. In theory, the directive permits medical care givers to know a patient's wishes if that patient becomes unable to state an opinion.
In real life, the possible number of situations related to a patient's medical care is so great and the possible conditions are so unpredictable that many doctors and other experts feel advance directives relating to future medical care usually do more harm than good.
3-14 Does the author recommend that patients sign an advance directive relating to future medical care?
No. Prior to writing this book, the author read the advance directives relating to future medical care in every current state law and found all of them too simple and insensitive, and more likely to do harm than good.
3-15 What are the apparent advantages of advance directives relating to future medical care?
1) Advance directives appear to give competent persons control over medical decisions at a future time when they might become incompetent. They appear to empower people by extending the perceived scope of personal autonomy to possible situations in the future where actual autonomy cannot be exercised because the person is no longer competent.
2) Advance directives, if specific enough, seem to permit a patient to control his future by providing a workable rule for treatment and non- treatment decisions. The directives seem to respect autonomy by presently applying rules stated previously by patients who have since become incompetent. However, an advance directive permits treatment to be stopped if certain conditions are met, thereby usually causing the patient's death.
3) By permitting medical care to be cut off (usually causing the patient to die), the amount of money spent on medical care can be reduced.
3-16 What are the disadvantages of advance directives relating to future medical care?
A person who has a trusted primary doctor or a close relative likely to make reasonably good decisions should he become incompetent is usually much better off not signing an advance directive. The typical advance directive cannot foresee even one percent of the countless billions of very different possible future situations, only one of which will apply to a patient at any given time. They are a one size fits all document. A really good advance directive would probably have to be the size of a large dictionary to specifically cover a sufficient number of possible medical decisions, then would have to be updated each year to account for advances in medical technology.
A patient's interests when signing an advance directive are not likely to be the same as later if he becomes incompetent. Yet one premise of the advance directive relating to medical care is that a patient's interests and values remain significantly the same, so that those interests are best served by following the directive signed when the patient was competent. When anyone's situation changes drastically, his interests and preferences also change. There are many stories of patients who were grateful for a treatment after recovery in spite of contrary orders in an advance directive. Please see chapter 5 for examples of why it is frequently impossible for an advance directive to fulfill a patient's wishes. (RO)
It is doubtful whether many of those signing advance directives have truly given informed consent to a future probably fatal withdrawal of medical treatment. Any consent given was probably based on insufficient knowledge for the consent to be informed. In most cases, those signing can not have foreseen their future situations with enough specificity, nor can they have understood their future options nor can they have been sufficiently informed about the conflict between their present interests while signing the document and their future interests when and if they become incompetent.
3-17 How many have signed advance directives of any kind for future medical care?
As of the writing of this book, no estimate seen by this author states that more than a tiny minority of Americans have signed any form of advance directive for future medical care.
LIVING WILLS
3-18 What is a living will?
The living will was introduced at a pro-euthanasia meeting as an advance directive relating to future medical care which is heavily slanted toward euthanasia and is about dying, not living. A living will asks that the patient who signed it be killed if he has any of a number of physical problems or disabilities. The language is chosen to sound to the signer as if problems or disabilities which need not be serious make life too burdensome to continue. A living will can cause someone to die when there is still an excellent chance for full recovery or recovery with bearable residual problems. A living will assumes that if any of its stated conditions occurs, no meaningful quality of life remains and the patient is better off dead. Living wills came out of the euthanasia movement for the express purpose of progressing from passive euthanasia to active euthanasia.
3-19 Can living wills improve medical care?
No. No living will states: "I want the appropriate treatment consistent with my medical diagnosis, yet this is why we employ doctors. Doctors already have a duty to give patients the best care possible under the circumstances. Over this prior existing duty, a living will places a pro-euthanasia statement that is so ambiguous it can cause a doctor or someone else to kill a patient by direct action or by omitting medical care that the doctor is otherwise necessary.
3-20 What does experience say about living wills?
Thousands of people have expressed a wish to die if some feared disability should befall them. To their surprise, if they later became disabled, they found that life was still precious and they still wanted to live. While they originally viewed their choice as one between life as a healthy person and life as a disabled person, in reality it is a choice between life and death. If cared for physically and emotionally, essentially everyone who is disabled chooses life. The typical patient entering a hospital to face a disease such as cancer will feel that they want to die quickly, before they feel the cancer's worst pain. Surprisingly, after feeling the worst pain, they typically change their mind and appreciate what life remains.
3-21 What is the most important factor causing patients to choose euthanasia?
Lack of emotional support and a failure to give reasonably good medical care are the main reasons people seek euthanasia. Patients given reasonable emotional support and reasonably good medical care do not choose euthanasia. (LA)
DIRECTIVES TO KILL
3-22 What are directives to kill?
Directives to kill permit a patient to be killed under certain conditions. At the time of publication they are illegal every place except in Holland where judges made them legal by court decisions in which they refused to prosecute doctors who killed. In perhaps half of Holland's cases, the patient is killed without giving consent in any way. (FE)
In 1994, Oregon voters passed by 51-49% an initiative giving doctors the right to prescribe, but not administer a fatal dose to kill a patient. The initiative was prevented from going into effect because Federal law does not permit such a prescription.
3-23 Can an informal statement cause you to be starved to death?
Yes, although usually in cases where starvation is ordered, food and water have both been cut off, and the patient usually died of dehydration before starving to death.
3-24 What is it like to die of dehydration in a hospital setting?
Technically, nobody knows, because those who have died cannot tell us. It is possible, however to observe symptoms as the patient's body loses the necessary fluids. In the case of "In re Matter of Brophy", Judge Kopelman adopted as his finding the following expert medical testimony: "If food and water were withheld from Brophy pursuant to the guardian's request, his prognosis would be certain death from starvation, or more probably from dehydration, which would occur within a period of time ranging from a minimum of five days to a maximum of three weeks.
"During this time, Brophy's body would be likely to experience the following effects from the lack of hydration and nutrition.
(a) His mouth would dry out and become caked or coated with thick material.
(b) His lips would become parched and cracked or fissured.
(c) His tongue would become swollen and might crack.
(d) His eyes would sink back into their orbits.
(e) His cheeks would become hollow.
(f) The mucosa (lining) of his nose might crack and cause his nose to bleed.
(g) His skin would hang loose on his body and become dry and scaly.
(h) His urine would become highly concentrated, causing burning of the bladder.
(i) The lining of the stomach would dry out, causing dry heaves and vomiting.
(j) He would develop hyperthemia, a very high body temperature.
(k) His brain cells would begin drying out, causing convulsions.
(l) His respiratory tract would dry out, giving rise to very thick secretions, which could plug his lungs and cause death.
(m) Eventually his major organs would fail, including his lungs, heart and brain. (BR)
3-25 What fundamental difference caused by modern medical technology has made advance directives seem more important?
Modern medical technology is continually improving. Life expectancy has increased by thirty years in the past century. We now know more ways to interrupt, stop or slow the dying process.
While the most effective healing techniques return patients to good health, a number of others merely slightly improve the patients' health, leaving them living, but not in ideal health.
3-26 Why have advances in medical technology caused pressure for euthanasia?
When medical care was less sophisticated, critically ill patients usually died quickly. Now, in some cases, critically ill patients can be kept alive, even though they are not in medically good condition. The cost of keeping alive patients with some illnesses, injuries or disabilities can be quite high. Since many patients receive government assistance for paying medical bills, any increase in numbers of patients requiring medical care increases cost to the government.
Sophisticated new technologies enable many more critically ill patients to survive, many of these patients can only be kept alive at great financial cost and under conditions of partial or total disability.
3-27 What arguments related to improved medical care lead some to favor killing patients?
We might become injured or ill so that we are unconscious, incompetent or physically disabled, but still alive through modern technology. Under these conditions, some might consider death to be preferable. The increased cost of medical care tempts some people to reduce medical costs by eliminating patients.
3-28 Does each person have the legal power to control his medical treatment?
Each adult usually has the legal power to control his medical treatment, power which can be lost only if the adult loses competence. Because children and adolescents may not yet have developed the ability to think with the maturity and experience necessary to make major medical decisions, the law requires parental consent or the equivalent before medical treatment of minors. This power does not extend to any alleged right to kill oneself if the minor is competent.
3-29 Who controls medical treatment for people who are not able to control their own medical treatment?
For a minor, the parents or guardians, with advice from the doctor, control medical treatment. For an adult who has lost the ability to control his medical treatment, the power may be controlled, depending on the circumstances, by his doctor, relatives, guardian, his own prior statements, or a court order. A patient's prior statements may be oral or written.
INFORMAL STATEMENTS NOT INTENDED TO CONTROL MEDICAL CARE
3-30 What is "an informal statement not intended to control medical care"?
"An informal statement not intended to control medical care" can be any statement, either written or oral. It will not necessarily have any effect on medical decisions (it can be ignored), but it can have a decisive effect, even, as in the Cruzan case, causing the patient's death. (CR)
3-31 Did Nancy Cruzan, whose case reached the U.S. Supreme Court in 1989, die because of an oral informal statement?
Yes. Nancy's parents asked the hospital to starve her to death. When the hospital refused, the parents sued and won in the trial court. When the State of Missouri appealed, The Missouri Supreme Court reversed the trial court's decision and held that Missouri law did not require Nancy to be starved. The U.S. Supreme Court upheld the Missouri decision and ruled that there is no U.S. Constitutional Right to Die. (CR) (Only the Right to Life, not any Right to Die, is mentioned in the U.S. Constitution, Amendments 5 and 14). Nancy's parents then found another witness who claimed that before she became disabled, Nancy had made an oral statement, ruled by the judge as sufficient clear and convincing evidence, that Nancy would have wanted her food and water discontinued. Nancy's food and water were cut off, and she died of thirst a few days later. No appeal was taken from this second court decision.
PATIENT PROTECTIVE DOCUMENTS
3-32 What is a patient protective document such as a "loving will" or "will to live statement"?
A "loving will" or "will to live" statement attempts to protect a patient from having medical or other care cut off if he is disabled. Signing a loving will published by American Life League or other patient protective document can possibly protect a patient's life by establishing what he really wants done in writing, so contrary statements of what he allegedly said do not result in a pro-euthanasia judge issuing an order to have him die of thirst.
3-33 Have all states made at least some advance directives enforceable?
Yes. Nearly all states have made enforceable durable powers of attorney and advance directives relating to medical care. State law specified advance directives are usually less slanted toward killing and less ambiguous than living wills. Nevertheless, even these laws suffer from too much ambiguity. Signing an advance directive relating to medical care may cause a patient to die before he is ready.
3-34 What is the advantage of a durable power of attorney?
Courts appoint people to control medical care and to decide whether to cut off food and water for incompetent patients. The advantage of a durable power of attorney is that you choose the person who will decide. This enables you to choose somebody who knows your wishes and moral values.
3-35 What is the disadvantage of a durable power of attorney?
The person exercising the durable power of attorney usually has little medical knowledge.
Additionally that person may be emotionally overwrought due to stress caused by the patient's illness. Further, the patient's actual medical condition usually has only a general relationship with any conditions discussed when the patient was competent. Finally, the person exercising the power is, to a great extent, at the mercy of the primary treating doctor, who can slant medical information either way to make it look like further medical care is or is not warranted.
3-36 What is the best protection against too much or too little medical treatment when a patient is disabled and may be near death?
The best protection is a competent and wise doctor, profoundly respectful of human life, who sympathizes with the patient's philosophy of life and afterlife. A doctor, by virtue of his position and knowledge, has tremendous influence on life and death decisions. A patient should learn his doctor's philosophy and not hesitate to switch to a different doctor if appropriate. It may also be helpful for a patient to discuss his feelings towards his doctor if appropriate. It may also be helpful for a patient to discuss his feelings towards his care in various situations with the doctor.
3-37 How can the defects of a durable power of attorney best be corrected?
The typical durable power of attorney permits one designated person to stop medical treatment but has no controls to prevent bad decisions. One way to prevent bad decisions is to name more than one attorney in fact and require them to a approve a decision unanimously before medical care is cut off. Also, discuss your philosophy with your attorneys in fact. Additionally, you can sign a will to live document and require your attorneys in fact to abide by it, or you can incorporate by reference a statement against euthanasia such as the Vatican Declaration on Euthanasia. (VA) The author would add:
"Euthanasia by act or omission is not among the powers given by this document."
3-38 How can you make a simple document best control each of the thousands of possible conditions which might occur if you become disabled?
A simple document can incorporate by reference a more complicated set of guidelines such as the Vatican Declaration on Euthanasia.
3-39 How do I best protect myself from euthanasia and both too much or too little medical care if
I become incompetent?
Formerly, it was probably best to do nothing except talk to your relatives and doctor. However, even without laws that permit the killing of the incompetent, judges have recently issued a substantial number of orders cutting off food and water for the purpose of killing disabled patients. Accordingly, many are now saying that it is best to make a written statement unless your closest relatives know and agree with your wishes.
3-40 What type of advance directive is best?
If you have confidence in your relatives, but want to give them a bit of support, perhaps some short informal written statement would be best. If you respect the Catholic analysis of euthanasia, you might want a statement that nothing be done to you contrary to the Vatican Declaration on Euthanasia. If you want a more formal loving will document or related information, write for information to ALL, PO 1350, Stafford, VA 22555.
REFERENCES
(BR) Judge David H. Kopelman, "In re Matter of Brophy", Massachusetts
(CR) See Cruzan V Director, Mo. Health Dept, (1990) 111 L Ed 2d, p324
(FE) "The Report of the Dutch Governmental Committee on Euthanasia" by Richard Fenigsen, MD, PhD, Issues in Law and Medicine, Vol 7, No 3, Winter 1991, p344
(FP) Patient Self Determination Act of 1990 (Medicare Self Determination Act) Pub Law No. 101-508, Sec. 4206, 4751,
(RO) John A. Robertson "Second Thoughts on Living Wills" Hastings Center Report, Nov-Dec 1991
(VA) See Chapter 21 for a copy of the Vatican Declaration on Euthanasia
CHAPTER 4
DOCTORS CRITICIZE ADVANCE DIRECTIVES FOR FUTURE MEDICAL CARE
4-1 What do detailed advance directives for future medical attempt to do?
4-2 What is the main disadvantage of detailed advance directives?
4-3 What is the Medical Directive?
4-4 Describe the options the Medical Directive gives the patient.
4-5 Ideally, how are difficult medical decisions made?
4-6 Why does the detailed advance directive fail to answer the questions that really matter?
4-7 How can detailed advance directives such as the Medical Directive contradict the patient's goals?
4-8 What is the inherent weakness of detailed advance directives such as intervention-focused directives for future medical care?
4-9 Why can't you just make the advance directive more detailed?
4-10 Why can't you incorporate an escape mechanism that enables a proxy to override the advance directive in certain cases?
4-11 What are some disadvantages of elaborately detailed advance directives such as the Medical Directive?
4-12 What are some disadvantages of values histories advance directives?
4-13 How does a living will tie the doctor's hands in cases where he might be able to do great good?
4-1 What do detailed advance directives attempt to do?
Regular advance directives for future medical care have been criticized for doing more harm than good because they do not give instructions in sufficient detail to help a physician know what a patient might want done in many medical situations. Detailed advance directives attempt to solve this deficiency by providing more instructions, hoping to increase the patient's self determination by substituting his judgment when the patient was competent. Thus, the judgment of a patient while competent but unaware of future medical situations is used to advise a physician later when the same patient is experiencing a medical situation while longer competent.
4-2 What is the main disadvantage of detailed advance directives?
Detailed advance directives usually give a doctor instructions as to whether or not he should treat in about a hundred possible future care situations. These directives give a patient false confidence that instructions have been provided for everything or nearly everything possible. Unfortunately, even a million scenarios are only a very small percentage of the possible future care situations. Accordingly, the possible number of future medical care situations for a patient which must include combinations of medical problems, is many billions. Accordingly, in many cases, the future medical problem with its complications will not be one of those foreseen by the patient, so that the directive could do more harm than good.
4-3 What is the Medical Directive?
The Medical Directive, a very detailed advance directive distributed by the Harvard Medical School Health Letter, is specific and focuses on selected examples of medical care such as discrete diagnostic and therapeutic interventions. Analysis of the Medical Directive illustrates the probable inability of any detailed advance directive to help the physician know what the incompetent patient would advise in a complicated future medical care situation.
4-4 Describe the options the Medical Directive gives the patient.
"Four hypothetical clinical scenarios are described, each representing a situation that involves altered mental status or coma, with or without an accompanying terminal illness. For each scenario, 12 possible medical interventions are listed (eg., mechanical ventilation, surgery, dialysis, diagnostic tests, antibiotics, transfusions). The person completing this document marks whether he or she would choose each therapy or procedure for each of the clinical scenarios. In other words, the person is asked to make 48 hypothetical clinical judgments. Although the document also provides space to name a proxy for health care decisions, and to give a narrative account of one's general wishes, its central feature is clearly its 4x12 grid (containing 48 possible examples of medical care decisions)." (BR)
4-5 Ideally, how are difficult medical decisions made?
"The patient's perspective is the usual yardstick by which we judge the appropriateness of medical interventions-life-sustaining and otherwise. Patients, however, do not select or reject diagnosis or therapeutic interventions in a vacuum; they choose interventions according to the clinical context in which they find themselves. Two basic contextual questions are relevant. "First, what are the plausible courses of medical care that could be provided for this patient, given the patient's medical and personal situation? And second, which of these possible courses is most desirable from the patient's perspective? If we can answer these questions, we are generally in a position to treat patients according to their conceptions of their own best interests.
"This thinking shifts the focus away from judging the appropriateness of medical interventions according to impersonal standards (eg. invasiveness) and toward a view of interventions as means to a patient-specified end. Thus, the use of mechanical ventilation, dialysis, or transfusions is appropriate or inappropriate primarily with reference to objectives such as living longer, living more comfortably, or dying more peacefully." (BR)
4-6 Why does the detailed advance directive fail to answer the questions that really matter?
"The person is given a clinical context (eg. advanced irreversible dementia) and asked whether he or she would choose an intervention (eg. use of antibiotics). But a problem quickly arises, because the person would be unable to choose or reject antibiotics categorically without knowing the reasons they were proposed and whether those reasons were consistent with his or her perspective. For example, assume the position of a person whose projected wish in such a context would not be longevity, but rather physical comfort until death ensues. This person might desire penicillin for a painful skin infection, but not a relatively toxic antibiotic such as amphotericin for a probably fatal systemic fungal infection. Or, the patient may not want an antibiotic for a virulent pneumonia that will lead to rapid death, but prefer an antibiotic for an indolent pneumonia that is not expected to result in death but is causing an uncomfortable cough and chest pain.
"The point here is that the check list of interventions does not answer the two questions that really matter:
1. What general views about medical care and life-sustaining treatment would this person espouse for the situation of advanced dementia? and
2. When those views are applied to the context of a specific infection will antibiotics produce a greater balance of benefits than burdens. The first question probably could be answered in advance, but the second could not." (BR)
4-7 How can detailed advance directives such as the Medical Directive contradict a patient's goals?
"Consider the case of one of my own patients who completed the Medical Directive: in the context of advanced dementia, he selected blood transfusions, but rejected diagnostic procedures such as upper gastrointestinal endoscopy. If that patient developed upper gastrointestinal bleeding, we would be asked to administer transfusions, while avoiding an endoscopic procedure that might not only be diagnostic but also therapeutic ( eg., by coagulating the bleeding site). If the patient's goal in these situations was a speedy death, he would likely not want either transfusions or endoscopy. If he wanted to continue to live, he would likely want both. But it is absurd to dissociate the two interventions by replacing blood losses but not performing a simple procedure to stop the bleeding." (BR)
4-8 What is the inherent weakness of detailed advance directives such as intervention-focused directives for future medical care?
"In summary, the intervention-focused directive runs the risk of promoting the selection or rejection of interventions because of their inherent characteristics, rather than as appropriate means to the ends that the patient would have wanted." (BR)
4-9 Why can't you just make the advance directive more detailed?
"...this refinement is logistically problematic (ie., the number of plausible combinations and permutations of interventions and clinical contexts is virtually limitless), and it still fails to give precedence to treatment goals." (BR)
4-10 Why can't you incorporate an escape mechanism that enables a proxy to override the advance directive in certain cases?
"If proxies or physicians are given license to override the patient's written choices according to their own conception of what is now 'medically reasonable,' little reason existed to complete a detailed check list in the first place." (BR)
4-11 What are some disadvantages of elaborately detailed advance directives such as the Medical Directive?
Elaborate advance directives such as the Medical Directive appear so complicated that they make the patient think they have covered most possibilities. If we consider secondary complications, the number of possible future medical conditions is so large that even the most elaborately detailed medical directive would shed light on only a tiny percentage of the possibilities. The Medical Directive might require some action to be taken or not taken which would be inappropriate in view of some secondary complication.
4-12 What are some disadvantages of "values history" advance directives?
Values history advance directives tell a doctor about the values the patient held while competent in the hope that such knowledge will assist in establishing general rules governing treatment. As with other advance directives, values history advance directives shed light on simple situations, but are frequently worse than no statement in complicated situations. Properly done, however, they can help a doctor apply his patient's general philosophy of treatment.
4-13 How does a living will tie the doctor's hands in cases where he might be able to do great good?
"The 'living will,' a document in which the patient permits and instructs his physician to let him die if his condition is hopeless, really solves nothing but does create problems of its own. The danger is that relatives, deciding for any number of reasons that active treatment should be stopped, will attempt, with or without legal support, to prevent the doctor from continuing his life-saving efforts, or that the doctor will find that the existence of such a document will be one reason' to terminate his active treatment. "In any case, the complex and difficult decisions faced during the care of the critically, and possibly terminally, ill patient are in no way going to be simplified by 'the living will,' which would merely convert a possibly fatal outcome into a certainly fatal one. "The 'right to die' concept implies that, if our death is certain and immediate we have the 'right' to make it even more immediate. The now obvious fallacy is that the patient or the doctor can know when death is certain. This is the 'hopeless case' problem in human rights clothing except that the 'right to die' is the one 'right"' we all are absolutely guaranteed at the moment of our conception.
"We must never forget that on occasion patients, their families, and their physicians will conclude that a disease has reached the hopeless stage and death is imminent-and be wrong. If they can stop treatment on the basis of their hopelessness, the prophecy becomes self-fulfilling.
"Whether the patient was going to die or not, their action ensures his death and the physician's confidence in his ability to predict death is dangerously enhanced. We must keep in mind that all medical therapy, curative or palliative, only prolongs life and hopefully improves its quality, or what we call its 'health.'
"Finally, what many laymen fear is that the doctor, in a pointless attempt to postpone death, will keep them in agony for long periods of time-the prolongation of suffering problem. A number of studies have shown, and this corresponds to my experience, that the majority of critically or terminally ill patients do not have pain and that those who do can be controlled by the judicious use of pain-killing medicines.
"It is essential that everybody understand that while a physician strives to cure a patient or to bring his incurable disease under control, suffering can be prevented and severe pain need not occur."
"We can now see that such approaches as legalized euthanasia and 'the living will' are based upon the misconception that the point of hopelessness can be known with accuracy and that the physician may uselessly prolong suffering beyond that point of hopelessness can be known with accuracy and that the physician may uselessly prolong suffering beyond that point unless forbidden by law or similarly excused from his obligation.
"I fear that, unless people understand the false reasoning behind these concepts, the physician's hands may be tied in just those cases where his skill and modern technology can make the greatest contribution to the saving of lives and the control of disease." (FO)
REFERENCES
(BR) "Limitations of Listing Specific Medical Interventions in Advance Directives" Allan S. Brett, M.D., Journal of American Medical Association, 8/14/91, Vol. 266, No. 6 P. 825
(FO) Testimony of Laurance V. Foye, MD, Director of Education Services of U.S. Veterans Administration, formerly with National Cancer Institute, before U.S. Senate Special Committee on Aging, 8/7/72
CHAPTER 5
WHAT YOU SHOULD CONSIDER ABOUT INTERPRETATION OF ADVANCE DIRECTIVES
5-1 What difference can the interpretation of advance directives relating to future medical treatment make?
5-2 What are the two main conflicting general standards for interpreting advance directives?
5-3 How does the best interests standard work?
5-4 What is considered so wrong about the best interests standard, that some consider the right to forego medical treatment method necessary?
5-5 How is the right to forego medical treatment method used to kill?
5-6 If I have signed an advance medical directive for future medical care, how do I protect myself from being killed by someone exercising my right to forego medical treatment?
5-7 What can you put into an advance directive to protect yourself?
5-1 What difference can the interpretation of advance directives relating to future medical treatment make?
The interpretation of an advance directive can be the difference between life and death. The nearly infinite number of possible disability conditions to which any advance directive relating to future medical treatment must be applied makes it impossible to explicitly cover more than a tiny fraction of the future possible conditions. Thus, the interpretation may be more important than what the directive states.
5-2 What are the two main conflicting general standards for interpreting advance directives?
The older standard used by courts is the "best interests" standard. Since it is not always easy to show that nontreatment is in someone's best interest, many courts have adopted a new standard called "substituted judgment". (See chapter 22) Substituted judgment is frequently used to exercise an alleged right to forego medical treatment for the purpose of killing the patient.
5-3 How does the "best interests" standard work?
When there is any ambiguity or any interpretation to be made, the document is to be interpreted to further the best interests of the patient.
5-4 What is considered so wrong about the best interests standard, that some consider the substituted judgment standard necessary?
It is usually difficult to show that non-treatment or non-feeding which everyone knows will result in the patient's death is in the best interest of the patient. So, if you seek non-treatment or non-feeding in order to kill a patient, some other method of interpretation that sounds good, but permits non-treatment and non-feeding, becomes necessary.
5-5 How is the "right to forego medical treatment" method used to kill?
Everyone will die if food is cut off. They will die much sooner if they receive no water or other fluids. If food and fluids are defined as medical treatment, then they can be cut off for the purpose of killing the patient. This killing is disguised as an exercise of the patient's right to forego medical treatment.
5-6 If I have signed an advance directive for future medical care, how do I protect myself from being killed by someone exercising my right to forego medical treatment?
Read your advance directive for future medical care carefully. Unless it covers every possible future event in the way you would wish (which this author believes to be impossible), or if you do not understand it completely, cancel your advance directive. You would not sign a will unless you understood it completely. Why sign a document that could kill you unless you understand it completely? You would be better off with no advance directive than with an imperfect advance directive. Realize that a doctor who favors killing incompetent patients is going to kill them in situations where other doctors would attempt to care for them. Learn your doctor's philosophy about treatment. It is your right to ask and his duty to answer. You should also discuss future care with a relative. If you still have any doubts about future care, it might be prudent to state in writing that your future medical care should not include euthanasia by act or omission, or in any way be contrary to the Vatican Declaration on Euthanasia or some similar protective document such as the Loving Will from American Life League.
5-7 What can you put into an advance directive to protect yourself?
Tell your relatives and/or doctor and state in your advane directive that: "Euthanasia by act or omission is forbidden by this document."
CHAPTER 7
FREEDOM TO REJECT UNWANTED MEDICAL CARE
7-1 Is there a legal duty to receive unwanted medical care?
No. In the Cruzan case, 111 L Ed 2d 224 (1990), the U.S. Supreme Court stated: "...the common-law doctrine of informed consent is viewed as generally encompassing the right of a competent individual to refuse medical treatment." (CR)
7-2 Why do euthanasia advocates tell horrible stories about people who have tubes, cannot die, and are being painfully treated without their consent and contrary to common sense?
These stories are usually embroidered and misleading fiction. The stories are told because they are horrible. Euthanasia advocates want the public to believe there are only two choices, euthanasia, and fictional over treatment which must be made to appear even worse so that euthanasia will be chosen as the lesser of two evils.
7-3 How many patients need tubes to prevent unbearable pain?
Very few. See chapter 1.
7-4 How do you draw the line between permissible allowing to die and killing?
In permissible letting die, the disease or condition is the cause of death. In killing by euthanasia, death is caused by one or more acts or omissions which are intended to cause death.
7-5 Is there a moral duty to accept extraordinary or disproportional care?
No, and there never has been. One does have a moral duty to avoid suicide and other forms of self destruction.
Chapter 8
THE DOCTOR/PATIENT RELATIONSHIP
8-1 If a person does not want to, must he see a doctor or enter a hospital?
8-2 Does a patient have to accept the doctor's advice if he does not want to accept it?
8-3 Does a patient have an absolute right to order the doctor to stop treating him or to stop a course of treatment that has begun?
8-4 If the doctor and patient communicate, will the patient discharge the doctor or ask to die?
8-5 What should the seriously ill patient be told?
8-6 Will the judgment of a well-informed family differ from the judgment of a well-informed physician?
8-7 What if conditions change so a previous decision is no longer correct?
8-8 What forms of treatment should be used?
8-9 How easy should it be to reverse medical decisions, such as a decision to go home or forego or undergo a treatment?
8-10 How do you decide whether to go home or to the hospital or hospice?
8-11 What is the most important thing a patient can do to make certain he does not receive euthanasia if he becomes incompetent?
8-12 What is the most important factor in determining if an incompetent patient will be given euthanasia directly or via a failure to give the patient the best medical care?
8-13 How does a doctor who favors euthanasia slant information so that more of his patients die more quickly?
8-1 If a person does not want to, must he see a doctor or enter a hospital?
No. (FO) However, incompetent people may be hospitalized without their consent.
8-2 Does a patient have to accept a doctor's advice if he does not want to accept it?
No. (FO) However, people should ordinarily follow their doctor's advice.
8-3 Does a patient have an absolute right to order a doctor to stop treating him or to stop a course of treatment that has begun?
Yes. "He has the perfect right at any instant to say: 'I am going home. I am leaving the hospital. I am discharging you from the case. I am refusing the next form of treatment you offer.' That is absolutely essential in this medical relationship." (FO)
8-4 If the doctor and patient communicate, will the patient discharge the doctor or ask to die?
"My experience, however, with hundreds of incurable cancer patients over a period of 9 years is that I have never had one single patient refuse treatment or request that I let him die. I have never had it happen." (FO)
8-5 What should the seriously ill patient be told?
"Every patient, of course, knew what was going on, knew what we could and what we couldn't do, knew what the risks were, knew that he was a totally free agent to say at any point, 'I am leaving,' or 'I don't want any more,' or, 'Stop now.' And this was made very clear to them repeatedly. Every patient understood that." (FO)
8-6 Will the judgment of a well-informed family differ from the judgment of a well-informed physician?
"I have never known of an instance where the judgment of a well-informed family in this matter was different from the physician's. In other words, if the patient was in pain, both the doctor and the family wanted the pain relieved. If the patient appeared to have any number of different symptoms, both the family and the doctor wanted any discomfort controlled. "So I think the critical factor in achieving this kind of harmony of desire and interest in the patient's welfare is very thorough education of the patient and the family. I think they both must thoroughly understand what can be done, what is going on with the patient, what he is suffering, and what given manifestations mean; I just have not experienced a conflict in this matter between the well-informed family and myself." (FO)
8-7 What if conditions change so a previous decision is no longer correct?
"At each point in the path one has to make a decision, Do we go on? Do we try some new form of treatment to try to control the disease, something more 'heroic,' as the term is or is this the point where the patient might consider going home and when we say that we have tried everything that offers any chance?" (FO)
8-8 What forms of treatment should be used?
"I am not advocating using every machine in the building because it is there, but I am advocating using those forms of treatment that offer any hope of success." (FO) 8-9 How easy should it be to reverse medical decisions, such as a decision to go home or forego or undergo a treatment?
"After discussion between the wife, the patient, and myself, we may have decided that the best next move is that the patient go home, and then if his condition suddenly deteriorates, he can always come back. In other words, the decision to go home must in no way make it more difficult to return. One maintains a two-way street very easily traveled back into the institution and back out to the home. I think this is the ideal situation." (FO)
8-10 How do you decide whether to go home or to the hospital or hospice?
"There was nothing wrong with care at home, let's say, dying at home or birth at home, when there was no better care available anywhere else. There was no point in going to the hospital for these conditions because nothing more could be done there than at home. Today, birth at home would not be the safest form of birth if you have a complication, if you are not where the modern techniques for handling severe complications exist. "The same thing may apply to the seriously ill patient, the incurable patient, the 'hopeless' patient.
He, for certain reasons, may need to be in an institution, and, at other times, may be better off at home, and he should have, I believe, the freedom to move back and forth as his condition and needs change." (FO)
8-11 What is the most important thing a patient can do make certain he does not receive euthanasia if he becomes incompetent?
A patient with a serious illness should ask how his doctor feels about euthanasia, and the patient should tell his doctor that he opposes euthanasia.
8-12 What is the most important factor in determining if an incompetent patient will be given euthanasia directly or via a failure to give the patient the best medical care?
The doctor's attitude toward euthanasia plays a gigantic role in determining whether a patient receives euthanasia, according to doctors with whom the author has discussed this matter, since the doctor has control of the medical information. This information is sometimes so complex and beyond the normal family's experience that the family must rely on the doctor's interpretation of the facts and his projection of what is likely to happen in the future. A doctor can easily mislead by omission. A doctor who favors euthanasia can control the family by shading his opinion just slightly here and there or omitting this or emphasizing or not emphasizing that to give the family a misleadingly pessimistic view. This is why some identically ill patients live substantially longer with some doctors than others.
8-13 How does a doctor who favors euthanasia slant information so that more of his patients die more quickly?
A doctor need not lie to mislead relatives. The type of questions asked when a loved one is seriously ill and incompetent are general questions. The patient's relatives do not ordinarily know enough to ask questions that require precise answers that would allow the relatives to precisely evaluate the patient's condition and prospects. Accordingly, in answering questions or giving opinions and information, a doctor's philosophy will cause him to emphasize aspects of the patient's condition that the doctor believes are more important. If a doctor favors euthanasia, he is far more likely to describe the patient's condition in a way that will justify the outcome the doctor believes to be best, even if this outcome is euthanasia.
REFERENCE
(FO) Testimony of Laurance V. Foye, MD, Director of Education Services of Veterans Administration, formerly with National Cancer Institute, before U.S. Senate Special Committee on Aging, 8/7/72
CHAPTER 9
NURSES AND EUTHANASIA
9-1 What insights do nurses bring to the euthanasia question?
9-2 In the Nancy Cruzan case, did the nurses who cared for Nancy agree that her food and water should be cut off?
9-3 Have any nurses commented on practical problems with living wills?
9-4 How did Nurses for Life characterize the relationship between nurses and the dying in their brief to the U.S. Supreme Court in the Cruzan case?
9-1 What insights do nurses bring to the euthanasia question?
As anyone who has been hospitalized has observed, doctors spend relatively little time with patients. Nurses spend far more time with patients than doctors, and accordingly, have far more time to observe and relate to patients.
9-2 In the Nancy Cruzan case (CR), did the nurses who cared for Nancy agree that her food and water should be cut off?
No. There were 39 nurses who cared for Nancy Cruzan. These 39 nurses unanimously refused to cooperate with the cutting off of Nancy's food and water. (CR)
9-3 Have any nurses commented on practical problems with living wills?
Madeline Satwicz, RN, made these comments about the practical problems living wills cause nurses:
"You bet death is a dirty word. And, by golly, the anti-abortionists are right. Abortion really does lead to mercy killing, and the promoters are using exactly the same language and the same tactics. And the same media is flooding us with the same hard soft sell. All in the name of mercy, personal right and freedom.
"As a nurse, I have a few thousand questions to address to the signers of the 'living will' because I may be the one expected to administer it. If I misinterpret what you sign, or just let my fatigue show near the end of a wild eight-hour shift, I may just shove you into the great beyond before you are ready. "Do you present this document to me when you check in? Do you give it to the gal in admitting so you can be put in a special section? What name do we give this section? "Do I accept it from trusted relatives and/or friends? How do I know who this is? Will the untrusted ones look different? "Do I only follow your doctor's orders? Suppose he takes off on a world tour; can the resident write in final orders?
By bodily functions, I assume you mean bladder and bowel control. As so few patients following surgery are left with this dignity, does the need for a catheter, or an enema, put you in the 'worthless' category? How many soiled beds should I allow you before I put you out of your misery, and mine?
"All of us exhibit signs of senility at least once each day, including editors that publish 'living wills.' Do we put you through a memory and sanity test each hour? What's a passing score? "How about two weeks and one hour, or two weeks and one day, as the limit on dependence on some life saving gimmick? Who does the countdown? What constitutes 'full recovery' of vital organs? Emphysema is an irreversible condition of the lungs; no way can this vital organ be made whole again. How do I resolve this? "Do I ask you if you have had enough intravenous feedings? Do we, in committee, decide? Or will there be a standing house order?
And if I chicken out, can I leave scalpel or syringe or pills at your bedside? What if you botch the job? Do we all get another chance? Do I tell you when I bring in the final dose? Do I insist you take it even if you change your mind? "How do I keep the confidence of my other patients who get nervous with all this insanity swirling around them?" Madeline Satwicz, RN, Detroit. (HE)
9-4 How did Nurses for Life characterize the relationship between nurses and the dying in their brief to the U.S. Supreme Court in the Nancy Cruzan case? (CR)
"Disabled people remind us of our own vulnerability, fragility, and mortality. We find that frightening. We would prefer to think of her as different from us. But we cannot.
"All of us, in some way are disabled from blindness, retardation, paralysis, mental illness or any number of things. Others of us are invisibly disabled from greed, intolerance, pride, apathy, selfishness, etc. Sadly, these invisible disabilities may be the most severe of all.
"As nurses, we are sometimes called upon to be the 'last friend' of people abandoned by relatives, friends, or even society. We are the ones who care for those with AIDS, the terminally ill, the severely deformed, the comatose, the cantankerous, the deranged, the homeless. We do not change our level of commitment or caring. We are professionals; we do not discriminate.
"In court cases involving people like Nancy Cruzan we are often one of the few voices upholding our patients' right to be fed and cared for. Why? Not because we are paid large sums of money for our work. Not because we are ignorant. Not because, as one witness put it, we are too emotionally involved' with our patients. "We speak out because we are professionals. We speak out because justice demands it. We speak out because our patients cannot.
"By caring for these people whose very existence seems to trouble society, we nurses are affirming the humanity of us all. "The role of nurses is not only to provide care for a patient but also to be an advocate for that patient. The amount of time spent with patients, the intimacy of the nurse-patient relationship, and the emphasis nursing places on meeting the physical and emotional needs of patients and their families places nurses in a unique position to contribute to discussions of health care ethics and public policy.
"As patient advocates, the best interests of the patient is our foremost consideration. The judgment of the doctor, the policies of the health care institutions, and the wishes of the family cannot take precedence over the rights of the patients.
"While we agree that the question of who should make health care decisions when a patient is unable to speak for himself is an important question, the larger question should be what decision is being made. We strongly believe that health care' decisions to cause the death of a patient are illegitimate no matter who is making the decision. Therefore we conclude that it is not ethically permissible to withhold or withdraw food and water from people in the so-called 'persistent vegetative state' or from other categories of seriously disabled but non-terminal persons.
"We feel such actions constitute abandonment of the patient. Even when cure is not possible we still have a responsibility to care for the patient. Justice requires that we extend the basic necessities of life to all persons, regardless of race, age, socioeconomic status, disabilities, etc. To deny these necessities to some (rapidly expanding) groups of people based on their degree of disability is discrimination. Causing death by starvation and dehydration should not be more morally palatable simply because it occurs (for now) in a medically sanitized setting.
"Withholding nutrition and hydration from non-dying, disabled people does not 'allow' these people to die, it forces them to die. Starvation and dehydration is a slow, painful, and disfiguring process. For example, in 1988 Marcia Gray, a Rhode Island woman, reportedly lost 50 pounds and required medication to control seizures during the 15 days it took her to die following court-sanctioned removal of her feeding tube. Death by starvation and dehydration is hardly 'death with dignity.' The main witnesses to these kinds of deaths are nurses. The negative effects, both personally and professionally, of participation in these kinds of deaths may mandate the institution of special wards to insulate the stress from other patients, staff, and visitors.
"Furthermore, we deplore the recent trend in some court cases to force institutions and health care providers by court order to remove feedings in violation of conscience rights. If this trend continues, health care professionals will be reduced to mere technicians dispensing a consumer service. Usual standards of professional accountability and judgment will be rendered inoperative in these cases. The effect on the art and science of health care will be devastating.
"The perceived economic imperative of rationing health care will almost certainly expand the pool of vulnerable people. Quality of life criteria could even come to include socioeconomic status, family support, and the willingness of society to offer services. We have already seen this in the current Johnson case in Oklahoma. In that case an actual formula was devised to decide which babies with spina bifida would receive aggressive treatment. The formula was even published in a pediatric journal: QL=NE(H+S): quality of life equals natural endowments times the expected contribution from the home and society. Using this equation could logically mean that a perfectly healthy but deprived child could come up with a low score on quality of life. For example QL=100(0+0)=0.
"Discrimination. Consciously or unconsciously many of us are accepting the removal of feedings because of personal fears of becoming disabled or being a 'burden' on loved ones. Most healthy people cannot imagine what it is like and assume that life would be devoid of comfort or happiness with even a partial disability. However, our natural fear of becoming disabled and 'losing control' must not allow us to discriminate against people with disabilities. Quality of life must not take precedence over the sanctity of life. "Disabilities can range from mild to severe. It is impossible to arbitrarily choose one point for non-treatment without risking the lives of people with lesser disabilities. As nurses we care for people some of whom can be returned to normal health, some of whom we cannot save, and some of whom are left with impairments. Our commitment to caring for each of these groups is the same.
"Too, as nurses, we have been impressed and inspired by our patients and their relatives. The will to live, ability to accept hardships, and love of life we see in these people teaches us much and makes our work very rewarding. It is sad when we hear that people like Nancy Cruzan lead a 'degrading' life by having others bathe, toilet, and feed her. We believe that our care is not degrading but rather an act of love.
"More and more we are encountering an attitude in society that no one should be a burden on anyone else. However, we must realize that total independence is a myth; the reality is interdependence. All of us are dependent on each other: we need farmers and truck drivers to provide us food. We need builders to shelter us, etc.
"Also, at some point in our lives, we are all 'burdensome.' All of us begin life as helpless babies totally dependent on others. Illness, injury, old age, even the stresses of being a teenager can make us burdens on our families or society.
"As we all know, too, it is a humbling experience to require or to ask for help. But both giving and receiving help has its own rewards and strengthens our commitment to each other. The measure of our humanity and our civilization is how we take care of one another, particularly the weakest and most vulnerable among us.
"To deny feedings to non-dying, disabled people like Nancy Cruzan will have many adverse repercussions: it would have a discouraging effect on other people with disabilities, their families, and care givers by discounting their efforts. It could lead to economic coercion by leading to withdrawal of insurance payments. It could subtly increase other discrimination against the disabled and promote the myth that the disabled are burdens. A person's limitations do not decrease a person's humanity or worth.
"To sanction the denying of feedings could lead to lawsuits against families and care givers who follow their consciences. It could lead to further shortages of nurses who, by being the main witnesses to these kinds of deaths, might leave the profession or never enter it. It could lead to ]the destruction of trust between nurse and patient because the nurse (and doctor) would assume a dual role as killer/care giver. The patient might be reluctant to discuss negative or ambivalent feelings for fear that it might influence a decision that his or her quality of life was not high enough. It could produce a deadening effect on doctors and nurses in relating to commitment to patients and respect for life. Rationalizing active euthanasia like injections would become easier.
"Sanctioning denial of feedings could lead to more lawsuits like Nancy Farnum's (Farnum v Crista, Superior Court of Washington for King County. Farnum, who previously had a good record, was fired for refusing to withdraw a patient's feeding tube when the doctor who wished to kill the patient ordered her to do so) - as other nurses who refuse to participate are fired, encouraged to resign, or have other sanctions imposed by health care facilities. If sanctioned, it would be impossible to limit denial of feedings to institutions and what used to be considered abuse or homicide in the home setting could be socially or legally sanctioned. If feedings are denied, it could make it difficult to enforce any mandatory minimum care.
"Tube Feedings. We recognize that it is ethically permissible to remove treatments or care which is useless or burdensome to the patient. However, in deciding what treatment or care can be ethically withdrawn, it is important that the treatment itself be judged, not the 'quality' of the person's life. We should not deliberately cause death and then disingenuously claim death came "naturally."
"Feeding whether by tube or mouth can rarely be considered either useless or burdensome unless, for example, a person is imminently dying. In general, supplying food through a feeding tube costs less and is usually less troublesome to provide than a prepared meal. Most people tolerate this form of feeding quite well with no pain or discomfort. Discomfort or problems that do occur are usually manageable. For many people attempts at oral feedings would be far more burdensome or even dangerous. For example, many people in nursing homes receive tube feedings for convenience reason or because the ability to swallow is partially impaired.
"The new trend of calling tube feedings useless or 'artificial' is problematic. The purpose of tube feedings is to maintain the nutritional status of a person. Tube feedings do not treat illnesses. Tube feedings cannot cure brain damage. To call tube feedings 'useless' is to ignore the purpose for which they are intended.
"To call tube feedings 'assisted feedings' rather than 'artificial feedings' also raises other questions: if feedings can be artificial could not also clothing or maintenance of room temperature also be considered artificial? Is bottle-feeding a baby artificial? If tube feedings consist of nothing more than blenderized food would they then be considered natural? With so much of our nation's food supply artificially processed could not our regular food be considered artificial? Is the tube itself more analogous to a machine or a simple soda straw? Why would an "artificial" medical treatment such as a morphine drip for pain be considered necessary for prevention of discomfort while feedings would not? Why is bathing or turning patients who have their feeding tubes removed considered mandatory?
"Tube feedings have been in existence since the l9th century. In recent years there have been great innovations in tube feedings. Tubes can now be inserted at the bedside. Gastrostomy buttons (small mushroom-shaped devices which lie flat on the abdomen) can be inserted and even changed or reinserted by a conscious patient. Tube feedings can now be given either intermittently or continuously to minimize problems.
"We believe the attempts at practical or ethical justifications for removal of feedings will mislead people to believe that causing death by omission is different fundamentally from active euthanasia by lethal injection, overdose, etc. Indeed it is ironic that both we and pro-euthanasia groups agree that there is no real difference between causing death by starvation and dehydration or causing death by giving a lethal injection or other active means. Some pro-euthanasia groups logically consider lethal injections more 'humane' since death by starvation and dehydration is a slow, painful and disfiguring process.
"Persistent Vegetative State. This is an unfortunate and imprecise term used to describe people who are severely brain-damaged but not dying or brain-dead."
REFERENCE
(CR) Cruzan v Director, MO Health Dept (1990) 111 L Ed 2d 224 (See Chapters 10 and 11 for additional details)
(HE) Handbook on Euthanasia, (1975) Sassone, p108
CHAPTER 10
THE COURTS AND THE NANCY CRUZAN CASE
10-1 Who was Nancy Cruzan?
10-2 What did the U.S. Supreme Court decide in the Cruzan case?
10-3 What happened after Nancy won in the U.S. Supreme Court?
10-4 Of the 39 nurses who cared for Nancy, how many favored cutting off her food and water?
10-5 What did the trial transcript say about how injured Nancy Cruzan was and about what Nancy could still do?
10-1 Who was Nancy Cruzan?
Nancy Cruzan was a young woman who suffered brain injury in a 1983 automobile accident in Missouri. She was hospitalized in what was called a persistent vegetative state. Nancy was initially fed by mouth, but after a time, was fed instead by tube. The change to tube feeding was made not because Nancy could not be fed by mouth, but because tube feeding saved nurses' time. Her parents decided to seek a court order to kill Nancy by cutting off her food and water, based on the allegation that would be Nancy's wish if she could talk.
10-2 What did the U.S. Supreme Court decide in the Cruzan case?
The trial court granted the request of Nancy's parents to cut off her food and water. The Missouri Supreme Court reversed, holding that clear and convincing evidence had not been shown that Nancy would want to be killed by having her food and water cut off. It further held that Nancy had a right to refuse care, but that the refusal was personal to Nancy. The U.S. Supreme Court then held that there is no U.S. Constitutional right to die or right to cause death. (The right to life is guaranteed by the U.S. Constitution, but the U.S. Constitution does not mention a right to die.) The U.S. Supreme Court also held that nothing in the U.S. Constitution prevents Missouri from requiring clear and convincing evidence of Nancy's intent before cutting off Nancy's food and water. (CR)
10-3 What happened after Nancy won in the U.S. Supreme Court?
Her parents alleged that they had found new evidence of Nancy's intent to have food and water cut off which was stated before her automobile accident and subsequent disability. The same trial judge who had previously ordered Nancy killed ruled again that Nancy's food and water should be cut off. There was no appeal, and Nancy died of dehydration a few days later.
10-4 Of the 39 nurses who cared for Nancy, how many favored cutting off her food and water?
None. All 39 nurses who actually had some experience caring for Nancy and could see both how injured she was and how much she was still capable of refused to cooperate in the removal of food and water from Nancy.
10-5 What did the trial transcript say about how injured Nancy Cruzan was and about what Nancy could still do?
More than 100 entries of testimony from a dozen different care givers established that Nancy was the least injured and most capable of all PVS patients at the hospital. For example, she was able to eat by mouth, respond to pain by withdrawing, respond appropriately to other stimuli, and showed appropriate emotions, such as crying when something happened that would have made a reasonable person very sad. Nevertheless, she was killed.
CHAPTER 11
WHAT DID THE U.S. SUPREME COURT SAY ABOUT EUTHANASIA IN THE NANCY CRUZAN CASE?
11-1 What did the Cruzan case decide?
11-2 Does the individual have a common law defined legal right to refuse medical treatment?
11-3 Does the 14th Amendment include a right to refuse medical treatment?
11-4 Can a person refuse life saving hydration and nutrition?
11-5 Do incompetent persons have the same right to decline hydration and nutrition as competent persons?
11-6 Does the Constitution require that we consider quality of life in making life and death decisions?
11-7 May a State place added burdens of proof on those seeking to terminate a life?
11-8 Are stopping-treatment cases fundamentally different from other cases?
11-9 May oral testimony be excluded in stopping treatment cases?
11-10 Must a state recognize substituted judgment?
11-11 Does the U.S. Constitution grant a right to die?
11-1 What did the Cruzan case decide?
In Cruzan v Director, Mo. Health Dept, (1990) 111 L Ed. 224, the U.S. Supreme Court, by a 5-4 vote, upheld Missouri law and held that there is no U.S. Constitutionally protected right to die. Selected quotations from the majority opinion include answers to the following questions stated by the author to introduce parts of the Court opinion. After each quotation, the page number of the quotation in the opinion is stated:
11-2 Does the individual have a common law defined legal right to refuse medical treatment?
"As these cases demonstrate, the common-law doctrine of informed consent is viewed as generally encompassing the right of a competent individual to refuse medical treatment." (at 241).
11-3 Does the 14th Amendment include a right to refuse medical treatment?
"(3) The Fourteenth Amendment provides that no State shall 'deprive any erson of life, liberty, or property, without due process of law.' The principle that a competent person has a constitutionally protected liberty interest in refusing medical treatment may be inferred from our prior decisions." (at 241) "The forcible injection of medication into a nonconsenting person's body represents a substantial interference with that person's liberty." (at 242)
11-4 Can a person refuse life saving hydration and nutrition?
"Petitioners insist that under the general holdings of our cases, the forced administration of life-sustaining medical treatment, and even of artificially-delivered food and water essential to life, would implicate a competent person's liberty interest. Although we think the logic of the cases discussed above would embrace such a liberty interest, the dramatic consequences involved in refusal of such treatment would inform the inquiry as to whether the deprivation of that interest is constitutionally permissible. But for the purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition." (at 242)
Note that the Court does not state there is a constitutional right to refuse lifesaving hydration and nutrition, but only assumes it as discussed below to show that incompetent persons must be treated differently.
11-5 Do incompetent persons have the same right to decline hydration and nutrition as competent persons?
"Petitioners go on to assert that an incompetent person should possess the same right in this respect as is possessed by a competent person." (at 242) "The difficulty with petitioner's claim is that in a sense it begs the question: an incompetent person is not able to make an informed and voluntary choice to exercise a hypothetical right to refuse treatment or any other right. Such a 'right' must be exercised for her, if at all, by some sort of surrogate. Here, Missouri has in effect recognized that under certain circumstances a surrogate may act for the patient in electing to have hydration and nutrition withdrawn in such a way as to cause death, but it has established a procedural safeguard to assure that the action of the surrogate conforms as best it may to the wishes expressed by the patient while competent. Missouri requires that evidence of the incompetent's wishes as to the withdrawal of treatment be proved by clear and convincing evidence. The question then is whether the United States Constitution forbids the establishment of this procedural requirement by the State. We hold that it does not." (at 242)
11-6 Does the Constitution require that we consider quality of life in making life and death decisions?
"Finally, we think a State may properly decline to make judgments about the 'quality of life' that a particular individual may enjoy, and simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual." (at 244)
11-7 May a State place added burdens of proof on those seeking to terminate a life?
"We believe that Missouri may permissibly place an increased risk of an erroneous decision on those seeking to terminate an incompetent individual's life-sustaining treatment." (at 245)
11-8 Are stopping-treatment cases fundamentally different from other cases?
"We think it self-evident that the interests at stake in the instant proceedings are more substantial, both on an individual and societal level, than those involved in a run-of-the-mine civil dispute....An erroneous decision not to terminate results in a maintenance of the status quo, the possibility of subsequent developments such as advancements in medical science, the discovery of new evidence regarding the patient's intent, changes in the law, or simply the unexpected death of the patient despite the administration of life-sustaining treatment, however, is not susceptible of correction."
11-9 May oral testimony be excluded in stopping treatment cases?
"It is also worth noting that most, if not all, States simply forbid oral testimony entirely in determining the wishes of parties in transactions which, while important, simply do not have the consequences that a decision to terminate a person's life does." (at 245)
11-10 Must a state recognize substituted judgment?
"Petitioners alternatively contend that Missouri must accept the ' substituted judgment' of close family members even in the absence of substantial proof that their views reflect the views of the patient. In Michael H., we upheld the constitutionality of California's favored treatment of traditional family relationships; such a holding may not be turned around into a constitutional requirement that a state must recognize the primacy of those relationships in a situation like this... constitutional law does not work that way." at (246, 247) 11-11 Does the U.S. Constitution grant a right to die?
"This is the first case in which we have been squarely presented with the issue of whether the United States Constitution grants what is in common parlance referred to as a 'right to die.'" (at 241)
If the Court had read a "right to die" into the Constitution, it would have had to reverse the Missouri supreme court. The U.S. Supreme Court, however, decided Cruzan in a way opposite to the decision a "right to die" would require, and in so deciding, followed a line of reasoning contradicting any alleged Constitutional "right to die" by permitting the Missouri decision to stand.
Chapter 12
EUTHANASIA AND THE U. S. CONSTITUTION RIGHT TO LIFE FOR PERSONS
12-1 Does the U.S. Constitution protect our right to life?
The U.S. Constitution Fifth and Fourteenth Amendments state that all persons have the Right to Life, which is God-given and unalienable.
12-2 If the U.S. Constitution protects the Right to Life of all persons, how can there be killing by abortion and euthanasia?
The U.S. Supreme Court has defined three exceptions to the protection from killing given by the Right to Life:
a) deny those to be killed are persons, (an example is abortion);
b) claim that the person to be killed wants to die and therefore has given up the protection of the right to life, (an example comprises those who are unconscious, are assumed to want to die, then deprived of food and fluids; and
c) claim that killing is not prevented by the U.S. Constitution if done in a selected manner or to a selected class such as criminals.
12-3 Who decides who is or is not a person pursuant to the U.S. Constitution?
All Fourteenth Amendment power is given to Congress. Congress has power to extend personhood to humans and non-human entities. After Congress passes a law, however, when a case is filed pursuant to the law, the U.S. Supreme Court has ultimate power to decide the meaning and application of the law passed by Congress.
12-4 What law has Congress passed to give all human beings the protection of persons? The very first section of U.S. Law, Title 1 Section 1 of U.S. Code defines person to include "individual". When Section 1 was originally passed, it did not include "individual" among those entities protected as persons. 1947/1948 was the time of the War Crimes trials which publicized the Nazi killing millions by defining them not to be persons and therefore not entitled to any rights or protections. Presumably, the Nazis killing via defining certain humans to be non-persons caused the same Session of Congress that passed Section 1 to quickly amend it by adding the term "individual" to those given protection as persons under the U.S. Constitution.
CHAPTER 13
FOOD AND WATER, BETTER DEAD THAN FED?
13-1 What do food and water have to do with euthanasia?
13-2 Are food and water medical treatment?
13-3 What are nutrition and hydration?
13-4 Is cutting off food and water the most extreme change sought by euthanasia advocates?
13-5 Why are so many ill people fed by tube, rather than by mouth?
13-6 Why are food and water not medical treatment in the way they act on the body?
13-7 What do food and fluids do and not do that cause them to be unlike medical care?
13-8 What effect did a President's Commission have on the definition of food and water as medical care?
13-9 How do those who claim food and water to be medical care justify the definition, since food and water act on the body in a different manner for different purposes and with different results than medicines?
13-10 What is illogical about claiming the means of delivery causes food and water either to be or not be medical care?
13-11 Are food and water taken by hyperalimentation medical treatment? 13-12 What are medical treatments? 13-13 How does removing medical treatments act on the body differently from removing food and fluids?
13-14 How does killing by removing food and fluids differ from cutting off food and fluids and letting nature take its course?
13-15 When is removing life-prolonging treatments not killing?
13-16 Can removal of food and fluids be justified under the principal of double effect?
13-17 How does assisted feeding, such as by IV, NG or stomach tube, differ from respirators? 13-18 Has killing by dehydration been legal under state statutes?
13-19 If it has not been made legal under state law, by what doctrine are patients killed by cutting off food and fluids?
13-20 If no state law had been passed, what was the basis for this right to kill by dehydration?
13-21 How likely is any mistake to be made when it is assumed that a PVS (persistent vegetative state) patient would want food and water cut off?
13-22 Is it easy or painful to die when food and water are cut off?
13-23 What principles should determine whether food and water are to be cut off.
13-1 What do food and water have to do with euthanasia?
Cutting off food (nutrition) and water (fluids or hydration) so that a patient dies of dehydration has been a frequently used court ordered euthanasia technique. The strategy is as follow: cutting off food and water is legalized under the fiction that it is not euthanasia. Cutting off food and water kills by dehydration, one of the most painful ways to die, since the patient suffers from thirst. After the practice of cutting off food and water is legalized, the argument which established it is reversed. Euthanasia advocates then will claim that we already have euthanasia, since we allow food and water to be cut off, so it would be reasonable to make the killing less painful by allowing injections or other killing techniques.
13-2 Are food and water medical treatments?
Food and water are not medical treatment when one considers how the body uses them. Food and water may be delivered both through one's mouth in the normal manner or by various techniques such as via tubes which are effective when a patient is unable to swallow. Directing society's attention away from what is delivered, and to the means used to deliver it, euthanasia advocates claim that food and water delivered by tube are medical treatments in order to make it more reasonable to cut them off, thereby extending euthanasia to additional patients.
13-3 What are nutrition and hydration?
Food and water given to a medical patient are renamed nutrition and hydration to make them sound more like medical care. When a patient is fed by tube, the patient is frequently fed from a can of fluid containing nutrients similar to baby formula.
13-4 Is cutting off food and water the most extreme change in care of the seriously ill sought by euthanasia advocates?
No. It is only the first of many hoped-for changes. Dying of dehydration is a slow and horrible way to die. If euthanasia advocates can generally establish cutting off food and water as a legal option for treating patients, then it will seem reasonable to permit euthanasia by more direct means such as lethal injection. Compared to dying by dehydration, injection appears to be a much quicker and less painful way to die. Beginning about 1990, a number of states enacted legislation permitting cutting off food and water from incompetent patients or patients described by the diagnostic term persistent vegetative state.
13-5 Why are so many ill people fed by tube, rather than by mouth?
Substituting tube feeding for feeding by mouth reduces the employee time necessary to feed a patient from about an hour to about a minute, saving time and reducing cost of care.
13-6 Why are food and water not medical treatment in the way they act on the body?
Those who claim that food and water are medical treatments when given by medical means such as IV, NG, or stomach tube have not been able to point to any medical or clinical condition that food and water treat. Food and water are aspects of normal care and are not medical treatments because they act differently on the body than medical treatments. Food and water are extrinsic natural resources of the body that are used universally by the body to sustain its natural functions and support its natural defenses against diseases. Only those who are ill or injured require medical care. By contrast, everyone requires food and water. Food and water benefit the ill or injured in substantially the same way they benefit the healthy, while medical care does not help the already healthy.
13-7 What do food and fluids do and not do that cause them to be unlike medical care?
Directly, proximately and immediately, food and fluids do not cure any clinically diagnosable pathological conditions. Instead, food and fluids meet the need of the body for sustaining basic resources such as energy, proteins, vitamins and minerals. Indirectly, food and fluids might help slow the development of clinically diagnosable conditions, but this is not their direct or primary purpose or orientation. Food and fluids might temporarily alleviate pain and indirectly have some neurological impact, but they do this only because they meet a need of the body for basic and extrinsic resources. Food and water do not cure anything, but rather prevent deterioration caused by starvation and lack of fluids if food and water is cut off for too long a time.
13-8 What effect did a President's Commission have on the definition of food and water as medical care?
Food and water were formerly not considered to be medical care. State laws have not usually defined food and water to be medical care. In the early 1980's, a Presidential Commission studied end of life issues related to medical care. The Commission report defined artificially administered food and water, called nutrition and hydration, to be medical care. This caused some to accept the Commission definition.
13-9 How do those who claim food and water to be medical care justify the definition, since food and water act on the body in a different manner for different purposes and with different results than medicines?
Those who claim food and water are medical care ignore what food and water do and rely on the means used to deliver the food and water. They allege that use of a tube makes what the tube delivers medical care, so food and water delivered to a patient are caused to be medical care by the means of delivery. The claim is made whether the tube goes down the throat or bypasses the throat, since in either event, artificial means are used.
13-10 What is illogical about claiming the means of delivery causes food and water either to be or not be medical care?
Food and water act on the body the same way whether they are delivered into the body by tube, cup or spoon. Nobody thinks of antibiotics as food, even if they are taken by mouth. If you follow the logic that claims the means used to deliver determines if something is medical care, would not antibiotic pills taken by mouth be food, rather than medical care, while if injected the same antibiotics would again be medical care. Would not injected anesthesia remain medical care, while those which are breathed in would be defined as air, rather than medical care? If a tube makes a nutrient become medical care, it would logically follow that a milk shake taken by straw is medical care.
13-11 Are food and water taken by hyperalimentation considered medical treatment?
Hyperalimentation is a technique of feeding involving medical technology which is now considered ordinary medical treatment, as opposed to extraordinary medical treatment. It can be argued that even hyperalimentation is not medical care if one considers that it provides food and fluid.
13-12 What are medical treatments?
In areas not related to euthanasia, how something acts on the body determines if it is a medical treatment. Traditionally, medical treatments have been artificially administered impediments to either previously existing pathological conditions or to future possible lethal conditions. Medicine is an example of a medical treatment by the traditional definition. When euthanasia advocates cannot win with the normal meanings of words, they attempt to change those meanings. In the case of medical treatments, euthanasia advocates change the meanings from the use of what is given (food and water) to the means used to give it. With this new definition, food and water are claimed to be medical treatments when they are administered by tubes. The general rule of law has permitted medical treatments to be cut off, so if food and water are redefined as medical treatments, they can be cut off for the purpose of killing the patient. The new definition of things as medical treatments when they are administered by tube, if logically followed, could mean that medicines would not be medical treatments if taken by mouth.
13-13 How does removing medical treatments act on the body differently from removing food and fluids?
Medical treatments directly, proximately, and immediately cure, remedy, or ease the distress caused by clinically diagnosable conditions, and unlike food and fluids, are only indirectly and remotely natural extrinsic resources of the body. Removing medical treatment permits a previously existing pathological condition to run its course. Such a removal may allow the patient to die from the pathological condition, but it still permits a chance of survival. Removing food and fluids kills a person who may not be at death's doorstep and directly causes death, giving the patient no chance of survival.
13-14 How does killing by removing food and fluids differ from cutting off food and fluids and letting nature take its course?
Removing food and fluids and letting nature take its course is not immoral if the patient's body is unable to benefit from the food and fluids. This situation changes if the body can still benefit from food and fluids. Medicine is not yet so far advanced that doctors can be correct in their analysis of a patient's condition in all or even most of the cases where they urge removal of food and fluids. Removing food and fluids at the very least introduces a new lethal cause and causes direct killing. Removing medical care permits a presently existing cause to continue without impediment. Cutting off food and fluids introduces a new, certain and previously nonexistent cause of death.
13-15 When is removing life-prolonging treatments not killing?
When life is threatened by a condition internal to the patient, that is by a fatal pathology, the cause of death is already present. If life- prolonging treatments can offer the patient no benefit, their removal is not a decision to kill the patient. Rather it is a decision to forego interventions which are ineffective or too gravely burdensome, a decision to not prolong inevitable imminent death. Although in some circumstances death may be welcomed as a release from suffering, it is neither intended nor brought about as a means of ending the suffering.
13-16 Can removal of food and fluids be justified under the principle of double effect?
Not if the person's body can benefit from them. The principle of double effect permits an act to be done for one good, even though it is foreseen that an unintended evil side effect will occur. Removal of food and fluids fails to qualify for both reasons. First, the removal is not a sufficient good. Additionally, death, the side effect of removal of food and fluids, is intended rather than unintended and is the main reason for following this course.
13-17 How does assisted feeding, such as by IV, NG or stomach tube differ from the use of respirators?
Respirators assist the inhaling and exhaling functions of the body. Assisted feeding by IV, NG or stomach tube does not assist the swallowing function, but replaces it. Assisted feeding tubes are more like a tracheal tube which bypasses an impediment to breathing, than they are like a respirator which assists breathing. When a respirator is removed, it is common for the person to breathe naturally. In contrast, when assisted feeding is removed, the person soon and inevitably dies of dehydration. This is so because removing food and fluids creates a new, independent, certainly lethal circumstance, while removal of a respirator or medical treatment permits a previously existing pathological condition to run its course.
13-18 Has killing by dehydration been legal under state statutes?
In 1989, of the forty states having laws about advance directives relating to future medical care, fifteen specifically prohibited cutting off food and water. Thirty-five required comfort care, which by reasonable interpretation includes food and water. Thirty-three states specifically prohibited euthanasia. Cutting off food and water to kill is euthanasia. Thirty-six states had prohibited application of advance directives until death was imminent from other causes. Practically every state had made cutting off food and water for the purpose of killing illegal by adopting one or more of the preceding prohibitions. No states permitted food and water to be cut off for the purpose of killing the patient. However, since 1989, a few states have legalized killing by hunger and thirst.
13-19 If it has not been made legal under state law, by what doctrine are patients killed by cutting off food and fluids?
In some cases, courts do not permit the plain language of the law to be enforced. Food and fluids are just cut off, sometimes with approval of a judge. The usual excuse is the application of the dangerous doctrine of substituted judgment. The patient is assumed to have a right to refuse treatment. Because the patient is unconscious, and so is unable to exercise the right to refuse treatment, someone else is appointed by the court to exercise the patient's right to refuse treatment. The appointed person then exercises the patient's right by refusing treatment. The definition of treatment is expanded to include feeding of patients who are unable to feed themselves, and so the patient is killed, usually in about a week, by dehydration.
13-20 If no state law had been passed, what was the basis for this right to kill by dehydration?
State courts found this right to kill by thirst in either state constitutions or (before the Cruzan decision) in the federal constitution. The Cruzan decision established that there is no right to die or right to euthanasia in the U.S. Constitution. This is why the U.S. Supreme Court Cruzan decision was important (CR).
In the Cruzan case, the U.S. Supreme Court found no right to kill in the U.S. Constitution. The Cruzan decision thus eliminated the Federal Constitution excuse for killing by thirst. This does not prevent state courts from finding a right to kill in state constitutions. It has also not prevented some states from changing their state laws to permit killing by cutting off food and fluids.
13-21 How likely is it that a mistake will be made when it is assumed that any PVS (persistent vegetative state) patient would want food and water cut off?
This question cannot be answered with precision, since PVS patients are usually killed before they can confirm or deny that they would like to die. Only one PVS patient has awakened during the very short time between a court order for her death and subsequent death caused by deprivation of food and water. "The first woman ruled brain dead enough for starvation in New York, Carrie Coons, recovered when nurses, irritated by the court order, stimulated her." Coons awoke and when asked if food and fluids should be removed, replied: "These are difficult decisions." The court order was reversed, since Coons did not express agreement with it. (CO)
13-22 Is it easy or painful to die when food and water are cut off?
Painful. See Q3-24 for one judge's analysis.
13-23 What principles should determine whether food and water are to be cut off.
The author believes the following analysis gives useful guidelines: (MC)
1. Unconscious, Imminently Dying Patient
In an unconscious, imminently dying patient experiencing progressive and rapid deterioration, the dying process has begun and cannot be reversed. Nutrition and hydration are now useless and, all things considered, the burden of providing them is no longer a reasonable burden.
2. Conscious, Imminently Dying Patient In the conscious, imminently dying patient, nutrition and hydration are useless, possibly burdensome, and need not be artificially provided unless desired by the patient.
3. Conscious, Irreversibly Ill, Not Imminently Dying Patient This patient is conscious, beyond cure or reversal of the disease but able to function to some degree. Because nutrition and hydration sustain life, they are not useless, and usually they are not unreasonably burdensome. Nutrition and hydration should be provided unless or until there is clear evidence that such provision of nutrition and hydration constitutes an unreasonable burden for the patient.
4. Unconscious, Non-Dying Patient In the unconscious, non-dying patient, nutrition and hydration should be supplied. Feeding is not useless because it sustains a human life. There is usually no evidence that the person is suffering, nor is there any clear evidence that the provision of nutrition and hydration is an unreasonable danger or burden. In such a case, the withdrawal of nutrition/hydration brings about death by starvation/ dehydration. Absent any other indication of a definite burden for the patient, withdrawal of nutrition/hydration is not morally justifiable.
REFERENCES
(CO) St Louis Post Dispatch, 4/14/89, p2a
(MC) Analysis by Roman Catholic Bishop James McCue, Camden NJ Diocese
CHAPTER 14
BETTER DEAD THAN DISABLED?
14-1 What is the position of the disabled on euthanasia?
14-2 Are disabled people more likely to commit suicide?
14-3 Has euthanasia been advocated for the disabled in the U.S.?
14-4 What precedent is there for euthanasia for the disabled?
14-5 Did the early Nazi propaganda for euthanasia use the same arguments advanced by today's euthanasia advocates?
14-6 Did those most closely connected with the trials of the Nazi war criminals learn any lessons that they tried to pass on to us?
14-7 Is a healthy person's attitude toward being disabled an accurate indication of how that person will feel, if disabled?
14-1 What is the position of the disabled on euthanasia?
Disabled rights organizations are perhaps the strongest opponents of euthanasia.
14-2 Are disabled people more likely to commit suicide?
Federal and state governments keep a variety of statistics related to suicide and disability. Neither federal nor any state data indicates that disabled people are more likely to commit suicide than people without disabilities. There does not appear to be any data from disability organizations, suicide prevention organizations, euthanasia advocates or anyone else that indicates disabled people are more likely to commit suicide than people who are not disabled.
14-3 Has euthanasia been advocated for the disabled in the U.S.?
Most of the euthanasia cases that have reached higher courts in the U.S. have related to killing disabled people without their consent.
14-4 What precedent is there for euthanasia for the disabled?
The infamous Nazi killing program began as euthanasia for the disabled, then was extended by a series of small steps to the final killing program.
14-5 Did the early Nazi propaganda for euthanasia use the same arguments advanced by today's euthanasia advocates?
Yes. Today's arguments by the media are highly reminiscent of the Nazi arguments as summarized by numerous books and articles. One of the best summaries is in "Medical Science Under Dictatorship," New England Journal of Medicine 241:39-47, 1949 by Leo Alexander, MD which states in part:
"Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived.... There is no doubt that in Germany itself the first and most effective step of propaganda within the medical profession was the propaganda barrage against the useless, incurably sick..."
14-6 Did those most closely connected with the trials of the Nazi war criminals learn any lessons that they tried to pass on to us?
Yes. The leaders and experts of the U.S. War Crimes prosecution team warned us, their descendants, that we should never permit even the first steps toward euthanasia. This is stated in greater detail in "The German and Dutch Euthanasia Programs", soon available from ALL, PO Box 1350, Stafford, VA 22555 for $4.00 (includes postage).
14-7 Is a healthy person's attitude toward being disabled an accurate indication of how that person will feel if disabled?
No. Attitudes toward life with disability change when one becomes disabled. Advance directives are based on the theory that a person's attitudes do not change if he becomes disabled or less healthy. When healthy, many people think they would want to die if they were to become disabled. To their surprise if they should later be disabled, the lesser life and health remaining seems just as precious, the pain is less than they had expected and the rewards of continued life are greater, so they do not want to die.
CHAPTER 15
HARD CASES
15-1 How do euthanasia advocates phrase their most effective arguments?
Euthanasia advocates phrase their most effective arguments in the form of stories by telling hard case stories such as: "Scene: A busy young woman talking to a man: 'I went to the hospital yesterday to see my father. He's eighty, you know, with terminal cancer, and stuck full of tubes. Of course, he couldn't speak or move, but his eyes....Oh, God!...No I don't know how long, the doctor wouldn't say.'" (LR)
These stories horrify and distress the reader and make him want to do something, even if they are fictional, or not as bad and hopeless as they sound.
15-2 Why are hard case stories not a good reason for voluntary euthanasia?
Hard case stories are not a good reason for voluntary euthanasia because they are false propaganda. The story in answer 15-1 illustrates a man whose situation could not be changed by voluntary euthanasia since he cannot ask to be killed. In addition, tubes are used only as long as they help. Tubes which are not helping can be disconnected without legalizing euthanasia. If death has already won the victory, the dying process need not be extended. Hard examples promoting euthanasia are meant to horrify and mislead the reader into believing there are only two possibilities, so that he will consider euthanasia as the best of only two alternatives. The truth is that the alternative to both prolonging suffering and euthanasia is proper medical care. Keeping a patient alive too long constitutes malpractice, and the doctor in such a case could be sued. See Chapter 1, which shows how wrong the arguments are which claim that pain justifies euthanasia. Good medical care has made these pro euthanasia arguments obsolete.
REFERENCES
(LR) Last Rights by Marya Mannes, p2
CHAPTER 16
EUTHANASIA PRESSURES ON THE VULNERABLE
16-1 If euthanasia were legalized, would attitudes change toward the injured, the elderly, the disabled, and the weak?
16-2 How would even a tiny bit of euthanasia change the doctor/patient relationship?
16-3 How would legal euthanasia make the dying or vulnerable feel more guilty?
16-4 How would legal euthanasia increase friction between the dying and their loved ones?
16-5 How would euthanasia talk destroy a patient's's precious last days?
16-1 If euthanasia were legalized, would attitudes change toward the injured, the elderly, the disabled, and the weak?
Legalizing euthanasia, even in the most limited and carefully considered manner, would partially destroy the present presumption of compassion which is expected in health care. Presently unasked questions such as: "Do I have a duty to die now?" would frequently be considered or asked, and this would cause great harm.
16-2 How would even a tiny bit of euthanasia change the doctor/patient relationship?
Before the time of Hippocrates, doctors both cured and killed. When the patient was visited by a doctor and given a potion, the patient did not know if the doctor came to kill him or cure him. For more than 2,000 years, doctors have recognized that the greatest achievement of Hippocrates was to separate curing and killing so that physicians truly became healers. If euthanasia were to become a treatment option, it would change the attitude of many doctors toward their most vulnerable patients. Aware that euthanasia is a doctor's option, many patients would have reason to fear or at the very least mistrust their doctors.
16-3 How would legal euthanasia make the dying and elderly feel more guilty?
The dying and elderly usually know their care is costly. They also realize that they are unlikely to ever be able to earn enough to pay for the care they are receiving (though their contributions earlier in life should be considered more than adequate). Legalizing euthanasia would force the elderly to confront the question of whether they should value money over their own lives, and it would promote guilty feelings among patients who continue to live.
16-4 How would legal euthanasia increase friction between the dying and their loved ones?
Euthanasia forces the consideration of questions that can cause serious problems. Assume that you have a terminal illness. Would you be hurt by a relative who suggests euthanasia? Would you feel pressured to suggest euthanasia or agree to it, even if you did not want it, in order to cut costs or to stop the emotional or financial strain on loved ones? Would a relative suggesting euthanasia feel guilty afterwards?
Wouldn't you interpret statements, looks, tones of voice, etc., differently if euthanasia was an option? Wouldn't you wonder what others were thinking even if the topic of euthanasia never arose? Wouldn't the relationship between the dying and their dear ones change for the worse in many cases?
16-5 How would talk of euthanasia destroy a patient's precious last days?
What does a suggestion of euthanasia do to your self-esteem? to your concept of self-worth? to your hope for a cure? to your desire to go home just one more time? to your desire to have one more deep talk with a loved one? to your wish to cure a long term family problem by having a sincere loving talk? to your wish to make beautiful lasting memories for those who survive? to your wish to resolve problems and disagreements? to your wish to express love? to your wish to take advantage of the simplification of life when death is known to be near? Euthanasia has the potential to overshadow and spoil the precious last few days when good-by is said, disputes are reconciled and life time love is shared for the last time.
CHAPTER 17
ECONOMIC PRESSURE FOR EUTHANASIA
17-1 What economic assumption is made by euthanasia advocates?
17-2 What two fundamental errors make the economic projections of euthanasia advocates incorrect?
17-3 What differences do the errors of the euthanasia advocates make?
17-4 What has been the two trends in medical expenses?
17-5 What effect has new technology had on medical expenses?
17-6 When does a person spend the most money on medical care?
17-7 What is the fallacy in the theory of saving billions with no significant disadvantage by having patients die sooner?
17-8 Why are we unable to predict with relative certainty that a patient will die in six months?
17-9 What is an HMO?
17-10 What is the HMO problem?
17-11 Give a practical example of HMO conflict.
17-12 What percentage of U.S. health care costs are spent on the dying?
17-1 What economic assumption is made by euthanasia advocates?
The number of elderly people will continue to increase. The cost of maintaining each elderly person has been increasing much faster than the general rate of inflation. From this, euthanasia advocates postulate that many additional billions of dollars will be required to pay for medical care for increasing numbers of elderly people. Others agree that there will be an increase, but deny that the future increase will be so great as to justify euthanasia.
17-2 What two fundamental errors make the economic projections of euthanasia advocates incorrect?
Euthanasia advocates ignore improvements in technology. The first production models of any scientific advance are costly and do not work very well in comparison to later models. This is true because the models were never produced before and are stretching the scientific art which is then not yet well understood. The increase in capability and decrease in price of computers is illustrative of what can be done with medical technology and drugs. The second error is the assumption by euthanasia advocates that the trends for advances in medical and other fields to enable people to stay healthy longer will stop. 17-3 What differences do the errors of the euthanasia advocates make?
As an example, Daniel Calahan has in effect claimed there will be no reduction in the cost of artificial hearts. Since an artificial heart now costs $150,000.00 installed, and now provides only three years of useful life, he projects a cost of $50,000.00 per year of future life. This assumption and others like it are used to argue that the cost of medical care will soon make it necessary to cut off medical care to certain types of patients above certain ages. This logic wrongly assumes that artificial hearts will always cost at least $150,000.00 and will never provide an average of more than three years of future useful life.
Euthanasia advocates correctly assume that improving medical science will keep more elderly persons alive. While half their argument is based on improving medical science, the other half incorrectly assumes the contradictory position that medical science will stop improving. Accordingly, they ignore the trend for decreased costs for old technology. What is more likely to happen is a great decrease in the cost of presently used medical technology plus the use of new technology as medical science advances. Some of the new technology will be expensive, so there is likely to be an increase in medical costs for the elderly, but the increase is unlikely to be as high as suggested by euthanasia advocates.
17-4 What have been the two trends in medical expenses?
Medical expenses had increased much faster than other spending, prior to 1990. An increasingly higher proportion of medical expenses is being paid for patients by third parties such as government, insurance companies, health plans, and health maintenance organizations. Some economists state that the reason for the increase in medical costs was the shift of payment from the patient to others, since people will order more expensive care if another is to pay for it.
17-5 What effect has new technology had on medical expenses?
Technology has enabled us to do more to save and extend health and lives. As a result of new technology and the ability of more people to pay more for medical care, total medical expenses have more than doubled in a relatively short time.
17-6 When does a person spend the most money on medical care?
Health care spending is usually greatest during the last year of life. Those few people who have a prolonged last illness spend more on medical care during the last year of life than during the rest of their life combined. This spending on people who are likely to die soon is seen as a potential source of saving by euthanasia proponents. Apparently they believe all they have to do is have patients die sooner to save vast amounts of money. However, relatively few people have prolonged last illnesses. Twenty seven percent of U.S. medicare expenditures are for patients in the last year of life, but only 3.3 percent of total U.S. health care expenditures have been for people in the last year of life. (RD) The second fallacy is that we can know which people will not be helped by expensive medical care.
17-7 Why are we unable to predict with relative certainty that a patient will die in six months?
Another fallacy in arguments for euthanasia is the assumption that we can predict with certainty who will die and when they will die. Frequently on the last day or so before death, we can reliably predict that the patient will die soon. However, we cannot reliably predict this a month or more before death, when we can only describe the weakness of one or more major body systems. Although one or more bodily systems may be weak or have a cancer or other disease six months before death, they are not yet weak enough and the disease has not yet caused sufficient damage that we can accurately predict the date of death.
17-8 What is the fallacy in the theory of saving billions with no significant disadvantage by having patients die sooner?
Euthanasia proponents claim that doctors are at the same time so stupid that they waste billions by treating patients who are doomed regardless of treatment, but so intelligent that they can pick out those patients who should die sooner to save money. In reality, the only way to know for sure the date of someone's natural death is to wait until after they die.
In practice, a doctor decides what to do on the basis of probabilities. For example, a doctor might consider that if this possible medical treatment is not given, then these are the probabilities of various outcomes happening. On the other hand, if we intervene, the intervention will cost this much, but it will shift the probabilities. When it seems likely that medical intervention will on the average do more good than harm, a doctor intervenes.
17-9 What is an HMO?
HMO is the acronym for health maintenance organizations. In the past most people have gone to independent doctors for treatment. Increased medical knowledge has made it impossible for one doctor to know even a small percentage of all medical knowledge, so most doctors have specialized. An HMO is a very large group of doctors who combine to give medical care. Usually the doctors are employees paid a salary, and the income of the HMO comes from regular monthly payments like health insurance. HMOs show promise of greater efficiency, which in theory could either reduce medical costs or improve care.
17-10 What is the HMO problem?
An HMO is normally run for a profit. Its gross (total) income is usually the sum of the money paid by all its patients. The net income or net profit of the HMO is the gross income minus the expense of caring for all its patients. The first way for an HMO to increase net profit is to increase the number of patients who pay in but do not require the HMO to spend much money on medical care for them. Some patients, on the other hand, do not pay a substantial amount of money in as income to the HMO but require a great amount of medical care. The second way to increase net profit is to get rid of their patients who require more medical care than is covered by their fees. An HMO can efficiently reduce expenses and increase net profit by not paying for expensive medical treatment for which the HMO is not repaid. In practice, this means that for certain patients there is a conflict. These patients would be better off if they were given some needed medical care, but since that would cost the HMO money, the HMO is better off financially if the patients are not given needed medical care.
17-11 Give a practical example of HMO conflict.
The following description contains opinion based on a true case. George retired and was promised all needed medical care by an HMO in return for assigning over to the HMO his Medicare benefits. For several years, this worked fine, since the routine nature of George's care enabled the HMO to make a profit (the cost to the HMO of George's care was less than the Medicare reimbursements). Then George suffered a heart attack. Post-attack complications indicated that George should be treated by a specialist and should receive expensive care and medicine. The HMO gave him an alternative, less expensive medicine. Instead of an outside specialist whom the HMO would have had to pay more for than the Medicare reimbursement, the HMO continued to treat George with a non-specialist who was on staff and therefore did not add substantially to the HMO cost. The HMO continued to make a profit. Unfortunately for George, he soon died, probably because the HMO cut corners on his care to keep its costs down. No lawsuit was filed because of the difficulties of proof and the small value of a wrongful death case involving a heart attack damaged man such as George. Yet the HMO increased the risk of death to George in order to improve its profits, and its action was probably the cause of George's death. George probably would have lived substantially longer if he had been paying for treatment as received, instead of going to an HMO.
17-12 What percentage of U.S. health care costs are spent on the dying?
"A study by Dr. Exekiel and Linda Emanuel in úThe New England Journal of Medicine_ notes that 'less than one percent of the total American population dies each year.' They account for 'at most 3.3 percent of total national health care expenditures.'" (RD)
REFERENCES
(RD) Readers Digest October 1994, p94
(SL) Setting Limits Daniel Callahan (Simon and Schuster, 1987)
CHAPTER 18 THE WASHINGTON (1991), CALIFORNIA (1992) AND OREGON STATE (1994) EUTHANASIA INITIATIVES
18-1 What were the Washington Initiative 119, California Proposition 161 and the Oregon Ballot Measure 16 state euthanasia initiatives?
18-2 How did the three states vote on euthanasia?
18-3 What did polls indicate before each euthanasia election?
18-4 Why was there a 14% shift in voter sentiment against assisted suicide during the last month?
18-5 Why did the Washington State Medical Association switch from a neutral position to opposition to Initiative 119?
18-6 How strongly did the medical establishment feel about Initiative 119?
18-7 Give an example of an argument from a sheet of campaign literature of the Washington State Medical Association against Initiative 119?
18-8 How did opponents use TV against Initiative 119?
18-9 What reasons were given by those who opposed Initiative 119?
18-10 What groups joined with pro-euthanasia groups to back pro euthanasia initiatives?
18-11 How did various groups vote, according to exit polls?
18-12 Why did Oregon vote differently?
18-13 Did the Oregon initiative establish a workable system of euthanasia?
18-14 What tactics by euthanasia advocates can be expected in the future?
18-15 What should be done to block euthanasia initiatives?
18-1 What were Washington State Initiative 119, California Proposition 161 and the Oregon Ballot Measure 16 state euthanasia initiative?
Propositions 119 (Washington, 1991) and 161 (California, 1992) would have legalized physician assisted suicide. In addition, because of their many definitions slanted toward euthanasia, the Propositions would have changed certain presumptions which now favor life. The Oregon euthanasia initiative which passed by a narrow 51-49% margin in 1994 was a much weakened version of the Washington and California initiatives permitting physicians to prescribe enough poison to kill people.
18-2 How did the three states vote on euthanasia?
Both California and Washington voted 54% against, 46% for. (JA)(CS) Oregon passed its weakened version 51%-49%. (TV)
18-3 What did polls indicate before each euthanasia election?
In both Washington and California, about five months before the respective elections, public opinion was about 80%-20% in favor of the euthanasia Initiatives. About one month before the elections, polls indicated about 60% for, 40% against. (JA)
Absentee ballot totals in California, which consisted of voters who voted by mail within the month before the election, were about 55%-45% in favor of Proposition 161.
(TV) Proposition 161 was favored by about 49%-45% one week before the election, (LT) and by 51%-49% the night before the election.
(PC) In both states, the percentages at comparable times were nearly identical. (PC) In Oregon, initial polls also indicated that the measure was far ahead, then it lost votes down to 51% as the election approached.
18-4 Why was there a 14% shift in voter sentiment against assisted suicide during the last month?
Historically, there has been a substantial shift in voter sentiment against most pro-killing initiatives during the last month, as demonstrated by comparing polls and the actual election day vote of euthanasia and abortion elections. Four possible reasons include:
1. a pro-killing media may slant polls toward the pro-killing position to cause undecided people to think pro-killing is more popular, thereby attracting undecided voters to the pro-killing position.
2. people are more likely to think they are pro-killing before they have more carefully compared the arguments for and against;
3. right to life arguments are more convincing than pro-killing arguments; and
4. right to life election efforts are usually more effective. The pro-killing side makes effective use of the media, but just before elections, pro-life volunteers usually outnumber pro-killing volunteers by many thousands. (Contact American Life League for more details.)
In the case of Washington euthanasia Initiative 119, twice as much money was spent in favor of Initiative 119 ($1.4 million for and 0.7 million against).
(1) In the case of the California State Proposition 161, about twice as much money was spent against Proposition 161.
Contributing to the 14% shift was the switch of the Washington Medical Association from a neutral position to a position opposing Initiative 119 and three major newspapers editorializing against Initiative 119.
In California, very little election effort took place before the last week of the campaign.
18-5 Why did the Washington State Medical Association switch from a neutral position to opposition to Initiative 119?
An early poll of doctors found most approving of two of the three provisions of Initiative 119, which would have expanded the definition of a terminal illness and allowed the removal of food and water. Several months before the election, the leaders of the Washington State Medical Association finally realized the implications of the third section, legalizing physician aided suicide, and Washington State Medical Association delegates voted 5-1 to actively campaign against Initiative 119. (1)
18-6 How strongly did the medical establishment feel about Initiative 119?
A JAMA (Journal of the American Medical Association) article on Initiative 119 began:
"Medicine got lucky in Washington's historic vote this month to reject physician-assisted suicide for the terminally ill. The 55-45 margin (504,000 against, 418,013 for) was a pleasant surprise for the leaders of the Washington State Medical Association." (JA)
18-7 Give an example of an argument from a sheet of campaign literature of the Washington State Medical Association against Initiative 119?
"Check the Facts on Initiative 119
No Safeguards for the Poor.
No Safeguards for the Depressed.
No Safeguards for Families.
No Safeguards for the Mentally Incompetent.
No Safeguards for Seniors.
No Safeguards for Society.
Your Doctor Urges You to VOTE NO... "
18-8 How did opponents use TV against Initiative 119?
In one television advertisement that analysts say was pivotal in helping the opposition win converts, a man says he was told four years ago that he had only two weeks to live. Back then he might have chosen to die, he continues, and he is thankful that such a law did not steal the life that doctors misread. 'Initiative 119...it's more or less the right to kill,' says the man, Willliam A. Mahoney of Yakima, as the word 'Death' fades in with bold letters."
18-9 What reasons were given by those who opposed Initiative 119?
In a post election survey, those who voted against Initiative 119 cited several reasons as follows (NT):
41% of those opposing Initiative 119 stated they were morally opposed. This was expressed in statements like: "life is sacred"; "suicide is wrong"; "causing death violates religious teachings".
17% opposed doctors taking life. This argument had been voiced by the Washington State Medical Association in opposing the initiative and was the central message of a television add aired by opponents of the initiative during the campaign's final days. The ad featured former U.S. Surgeon General C. Everett Koop saying that society should not turn doctors into killers. This theme highlighted a flaw in the arguments used by supporters of 119. They exploited fear and distrust of doctors, saying that a "right to die" was a necessary defense against physicians who impose excessive and unwanted treatment on their patients. This was inconsistent with their claim that doctors could be trusted with the ultimate power over life and death and would never kill an unconsenting patient, a claim that seemed disproved by the realities of Nazi Germany and modern day Netherlands. In the latter country, a report has been interpreted by Richard Fenigsen, MD, as indicating that in cases of non sudden death, death was possibly or actually hastened by physicians in 56.5% of the time, or in about 49,000 possible cases. (FE)
12% of those voting against the initiative cited its "lack of safeguards." It provided for no waiting period when a patient requested death, no psychological testing for clinical depression and no notification of family members. While allegedly restricted to the "terminally ill," its definition of "terminal" was broad enough to cover patients who could live a long time with continued treatment. And it required doctors who oppose euthanasia to obey a patient's request for a lethal injection or transfer him or her to someone who would. The theme cited most often by supporters (47%) was:
"A person has a right to choose". So as The Seattle Times notes, the euthanasia debate has shaped up as a parallel to the longstanding debate on abortion: It is "a confrontation between moral beliefs and freedom of choice."
The surprise is that, in perhaps the least religious state in the nation, moral beliefs on these issues are holding their own.
Cited by 15% of supporters was the theme that euthanasia "could end someone's pain." Hemlock's claim that far too many people die in excruciating pain did strike a chord, yet even Hemlock founder Derek Humphrey has admitted that modern medicine can control 95% of the pain of terminal illness. The reality is that many doctors are simply untrained in these modern techniques or unwilling to use them.
The third reason cited by supporters was "personal experience" with serious illness (10%).
18-10 What groups joined with pro-euthanasia groups to back pro euthanasia initiatives?
January, 1992, "Campaign News" published by the backers of the California Proposition 161 lists California NOW and the Executive Director of the Los Angeles Gay and Lesbian Community Service Center.
18-11 How did various groups vote, according to exit polls?
Californians Against Human Suffering claimed that exit polls for the networks indicated the following percentages of support for Proposition 161 among the groups listed:
1) men 50%; women 44%;
2) young voters (18-29) 52%; older voters (60+) 43%; retired voters 43%;
3) Democrats 47%; Republicans 42%; independents 55%; liberals 56%; conservatives 35%;
4) Clinton voters 52%; Bush voters 34%; Perot voters 53%;
5) among religious groups, Anglo-Catholics gave the most support of any religious group, 46%; White born-again Christians 23%;
6) greater education and income made a yes vote more likely, with the only groups voting majority yes being those with post graduate education 54% and $75,000.00+ income 55%;
7) white voters 48%; black 39%; Asian 41%;
8) among issue orientation, environmentalists 55%, but those who said the environment was the most important issue, 60%; those who said health care was the most important issue, 50%; and pro-abortionists 57%.
18-12 Why did Oregon vote differently?
Pro-euthanasia initiatives lost in Washington and California in part because the medical associations and newspapers were opposed. In Oregon, the pro-euthanasia initiative was weakened. The Oregon sponsors apparently looked at the commercials used to oppose the earlier euthanasia initiatives in Washington and California and tried to take out everything they feared might cause people to oppose it. For example, the Oregon initiative does not permit killing by injection, which is the quickest way to kill a patient, apparently because they feared TV commercials of doctors with needles. It let physicians prescribe, but not administer the fatal dose.
Unlike In Washington and California, the Oregon Medical Association was neutral.
18-13 Did the Oregon initiative establish a workable system of euthanasia?
No. The Oregon euthanasia initiative was a fake that as worded could not accomplish its goals and was criticized by euthanasia advocates immediately after passage. Derek Humphrey, as the chief national fund-raiser for the initiative, wrote before the election:
"This is a carefully drafted law being put before the voters, surrounded with safeguards".
In direct contrast, less than a month after the election, he pointed out how hard a euthanasia death would be: "the Oregon law...could be disastrous" because it forbids doctors to give a "lethal injection" to kill their patients. "Evidence I have accumulated," he added, "shows that about 25% of assisted suicides fail, which casts doubts on the effectiveness of the new Oregon law, although it remains a significant demonstration of public opinion. The new Oregon way to die will only work if in every instance a doctor is standing by to administer the coup de grace if necessary."(NYT)
Also, after it was too late for voters to consider his criticism, Holland's leading euthanasia advocate, Peter Admiral, criticized the initiative in Oregon's largest newspaper as follows:
"About a quarter of the time, patients who have orally taken lethal drugs linger for hours or even days in an unconscious state, taking deep breaths. The patient will, of course, die," he said, "But it's very troubling for the family."
Commenting that such a death is not "acceptable in a civilized world," Admiral told Oregon voters: "You are in trouble. You have accepted phase one. Now phase two is coming." He omitted that the trouble was caused by the wording selected by euthanasia proponents.(OR)
Before the election, Oregon Right to Die, in its fact sheets, had misled the public into thinking that the Oregon initiative was all that was needed:
"The Act does not authorize mercy killing or active euthanasia...Medication prescribed under the Act must be self-administered." Oregon Right to Die chairman Peter Goodwin said this was a central safeguard against abuses such as involuntary euthanasia by claiming: "The patient controls the process, because it's only a prescription bill."
At the time this book was written, a Federal judge had prevented the initiative from going into effect because, among other things, it violates Federal prescription laws. (OS)
18-14 What tactics by euthanasia advocates can be expected in the future?
Euthanasia advocates will try to do the following:
1) exaggerate the pain, both physical and emotional, of not dying while taking public attention away from the advantages of not dying;
2) separate the concept of euthanasia from the idea of killing;
3) try to keep religion out of the euthanasia debate, since euthanasia has been considered a serious sin of killing by substantially all religions;
4) try to use the anxious to help media effectively;
5) try to convince people that most people now favor the limited amount of euthanasia that is all they seek;
6) try to move us to a pro-euthanasia position by a series of small steps;
7) try to establish euthanasia by short cuts such as court decisions establishing rights to euthanasia;
8) try to continually pressure society to take small, seemingly inconsequential steps toward the ultimate goal of euthanasia of anyone for trivial reasons, all the while claiming that the next step is the only advance they seek; and
9) emphasize that "it is a matter of choice", "uncontrollable pain and suffering" and "No one is forced to commit or participate in suicide".
18-15 What should be done to block euthanasia initiatives? White Catholics vote about the same as the general public, illustrating a defect in Catholic education. Catholics should make use of a sermon at least once every two years and an insert per year on parish bulletins. Much more intense and repetitive education should also be given to other Christians so they will be less likely to be fooled by pro-euthanasia commercials, slogans and media coverage. If Christian leaders educate on euthanasia as weakly as they educated on abortion, there is little hope for anti-euthanasia efforts. When there is an initiative, anti-euthanasia efforts must include a national funding effort backed by religious leaders to balance the national effort of euthanasia advocates. Euthanasia must be tied to killing which is still socially abhorrent. Six months before any election, every Christian should be strongly urged to place a euthanasia kills bumper sticker on his car, preferable with kills filling the bumper sticker and euthanasia written diagonally across it from one corner to the next. Experienced professional leadership and adequate funding are necessary.
REFERENCES
(CA) Californians Against Human Suffering letter of December 3, 1992 to supporters.
(FE) The Report of the Dutch Government Committee on Euthanasia, U.S. reference Vol. 7,
No. 3 Winter 1991 Issues in Law and Medicine
(JA) Journal of the American Medical Association, 11/27/91, p2895 (LT) Los Angeles Times, 10/27/92, page A18 (NT) New York Times, 11/4/91, A16 (NYT) New York Times, 12/3/94 (OR) The Oregonian, 12/4/94 (OS) Our Sunday Visitor, 12/25/94 "Why the euthanasia juggernaut has stalled" by Richard Doerflinger (PC) Personal contact with campaign leader (TV) Television accounts of the 1994 election Chapter 19
LESSONS FROM THE NAZI EUTHANASIA EXPERIMENT
19-1 What laws were passed permitting the German euthanasia program?
19-2 Did any written order authorize Nazi euthanasia?
19-3 What Nazi document authorized euthanasia?
19-4 How did the American prosecution in the medical case trial (Nuremburg Trials) warn us about euthanasia?
19-5 What did Justice Jackson of the U.S. Supreme Court, the head of the U.S. prosecution at the War Crimes Trials, say to warn us about euthanasia?
19-6 What did Leo Alexander, MD, U.S. medical expert witness at the Nuremburg War Crimes Trials say to warn us against Euthanasia?
19-7 What did Andrew Ivy, MD, the other American medical expert witness at the Nuremburg War Crimes Trials say to warn us against euthanasia?
19-1 What laws were passed permitting the German euthanasia program?
No laws were passed that permitted the German euthanasia program. (TT)
19-2 Did any written order authorize Nazi euthanasia?
There is no written record of any official order authorizing the euthanasia killings that followed.
Apparently the euthanasia killings grew in scope without specific order or authorization other than a 1939 Hitler letter. (TT)
19-3 What Nazi document authorized euthanasia?
The only document discovered which authorized authorizing euthanasia is a letter on Hitler's personal stationery written in October 1939, but dated back to the first day of the war, September 1, 1939. The letter of appointment stated:
"Reichsleiter Bouhler and Dr. Brandt, M.D., are charged with the responsibility of enlarging the authority of certain physicians to be designated by name in such a manner that persons who, according to human judgment, are incurable can, upon a most careful diagnosis of their condition of sickness, be accorded a mercy death." (TT)
19-4 How did the American prosecution in the medical case trial (Nuremburg Trials) warn us about euthanasia?
The medical trial had two main divisions, illegal medical experiments and euthanasia. The prosecution's opening statement declared:
"The defendants in this case are charged with murders, tortures, and other atrocities committed in the name of medical science. The victims of these crimes are numbered in the hundreds of thousands. A handful only are still alive; a few of the survivors will appear in this courtroom. But most of these miserable victims were slaughtered outright or died in the course of the tortures to which they were subjected...
"The responsibilities here imposed upon the representatives of the United States, prosecutors and judges alike, are grave and unusual. They are owed not only to the victims, and to the parents and children of the victims, that just punishment be imposed on the guilty, and not only to the defendants, that they be accorded a fair hearing and decision. Such responsibilities are the ordinary burden of any tribunal. Far wider are the duties which we must fulfill here.
"These larger obligations run to the peoples and races on whom the scourge of these crimes was laid. The mere punishment of the defendants, or even of thousands of others equally guilty, can never redress the terrible injuries which the Nazis visited on these unfortunate peoples. For them it is far more important that these incredible events be established by clear and public proof, so that no one can ever doubt that they were fact and not fable, and that this Court, as the agent of the United States and as the voice of humanity, stamp these acts, and the ideas which engendered them, as barbarous and criminal...
"We have still other responsibilities here. The defendants in the dock are charged with murder, but this is no mere murder trial. We cannot rest content when we have shown that crimes were committed and that certain persons committed them...
"It is our deep obligation to all peoples of the world to show why and how these things happened. It is incumbent upon us to set forth with conspicuous clarity the ideas and motives which moved these defendants to treat their fellow men as less than beasts. The perverse thoughts and distorted concepts which brought about these savageries are not dead. They cannot be killed by force of arms. They must not become a spreading cancer in the breast of humanity. They must be cut out and exposed, for the reason as well stated by Mr. Justice Jackson in this courtroom a year ago: 'The wrongs which we seek to condemn and punish have been so calculated, so malignant, and so devastating that civilization cannot tolerate their being ignored because it cannot survive their being repeated.'" (TT)
19-5 What did Justice Jackson of the U.S. Supreme Court, the head of the U.S. prosecution at the War Crimes Trials, say to warn us about euthanasia?
Justice Jackson took a leave of absence from the U.S. Supreme Court to lead the U.S. Prosecution at the Nuremburg War Crimes Trials after World War II. He warned us as follows:
"A freedom-loving people will find in the records of the war crimes trials instruction as to the roads which lead to such a regime and the subtle first steps that must be avoided. Even the Nazis probably would have surprised themselves, and certainly they would have shocked many German people, had they proposed as a single step to establish the kind of extermination institution that the evidence shows the Hadamar Hospital became. But the end was not thus reached; it was achieved in easy stages.
To begin with, it involved only the incurably sick, insane and mentally deficient patients of the Institution. It was easy to see that they were a substantial burden to society, and life was probably of little comfort to them. It is not difficult to see how, religious scruples apart, a policy of easing such persons out of the world by a completely painless method could appeal to a hard-pressed and unsentimental people. But 'euthanasia' taught the art of killing and accustomed those who directed and those who administered the death injections to the taking of human life. Once any scruples and inhibitions about killing were overcome and the custom was established, there followed naturally an indifference as to what lives were taken. Perhaps also those who become involved in any killings are not to be in a good position to decline further requests. If one is convinced that a person should be put out of the way because, from no fault of his own, he has ceased to be social asset, it is not hard to satisfy the conscience that those who are willful enemies of the prevailing social order have no better right to exist.
And so Hadamar drifted from a hospital to a human slaughter-house. (HA)
19-6 What did Leo Alexander, MD, U.S. medical expert witness at the Nuremburg War Crimes Trials say to warn us against euthanasia?
"Even before the Nazis took open charge in Germany, a propaganda barrage was directed against the traditional compassionate nineteenth century attitudes toward the chronically ill, and for the adoption of a utilitarian, Hegelian point of view. Sterilization and euthanasia of persons with chronic mental illnesses was discussed at a meeting of Bavarian psychiatrists in 1931. By 1936 extermination of the physically or socially unfit was so openly accepted that its practice was mentioned incidentally in an article published in an official German medical journal.
"Lay opinion was not neglected in this campaign. Adults were propagandized by motion pictures, one of which entitled 'I Accuse,' deals entirely with euthanasia. This film depicts the life history of a woman suffering from multiple sclerosis; in it her husband, a doctor finally kills her to the accompaniment of soft piano music rendered by a sympathetic colleague in an adjoining room.
Acceptance of this ideology was implanted even in the children. A widely used high school mathematics text, 'Mathematics in the Service of National Political Education,' includes problems stated in distorted terms of the cost of caring for and rehabilitating the chronically sick and crippled. One of the problems asked, for instance, how many new housing units could be built and how many marriage-allowance loans could be given to newly wedded couples for the amount of money it cost the state to care for 'the crippled, the criminal and the insane.'
"Whatever proportions these crimes finally assumed, it became evident to all who investigated them that they had started from small beginnings. The beginnings at first were merely a subtle shift in emphasis in the basic attitude of the physicians. It started with the acceptance of the attitude, basic in the euthanasia movement, that there is such a thing as life not worthy to be lived.
This attitude in its early stages concerned itself merely with the severely and chronically sick. Gradually the sphere of those to be included in this category was enlarged to encompass the socially unproductive, the ideologically unwanted, the racially unwanted and finally all non-Germans. But it is important to realize that the infinitely small wedged-in lever from which this entire trend of mind received its impetus was the attitude toward the non-rehabilitable sick.
"It is, therefore, this subtle shift in emphasis of the physicians' attitude that one must thoroughly investigate." (MS)
19-7 What did Andrew Ivy, MD, the other American medical expert witness at the Nuremburg War Crimes Trials say to warn us against euthanasia?
"However, I should again point out that the mass killings-the gassing chambers were related to the euthanasia edict secretly issued by Hitler in 1939 (see Q 19-3 for a copy of the edict). Paradoxically, German criminal law as late as 1945 held that euthanasia constituted murder and that 'the law must take care not to shatter the confidence of the sick in the medical profession.'
Medical ethics pledges that physicians are conservators rather than destroyers of life. In my opinion medicine is doomed if it ever consents to take part or permits any member in good standing to take part in a program of euthanasia applied for socioeconomic purposes. (NE)
REFERENCES
(HA) From The Hadamar Trial, Foreword by The Hon. Robert H. Jackson, Associate Justice, U.S. Supreme Court, and formerly U.S. Chief of Counsel for the Nuremburg Trials, Hodge and Co. & Ltd., 1949.
(MS) "Medical Science Under Dictatorship" New England Journal of Medicine, 241:39-47, 1949.
(NE) "Non Experimental Crimes; Mass Killings and Euthanasia" Journal of American Medical Association, Vol. 139, No. 3, 1/15/49, p131.
(TT) Trials of War Criminals Before the Nuremberg Military Tribunal Under Control Council Law No. 10, Volume 1, 1950, "The Medical Case".
CHAPTER 20 EUTHANASIA, RECENT HISTORY
20-1 Has widespread euthanasia been practiced in Christian countries?
20-2 How has American euthanasia support changed in recent years?
20-3 Since 1900, how many nations have made euthanasia legal?
20-4 How do the people of Holland feel about euthanasia?
20-5 How much involuntary euthanasia occurs in Holland?
20-1 Has widespread euthanasia been practiced in Christian countries?
No. Historically, Christianity has regarded euthanasia as morally the equivalent of murder, and so euthanasia has always been against the law in Christian nations.
20-2 How has American euthanasia support changed in recent years?
Euthanasia became popular, especially among non-Christians, in Germany, England and the U.S. after 1920. Because the War Crimes Trials publicized the Nazi euthanasia program, and because so many knowledgeable experts could point to so much strong uncontradicted evidence that euthanasia would to lead to much evil, euthanasia support nearly disappeared for about 20 years after World War II. Recently, since many of those who lived through World War II have died and abortion has destroyed the former prohibition against killing the innocent, euthanasia support has increased from its post-World War II low.
20-3 Since 1900, how many nations have made euthanasia legal?
Three nations have legalized euthanasia since 1900. Nazi Germany made euthanasia legal via an apparently narrowly and carefully drawn letter of Hitler. (See Q19-3 for a copy.) Judges, by refusing to prosecute doctors, made euthanasia legal in Holland about 1980 without the passage of any law. In the Soviet Union, Communists made euthanasia legal shortly after taking power, then made it illegal again about six months later because of abuses.
20-4 How do the people of Holland feel about euthanasia?
How people of Holland feel about euthanasia seems to depend on which class of people are asked. Polls have indicated a majority of those not threatened by euthanasia favor it, but those favoring euthanasia have not studied it in depth. There is a vast difference between the not threatened and the threatened. In opinion polls of the elderly and those in nursing homes, 93% of those interviewed in Dutch nursing homes opposed euthanasia, and 95% opposed legalization of euthanasia. (SE)
20-5 How much involuntary euthanasia occurs in Holland?
Dutch doctors admitted that in 1990 they sought to kill some 20,000 patients and that, in a clear majority of cases, this was done without the patient's request. (WJ)
This means that euthanasia without consent of the person killed now kills more than 10% of all people dying in Holland. Further, "A controversial 60 Minutes program in 1986 speculated that as many as one-sixth of all deaths in the Netherlands were due to euthanasia." (WJ)
If we take into account the likely possibility that doctors do not always admit it when they give euthanasia to people who want to live, it is possible that euthanasia is now or soon will be the leading cause of death in Holland. (WT)
REFERENCES
(SE) SEGERS, OUDERN EUTHANASIE, Elderly Persons on the Subject of Euthanasia (1987) U.S. Reference, 3 Issues in Law & Med., 417, 418, 1988.
(WJ) Wall Street Journal, 11/5/91, page A18, quoting the recent report by a Dutch government committee of inquiry into euthanasia survey of Dutch doctors.
(WT) Washington Times 11/12/91, F4 book review of Carlos F Gomez's "Regulating Death: The Case of the Netherlands"
This book deals only briefly with the history of euthanasia in 20th Century Holland and Germany.
For a more detailed analysis, order the soon to be published History of the Nazi and Dutch Euthanasia Programs, $4 per copy, includes mailing, from ALL, PO 1350, Stafford, VA, 22555.
CHAPTER 21 EUTHANASIA AND RELIGION
21-1 Is there a fundamental religious difference between euthanasia opponents and advocates?
21-2 How did the Old Testament look at life and death?
21-3 Did God command us to choose life rather than death?
21-4 Did God state that humans are substantially different from other animals?
21-5 Did God forbid killing the innocent.
21-6 Is the New Testament strongly pro-life?
21-7 What has been the Christian position on euthanasia and the killing of the innocent?
21-8 What did early Christian leaders say in condemning euthanasia and assisted suicide?
21-9 What does the Vatican Declaration on Euthanasia state?
21-10 What does the Catholic Catechism say about euthanasia?
21-11 Do most Protestant Churches condemn euthanasia and assisted suicide?
21-1 Is there a fundamental religious difference between euthanasia opponents and advocates?
Most active advocates of euthanasia do not have a strong belief in religion. Surveys by euthanasia advocates indicate strong religious belief correlates with strong opposition to euthanasia.
21-2 How did the Old Testament look at life and death?
Life is the greatest good and death is the worst evil.
21-3 Did God command us to choose life rather than death?
The last commandment Moses gave to the Israelites was: "'Here, then, I have today set before you life and prosperity, death and doom....I have set before you life and death, the blessing and the curse. Choose life, then, that you and your descendants may live.'" (Deut. 30:15-20)
This commandment to choose life is so important that it is repeated in separate books of the Bible.
21-4 Did God state that humans are substantially different from other animals?
Yes. God stated: "God created man in His image, in the Divine image He created him; male and female He created them." (Gen. 1:27) One of the major differences between those who advocate and those who oppose euthanasia is that most of the former claim that there is no substantial difference, that is no difference in kind, between humans and other animals. Those who believe in the Bible believe that there is a substantial difference, a difference in kind, between humans and other animals in that only humans are made in the image of God.
21-5 Did God forbid killing the innocent?
Yes. "Cursed be he who slays his neighbor in secret!...Cursed be he who accepts payment for slaying an innocent man." (Deut. 27: 24, 25)
"In hiding he (the wicked man) murders the innocent." (Ps. 10:8)
"There are six things the Lord hates,...hands that shed innocent blood;..." (Prov. 6:16-18)
21-6 Is the New Testament strongly pro-life?
Yes. "I came that they might have life and have it to the full." John (10:10)
"I am the resurrection and the life: whoever believes in me, though he should die, will come to life; and whoever is alive and believes in me will never die." (John 11:25,26)
21-7 What has been the Christian position on euthanasia and the killing of the innocent?
Prior to our generation, every Christian church for nearly 2,000 years condemned both abortion and euthanasia. During recent years, the traditional position has been maintained by most Christian churches, but certain of the non-Fundamentalist, non-Evangelical Protestant churches comprising less than 10% of all Christians have accepted abortion or euthanasia.
21-8 What did early Christian leaders say in condemning euthanasia and assisted suicide?
Kevin O'Rourke has published the following summary:
"There is no need here to cite the 77 authors of the patristic period whom Joseph V. Sullivan in his thesis, Catholic Teaching on the Morality of Euthanasia, counts as those 'who in some way indicate in their writing the Western tradition against the direct killing of the innocent,' but they include Irenaeus, Cyprian, Athanasius, Ambrose, Bede, and Popes St. Leo the Great, and Gregory the Great. Thus, before 150, The Sheperd of Hermas urged care for the poor lest they resort to suicide. About 125 A.D. St. Justin Martyr (Second Apology, PG 6.4, col. 450-51), to the pagan objection that if Christians really believed in heaven, then they would kill themselves to get there, replied by explaining that Christians obey God by living in the world to preach the Gospel.
"St. Augustine is often said to be the first to speak out unequivocally against suicide but there are earlier witnesses. Augustine simply took up the argument already stated very clearly about 313 A.D. by Lactantius. (Div. Inst. CSEL, 1961; p. 237).
Like Lactantius, Augustine argued from God's dominion over life and the commandment: 'You shall not kill,' but he, following St. Paul, thought this law also implied that governments have the duty to use force to prevent or punish crime and to wage just war, of which Augustine was the first Christian theorist. So understood, 'You shall not kill,' like, 'You shall not bear false witness,' was for Augustine an absolute law, admitting no exception in any circumstance, even for a good purpose. Hence he explained the 'suicides' of Biblical figures and of some martyrs either as authorized by God or as due to excusable but mistaken enthusiasm (Epist., 204, CSEL 57, p. 317ff).
Thus, by the end of the Patristic period a firm stand against suicide had been clearly expressed and generally accepted. "Augustine's teaching on the absolute law against suicide became standard for the monastic moralists such as Rabanus Maurus and Abelard. In the High Middle Ages, canonists, such as St. Raymund of Penafort, codified this tradition in their guides for confessors, whereas the scholastic theologians, like St. Thomas Aquinas, strove to reinforce it philosophically.
"Thus Aquinas (Summa Theologiae, II-II, a.64, a.5) uses Augustine's fundamental Biblical argument from god's dominion over life, but prefaces it with two others: suicide is metaphysically contradictory to the natural tendency of every being to maintain its own existence, and politically it unjustly deprives the community of one of its members. The values that Aquinas would see destroyed by suicide or assisted suicide (euthanasia) are the love of God, self, and community (neighbor).
"The fact that Aquinas places the Lactantius-Augustine argument in the context of these other two arguments drawn from the intrinsic teleology of human nature in its individual and political aspects is highly significant. Aquinas was the first Christian theologian to use Aristotle's Nicomachean Ethics, with its teleological methodology, to systematize the Biblical data patristic tradition on morals. Augustine's own Neo-Platonic ethics was itself strongly teleological but his interpreters had often stated the notion of God's 'dominion' in merely legal, deontological terms from which Aquinas freed it." (KO)
21-9 What does the Vatican Declaration on Euthanasia state?
The Vatican Declaration on Euthanasia, Prepared by the Sacred Congregation for the Doctrine of the Faith, May 5, 1980, states:
"INTRODUCTION"
"The rights and values pertaining to the human person occupy an important place among the questions discussed today. In this regard, the Second Vatican Ecumenical Council solemnly reaffirmed the lofty dignity of the human person, and in a special way his or her right to life. The Council therefore condemned crimes against life "such as any type of murder, genocide, abortion, euthanasia, or willful suicide" (Pastoral Constitution Gaudium et spes, no. 27).
"More recently, the Sacred Congregation for the Doctrine of the Faith has reminded all the faithful of Catholic teaching on procured abortion. The Congregation now considers it opportune to set forth the Church's teaching on euthanasia. "It is indeed true that, in this sphere of teaching, the recent Popes have explained the principles, and these retain their full force; but the progress of medical science in recent years has brought to the fore new aspects of the question of euthanasia, and these aspects call for further elucidation on the ethical level.
"In modern society, in which even the fundamental values of human life are often called into question, cultural change exercises an influence upon the way of looking at suffering and death; moreover, medicine has increased its capacity to cure and to prolong life in particular circumstances, which sometimes give rise to moral problems. Thus people living in this situation experience no little anxiety about the meaning of advanced old age and death. They also begin to wonder whether they have the right to obtain for themselves or their fellow men an "easy death," which would shorten suffering and which seems to them more in harmony with human dignity.
"A number of Episcopal Conferences have raised questions on this subject with the Sacred Congregation for the Doctrine of the Faith. The Congregation, having sought the opinion of experts on the various aspects of euthanasia, now wishes to respond to the Bishops' questions with the present Declaration, in order to help to give correct teaching to the faithful entrusted to their care, and to offer them elements for reflection that they can present to the civil authorities with regard to this very serious matter. "The considerations set forth in the present document concern in the first place all those who place their faith and hope in Christ, who, through His life, death and resurrection, has given a new meaning to existence and especially to the death of the Christian, as St. Paul says:
"If we live, we live to the Lord, and if we die, we die to the Lord" (Rom. 14:8; cf. Phil. 1:20).
"As for those who profess other religions, many will agree with us that faith in God the Creator, Provider and Lord of life-if they share this belief-confers a lofty dignity upon every human person and guarantees respect for him or her.
"It is hoped that this Declaration will meet with the approval of many people of good will, who philosophical or ideological differences not with standing, have nevertheless a lively awareness of the rights of the human person. These rights have often, in fact, been proclaimed in recent years through declarations issued by International Congresses; and since it is a question here of fundamental rights inherent in every human person, it is obviously wrong to have recourse to arguments from political pluralism or religious freedom in order to deny the universal value of those rights."
1. THE VALUE OF HUMAN LIFE
"Human life is the basis of all goods, and is the necessary source and condition of every human activity and of all society. Most people regard life as something sacred and hold that no one may dispose of it at will, but believers see in life something greater, namely, a gift of God's love, which they are called upon to preserve and make fruitful. And it is this latter consideration that gives rise to the following consequences:
"1. No one can make an attempt on the life of an innocent person without opposing God's love for that person, without violating a fundamental right, and therefore without committing a crime of the utmost gravity.
"2. Everyone has the duty to lead his or her life in accordance with God's plan. That life is entrusted to the individual as a good that must bear fruit already here on earth, but that finds its full perfection only in eternal life.
"3. Intentionally causing one's own death, or suicide, is therefore equally as wrong as murder; such an action on the part of a person is to be considered as a rejection of God's sovereignty and loving plan. Furthermore, suicide is also often refusal of love for self, the denial of the natural instinct to live, a flight from the duties of justice and charity owed to one's neighbor, to various communities or to the whole of society although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove guilt.
"However, one must clearly distinguish suicide from that sacrifice of one's life whereby for a higher cause, such as God's glory, the salvation of souls or the service of one's brethren, a person offers his or her own life or puts it in danger (cf. Jn. 15:14).
II. EUTHANASIA
"In order that the question of euthanasia can be properly dealt with, it is first necessary to define the words used.
"Etymologically speaking, in ancient times euthanasia meant an easy death without severe suffering. Today one no longer thinks of this original meaning of the word, but rather of some intervention of medicine whereby the suffering of sickness or of the final agony are reduced, sometimes also with the danger of suppressing life prematurely. Ultimately, the word euthanasia is used in a more particular sense to mean "mercy killing," for the purpose of putting an end to extreme suffering, or saving abnormal babies, the mentally ill or the incurably sick from the prolongation, perhaps for many years, of a miserable life, which could impose too heavy a burden on their families or on society.
"It is, therefore, necessary to state clearly in what sense the word is used in the present document.
"By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia's terms of reference, therefore, are to be found in the intention of the will and in the methods used.
"It is necessary to state firmly once more that nothing and no one can in any way permit the killing of an innocent human being, whether a fetus or an embryo, an infant or an adult, an old person, or one suffering from an incurable disease, or a person who is dying.
Furthermore, no one is permitted to ask for this act of killing, either for himself or herself or for another person entrusted to his or her care, nor can he or she consent to it, either explicitly or implicitly. Nor can any authority legitimately recommend or permit such an action. For it is a question of the violation of the divine law, an offense against the dignity of the human person, a crime against life, and an attack on humanity.
"It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, beside medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses.
III. THE MEANING OF SUFFERING FOR CHRISTIANS AND THE USE OF PAINKILLERS "Death does not always come in dramatic circumstances after barely tolerable sufferings. Nor do we have to think only of extreme cases. Numerous testimonies which confirm one another lead one to the conclusion that nature itself has made provision to render more bearable at the moment of death separations that would be terribly painful to a person in full health. Hence it is that a prolonged illness, advanced old age, or a state of loneliness or neglect can bring about psychological conditions that facilitate the acceptance of death.
"Nevertheless the fact remains that death, often preceded or accompanied by severe and prolonged suffering, is something which naturally causes people anguish. "Physical suffering is certainly an unavoidable element of the human condition; on the biological level, it constitutes a warning of which no one denies the usefulness; but, since it affects the human psychological makeup, it often exceeds its own biological usefulness and so can become so severe as to cause the desire to remove it at any cost.
"According to Christian teaching, however, suffering, especially suffering during the last moments of life, has a special place in God's saving plan; it is in fact a sharing in Christ's passion and a union with the redeeming sacrifice which He offered in obedience to the Father's will. Therefore, one must not be surprised if some Christians prefer to moderate their use of painkillers, in order to accept voluntarily at least a part of their sufferings and thus associate themselves in a conscious way with the sufferings of Christ crucified (cf. Mt. 27:34).
Nevertheless it would be imprudent to impose a heroic way of acting as a general rule. On the contrary, human and Christian prudence suggest for the majority of sick people the use of medicines capable of alleviating or suppressing pain, even though these may cause as a secondary effect semiconsciousness and reduced lucidity. As for those who are not in a state to express themselves, one can reasonably presume that they wish to take these painkillers, and have them administered according to the doctor's advice.
"But the intensive use of painkillers is not without difficulties, because the phenomenon of habituation generally makes it necessary to increase their dosage in order to maintain their efficacy. At this point it is fitting to recall a declaration by Pius XII, which retains its full force; in answer to a group of doctors who had put the question: "Is the suppression of pain and consciousness by the use of narcotics...permitted by religion and morality to the doctor and the patient (even at the approach of death and if one foresees that the use of narcotics will shorten life)?" the Pope said: "If no other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties: Yes." In this case, of course, death is in no way intended or sought, even if the risk of it is reasonably taken; the intention is simply to relieve pain effectively, using for this purpose painkillers available to medicine.
"However, painkillers that cause unconsciousness need special consideration. For a person not only has to be able to satisfy his or her moral duties and family obligations; he or she also has to prepare himself or herself with full consciousness for meeting Christ. Thus Pius XII warns: "It is not right to deprive the dying person of consciousness without a serious reason."
IV. DUE PROPORTION IN THE USE OF REMEDIES
"Today it is very important to protect, at the moment of death, both the dignity of the human person and the Christian concept of life, against a technological attitude that threatens to become an abuse. Thus some people speak of a "right to die," which is an expression that does not mean that right to procure death either by one's own hand or by means of someone else, as one pleases, but rather the right to die peacefully with human and Christian dignity. From this point of view, the use of therapeutic means can sometimes pose problems. "In numerous cases, the complexity of the situation can be such as to cause doubts about the way ethical principles should be applied. In the final analysis, it pertains to the conscience either of the sick person, or of those qualified to speak in the sick person's name, or of the doctors, to decide, in the light of moral obligations and of the various aspects of the case.
"Everyone has the duty to care for his or her own health or to seek such care from others. Those whose task it is to care for the sick must do so conscientiously and administer the remedies that seem necessary or useful. "However, is it necessary in all circumstances to have recourse to all possible remedies?
"In the past, moralists replied that one is never obliged to use "extraordinary" means. This reply, which as principle still holds good, is perhaps less clear today, by reason of the imprecision of the term and the rapid progress made in the treatment of sickness. Thus some people prefer to speak of "proportionate" and "disproportionate" means. In any case, it will be possible to make a correct judgment as to the means by studying the type of treatment to be used, its degree of complexity or risk, its cost and the possibilities of using it, and comparing these elements with the result that can be expected, taking into account the state of the sick person and his or her physical and moral resources.
"In order to facilitate the application of these general principles, the following clarifications can be added; "_If there are no other sufficient remedies, it is permitted, with the patient's consent, to have recourse to the means provided by the most advanced medical techniques, even if these means are still at the experimental stage and are not without a certain risk. By accepting them, the patient can even show generosity in the service of humanity.
"It is also permitted, with the patient's consent, to interrupt these means, where the results fall short of expectations. But for such a decision to be made, account will have to be taken of the reasonable wishes of the patient and the patient's family, as also of the advice of the doctors who are specially competent in the matter. The latter may in particular judge that the investment in instruments and personnel is disproportionate to the results foreseen; they may also judge that the techniques applied impose on the patient strain or suffering out of proportion with the benefits which he or she may gain from such techniques.
"_It is also permissible to make do with the normal means that medicine can offer. Therefore one cannot impose on anyone the obligation to have recourse to a technique which is already in use but which carries a risk or is burdensome. Such a refusal is not the equivalent of suicide; on the contrary, it should be considered as an acceptance of the human condition, or a wish to avoid the application of a medical procedure disproportionate to the results that can be expected, or a desire not to impose excessive expense on the family or the community. "_When inevitable death is imminent in spite of the means used, it is permitted in conscience to take the decision to refuse forms of treatment that would only secure a precarious and burdensome prolongation of life, so long as the normal care due to the sick person in similar cases is not interrupted. In such circumstances the doctor has no reason to reproach himself with failing to help the person in danger.
CONCLUSION "The norms contained in the present Declaration are inspired by a profound desire to serve people in accordance with the plan of the Creator. Life is a gift of God, and on the other hand death is unavoidable; it is necessary, therefore, that we, without in any way hastening the hour of death, should be able to accept it with full responsibility and dignity. It is true that death marks the end of our earthly existence, but at the same time it opens the door to immortal life. Therefore, all must prepare themselves for this event in the light of human values, and Christians even more so in the light of faith.
"As for those who work in the medical profession, they ought to neglect no means of making all their skill available to the sick and the dying; but they should also remember how much more necessary it is to provide them with the comfort of boundless kindness and heartfelt charity. Such service to people is also service to Christ the Lord, who said: "As you did it to one of the least of these my brethren, you did it to me" (Mt. 25:40).
"At the audience granted to the undersigned Prefect, His Holiness Pope John Paul II approved this Declaration, adopted at the ordinary meeting of the Sacred Congregation for the Doctrine of the Faith, and ordered its publication. "Rome, the Sacred Congregation for the Doctrine of the Faith, May 5, 1980."
21-10 What does the Catholic Catechism say about euthanasia?
(Numbers are paragraph numbers in the Catechism) "2276 Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible.
"2277 Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.
"Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator. The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded.
"2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted.
The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.
"2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable.
Palliative care is a special form of disinterested charity. As such it should be encouraged.
"2324 Intentional euthanasia, whatever its forms or motives, is murder. It is gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator."
21-11 Do most Protestant Churches condemn euthanasia and assisted suicide?
There are a substantial number of Protestant Churches, each differing from the others in one or more areas, so the positions of all will be summarized. A few more liberal Protestant Churches have accepted euthanasia and assisted suicide. The majority of Protestant Churches, of which the majority of Protestants are members, condemn euthanasia. For example, in the Washington State euthanasia election in November, 1991, and in the California euthanasia election in 1992, the majority of Protestant Churches worked against the legalization of euthanasia. According to exit polls (see 18-11), the religious group voting most strongly against euthanasia comprised white, born-again Protestant Christians.
REFERENCE
(1) "Assisted Suicide: An Evaluation" Kevin O'Rourke, JCD; Journal of Pain and Symptom Management, Vol. 6 No. 5 July 1991, p317
CHAPTER 22 SUBSTITUTED JUDGMENT, DEADLY FICTION
22-1 What is substituted judgment?
22-2 What is the false assumption that makes substituted judgment a very bad way to exercise rights?
22-3 How does the false assumption of substituted judgment attack the rights of the incompetent?
22-4 What are examples of rights so personal and intimate that no other person can accurately exercise them?
22-5 Why is substituted judgment a poor standard for life or death questions?
22-6 How did Carrie Coons show that two major substituted judgment findings of the court were wrong?
22-7 What is the substituted judgment concept?
22-8 What decision making standards for incompetent people does the substituted judgment concept replace?
22-9 What is the best interest standard?
22-10 What is the reasonable man standard?
22-11 What can a competent patient decide about his medical care?
22-12 What does a doctor usually do when a patient refuses treatment?
22-13 What is the logic behind the substituted judgment standard?
22-14 What is informed consent?
22-15 What is the right to privacy?
22-16 Does the right to privacy mean a right to do what we want so long as we do it privately?
22-17 Does the right to privacy forbid government practices which interfere with a parent's right to bring up children to be good or religious?
22-18 Why does substituted judgment contradict true privacy?
22-19 What types of cases is substituted judgment aimed at?
22-20 Why were substituted judgment and other euthanasia questions not so serious a problem in the past?
22-21 How does the court claim to act in a substituted judgment case?
22-22 Why is substituted judgment biased toward death?
22-23 Is there any limit to the rights that can be exercised by substituted judgment?
22-24 How does a court determine what the competent person would want if he could decide?
22-1 What is substituted judgment?
Substituted judgment is the exercise by a second person of rights belonging to a first person.
22-2 What is the false assumption that makes substituted judgment a very bad way to exercise rights?
Substituted judgment assumes that patients have rights. That is correct. Substituted judgment assumes that every right of one person can be exercised by another if the first person becomes incompetent. That is not correct. Some rights are so personal and so intimate that no other person can exercise them effectively.
22-3 How does the false assumption of substituted judgment attack the rights of the incompetent?
Substituted judgment assumes that the most intimate rights of an incompetent person can effectively be exercised by another person. This is not true. This incorrectly assumes that an incompetent person can act through another as if he were competent.
Incompetent persons, because of their disability, would frequently benefit from special protection rather than a fiction that enables someone else to exercise rights over their body that normal people have, but that they can no longer exercise.
22-4 What are examples of rights so personal and intimate that no other person can accurately exercise them?
Marriage is one. How would you like to wake up some morning and find that because you had once said you liked blondes, your sister had exercised substituted judgment and married you to one? The right to vote is another. It is a crime for one citizen to exercise the right to vote of another. There are many other intimate rights, important ones such as the right to have children or the right to freedom of speech, and less important rights such as what baseball team to cheer for or what to order in a restaurant. None of these rights are as important or as personal as the right to decide what medical care to seek or avoid when it is a life or death decision.
22-5 Why is substituted judgment a poor standard for life or death questions?
Substituted judgment assumes doctors can always accurately predict the future for a patient. It also assumes that what a patient would want can be reconstructed with certainty. The following true example shows that our society is not quite that wise. In November, 1988, in Rensselaer NY, Carrie Coons suffered a massive stroke and fell into coma. Her doctors inserted a feeding tube because she could not feed herself. Her doctors described Carrie's condition as an irreversible vegetative state and abandoned hope. Carrie's sister decided that rather than being fed, Carrie would be better off dying of thirst and sought court permission to stop the supply of food and water to Carrie. The evidence submitted convinced the court that if Carrie could talk, she would ask to die of dehydration, rather than continue being fed and treated. The New York Supreme Court, based on this evidence and relying on the substituted judgment of Carrie's sister, ordered that Carrie be killed by dehydration and starvation.
The court order that Carrie Coons be killed by dehydration was based on two findings. The first was the doctors' wrong prediction that Carrie would never wake up. The second was the wrong court finding that if Carrie could wake up and be asked whether she should be killed by dehydration, Carrie would agree with Carrie's sister that Carrie should be killed by dehydration and starvation. This case shows how wrong the predictions on which substituted judgement is based can be.
22-6 How did Carrie Coons show that two major substituted judgment findings of the court were wrong?
The first court finding was shown to be wrong over the weekend of April 8-9, 1989, when Carrie woke up. The second court finding that Carrie should be killed because she wanted to be killed, was also wrong. Carrie was asked if she wished the feeding tube to be removed if she slipped back into a coma, and Carrie replied: "These are difficult decisions," and fell asleep. The news account noted that Carrie's doctors, lawyers and sister were baffled. (NT)
Ironically, a woman waking up from coma immediately showed more wisdom in ten seconds than the entire highly paid U.S. judicial system has shown in ten years. The courts have been acting as if these are simple, easy decisions. They are not. These are difficult decisions.
22-7 What is the substituted judgment concept?
Substituted judgment is the court or some court appointed person making the most important and intimate decisions on behalf of an incompetent person without asking that person (who cannot be asked because he is incompetent and who has not given advance notice of what his wishes would be because he cannot have known the facts or the situation in advance).
22-8 What decision making standards for incompetent people does the substituted judgment concept replace?
The substituted judgment concept replaces the "best interest standard", the "reasonable man" standard, relying on the physician, and other standards for decisions.
22-9 What is the best interest standard?
The best interest standard requires that to be done which is in the best interest of the patient. When it is desired to kill the patient, the best interest standard is usually inconvenient, because killing is not in the patient's best interest. Unlike the substituted judgment standard, the best interest standard places objective limitations on the decision-maker.
22-10 What is the reasonable man standard?
By the reasonable man standard courts require that to be done which a reasonable man would do. For example, in driving a car, you are held to a reasonable man standard. The term "reasonable man" has been used for hundreds of years even though the standard can be applied to women. The reasonable man standard is sometimes inconvenient to those wishing to kill a patient, since they cannot prove killing is reasonable. Unlike the substituted judgment standard, the reasonable man standard places objective limitations on the decision-maker.
22-11 What can a competent patient decide about his medical care?
Normally a competent patient can decide everything about his medical care. The financially and otherwise independent competent patient can make all decisions relating to his medical care, and the doctor has a duty to explain the options so that the patient can make an informed decision.
22-12 What does a doctor usually do when a patient refuses treatment?
When a patient refuses treatment, the doctor usually accepts the patient's decision. The doctor usually gives the patient additional information if the doctor believes the patient's initial refusal of treatment is unwise. If the patient refuses to agree with the doctor and the doctor does not accept the patient's decision, the doctor usually has a duty to transfer the patient to a different doctor of the patient's choice.
22-13 What is the logic behind the substituted judgment standard?
The logic the substituted judgment standard is based on is a fiction, which is legal terminology that really means the substituted judgment standard is based on a lie. Substituted judgment combines a right to informed consent and the type of right to privacy made famous by abortion cases.
22-14 What is informed consent?
Every patient capable of deciding can decide to select or refuse medical treatment. This is contrary to many arguments for euthanasia, where the advocates of euthanasia lie to convince the public that a doctor or hospital can treat a patient against the patient's wishes. In truth, if you do not like the treatment you are receiving from a hospital, you can leave the hospital. If you do not like the treatment you are receiving from a doctor, you can fire the doctor and retain a different doctor who will give you more reasonable treatment. You have the right to fire your doctor even if you owe him money. You also have a right to be informed about a treatment so you understand both the treatment and possible alternative treatments with their advantages, disadvantages, and all other reasonably necessary information. Competent patients can choose or decline a treatment based on a reasonably complete understanding of their options.
22-15 What is the right to privacy?
The right to privacy is a nice sounding ambiguous phrase that has been used effectively by those advocating changes in public morality, morality based on traditional Christian morality, in areas such as promiscuity, abortion, euthanasia and homosexuality. The right to privacy is not found in the U.S. Constitution. In the 1920's, in the Prudential Insurance case, even the U.S. Supreme Court denied that the right to privacy exists. In 1965, in Griswold v Connecticut, the 1965 U.S. Supreme Court invented the right to privacy which the 1920's U.S. Supreme Court ruled did not exist in the U.S. Constitution.
22-16 Does the right to privacy mean a right to do what we want so long as we do it privately?
No. The right to privacy has even been held not to mean you can do what you want with your body in the privacy of your own home. For example, you cannot take heroin in your home. The right to privacy has been limited almost exclusively to a legal-sounding, but unsound excuse for courts to attack traditional sex-related laws based on Christian standards, such as laws forbidding abortion, euthanasia, deviant sexual practices such as homosexuality, etc.
22-17 Does the right to privacy forbid government practices which interfere with a parent's right to bring up children to be good or religious?
No, The right to privacy has nothing to do with most private acts.
22-18 Why does substituted judgment contradict true privacy?
The court stated purpose of the right to privacy is to permit the individual to make choices without government interference. Substituted judgment is the opposite of privacy in that the government makes the decision and the incompetent person is not permitted to contest the decision or, usually, to even present an opinion.
22-19 What types of cases is substituted judgment aimed at?
Substituted judgment is primarily used to dispose of cases involving a decision to discontinue or refrain from initiating therapy likely to maintain the life of an incompetent patient for an indefinite time, but which will not effect a cure. Examples of such therapy include dialysis, respirators, and some cancer therapies. In the typical substituted judgment case, treatment may be expensive or may not restore full health to an unconscious person who is unlikely to improve. Failure to treat, however, is likely to hasten death.
22-20 Why were substituted judgment and other euthanasia questions not so serious a problem in the past?
There are three reasons why euthanasia-related questions are now more important.
1. In the 1920's and 1930's, euthanasia was widely advocated. Nazi Germany subsequently tried euthanasia and the results were so horrible that euthanasia lost its appeal as long as those who remembered the Nazi experience dominated public policy.
2. The experts on the Nazi euthanasia experience warned us that a little bit of killing deadens our sensitivity toward further killing and inevitably causes a gradual widening of the reasons for killing innocent people. As a modern example, the initial change in attitudes caused by abortion has deadened sensitivity to other killings.
3. The technology of medicine has continually advanced, thereby increasing the number of patients who can be kept alive at some expense but cannot yet be cured, although they may be curable with tomorrow's technology. Years ago, we could do so little that it was logical to do everything we could for seriously ill or injured patients nearly all the time. Today, we can do so much more that there are thousands of cases annually (still a small minority of all cases) where it is reasonable not to do all we can to preserve a patient's life.
22-21 How does the court claim to act in a substituted judgment case?
The court claims to act on behalf of the incompetent in the same manner as the incompetent would act if he were competent. This is a contradiction in terms in the more personal areas. What the incompetent person expressed as an opinion in the past or might have decided in the past as shown by statements is assumed to be the decision the patient would have made today.
22-22 Why is substituted judgment biased toward death?
Incompetents cannot by themselves petition the court. Caretakers who do not strongly desire the death of a patient will not go to court, since the patient is already being kept alive. Accordingly, the entire collection of case law has been made in cases where the petitioner strongly desired the death of the patient, in contrast to an atmosphere of concerned, impartial inquiry. As a result, substituted judgment has become a means not of effectuating the patient's personal choice, but of enabling a relative or caretaker to kill the patient while soothing the conscience of the killer and of the court with the language of rights.
22-23 Is there any limit to the rights that can be exercised by substituted judgment?
There is no inherent limit to the number or type of rights that could be exercised by substituted judgement. Among other examples, substituted judgment has decided an incompetent should donate a kidney (Strunk v Strunk, 445 S.W.145 KY 1969) or should not donate a kidney (In Guardianship of Pescinski, 67 Wis.2d 4, 226 N.W.2d 180 1975), be sterilized (In re Moe, 432 N.E. 2d at 724), as well as numerous cases where the substituted judgment fiction was used to decide that an incompetent patient should die via dehydration.
22-24 How does a court determine what the competent person would want if he could decide?
The determining of the intent of the incompetent person, a determination which is by definition impossible since the patient is incompetent, causes a whole different set of problems when substituted judgment is used.
If the patient said anything that might shed light on the situation, the courts simplify a complicated situation by deciding that what the patient said before becoming incompetent should govern. This overlooks the usual tendency of patients to first fear continued life with disability so much that they say they would prefer death, then to change their mind and want continued life, even if disabled, after they experience disability and learn that it is better than they had feared.
REFERENCE
(NT) "Right to die order revoked as Patient in Coma Awakes" NY Times, 4/13/89 pB3
CHAPTER 23
PERSONHOOD IN THE CONSTITUTION AND EUTHANASIA
23-1 What is the personhood argument for euthanasia?
23-2 How does one become a person and therefore entitled to the Right to Life?
23-3 What is the U.S. law defining personhood?
23-4 If U.S. law defines every individual as a person, and humans not yet born are individuals, how could the U.S. Supreme Court make abortion legal up to the moment of birth?
23-5 How do euthanasia advocates use selected characteristics to justify killing?
23-1 What is the personhood argument for euthanasia?
The personhood argument for euthanasia states that only "persons" have a Constitutionally protected Right to Life, and that some people have become so disabled that they are no longer "persons".
23-2 How does one become a person and therefore entitled to the Right to Life?
There are three theories about how one becomes a "person" and therefore entitled to the right to life:
(a) Every human, no matter how defective has been chosen by God for life, and no mere human has the right to kill other humans who have not forfeited their right to life. This method leads to protection for all.
(b) Man defines by law who is a person and who or what is not a person. This theory has led to the Nazi holocaust, to abortion and to slavery in the U.S. and elsewhere.
(c) One becomes a person by demonstrating selected characteristics. This method was also used by the Nazis, who defined Aryan blood as a necessary characteristic of personhood. Requiring selected characteristics which are usually lacking among the incompetent is the prevalent method of defining personhood by the euthanasia movement. Theories (b) and (c) are used to argue for euthanasia. 23-3 What is the U.S. law defining personhood?
The Fourteenth Amendment gives Congress the power to define who or what is a person. Since only persons have rights, Congress placed the definition of personhood in the very first section of U.S. Code. Title 1, U.S. Code, Section 1 (1 USC 1) states that the term "person" includes individuals. Since both medical and standard dictionaries define every human from the time of fertilization until death as an individual, 1 USC 1 would appear to give the greatest possible protection to everyone by defining every individual to be a person and therefore entitled to the rights and protections of persons, including the Right to Life. This argument is made even stronger when one considers the circumstances under which 1 USC 1 was passed. It was the 1947/1948 Congress, legislating during the War Crimes trials of Nazis which passed 1 USC 1. 1 USC 1 had initially been passed without the provision defining every individual to be a person, but after publicity about Nazi atrocities, which they had justified by denying that all individuals are persons, the same Congress immediately amended the newly passed 1 USC 1 to add a provision which defined every individual as a person.
23-4 If U.S. law defines every individual as a person, and humans not yet born are individuals, how could the U.S. Supreme Court make abortion legal up to the moment of birth?
The U.S. Supreme Court simply ignores 1 USC 1, in spite of briefs which repeatedly reference 1 USC 1. In other words, when the law does not say what the justices want the law to say, they have the power to ignore it.
23-5 How do euthanasia advocates use selected characteristics to justify killing?
Because we permit the killing of animals who can demonstrate memory and perform logic on a low level, they define any human being who does not presently demonstrate at least this mental ability to be not a person. This defining people to be non persons makes it possible to justify the killing of any very young human who has not yet developed the capacity to use language that can be understood by strangers, as well as those who have temporarily or apparently permanently lost the capacity.
CHAPTER 24 PERSISTENT VEGETATIVE STATE
24-1 What is the persistent vegetative state (PVS)?
24-2 Do PVS patients resemble vegetables?
24-3 Illustrate coma patient potential mental capacity.
24-4 Are many patients still PVS because of doctors' emotional hangups?
24-5 What have many doctors assumed about PVS patients?
24-6 What has been the level of the medical research that has helped PVS patients recover?
24-7 What about more sophisticated efforts to understand and cure PVS patients?
24-8 Have any studies shown that with slightly more sophisticated techniques, far more PVS patients can improve?
24-9 Can PVS patients feel pain?
24-1 What is the persistent vegetative state (PVS)?
The persistent vegetative state (PVS) is a medical term used to describe most patients who are between a coma and normal consciousness. The author fears the term PVS may have been purposefully chosen to make it easier to kill patients, since killing a vegetable does not sound as bad as killing a mother, a child, or any other human being. Most PVS patients used to die quickly. Because of improvements in medical practice, we can now keep them alive. Meaningful medical research seeking cures for PVS patients is just beginning and it is hoped that there will soon be many partial or complete cures. In more rigorous medical terms, "In 1972 Jennett and Plum put forth a point of view with regard to a group of patients who, owing to improved and intensive care, had survived severe traumatic or ischemic brain damage. Such patients survive in a sleep like, insensible state, neither unconscious nor in coma, and never show evidence of a working mind. They are wakeful without being aware: their eyes open spontaneously or in response to verbal stimuli, but they do not obey commands, express comprehensible words, or sustain visual fixation and pursuit. They do manifest sleep/wake cycles and maintain cardiorespiratory function. For the most part they are described as exhibiting only patterned responses to noxious stimuli, not complex, intelligible communication." (JP)
Either the authors misstated the characteristics of PVS patients, or others since have added to the PVS class patients who are in substantially better condition than the preceding described patients. Some patients like, Nancy Cruzan, show some evidence of a mind that is working, though in less than a normal manner. Other patients have recovered and stated that their minds and ability to perceive and understand were working normally, but they were unable to communicate.
24-2 Do PVS patients resemble vegetables?
No. Not even the smartest carrot or other vegetable can do what PVS patients can do. PVS patients can sometimes do the following:
* recover totally to lead the life of a normal human being;
* recover partially to lead a more normal human life, although with some disability;
* swallow and eat;
* cry, laugh, feel happy or sad, or respond when it is appropriate to cry, laugh, feel happy or sad or otherwise respond emotionally;
* hear, see and remember what is going on around them;
* reason normally;
* be emotionally hurt, such as one woman who was upset during her PVS state when visitors would discuss what they were going to do later, such as going to dinner, making the PVS patient upset since she wanted to go and knew they could take her in a wheel chair, even if she was unable to ask them;
* perform functions appropriate to humans and not to plants, such as sitting, breathing, etc. 24-3 Illustrate coma patient potential mental capacity.
PVS patients are considered to be less injured than coma patients, so PVS patients should have greater capabilities than those of coma patients. Numerous examples of the capabilities of coma patients can be given. Examples are similar to the following: "One recovered patient could recall much of what her family said to her during her 53 day coma but wondered why her doctor didn't speak to her. She remembered thinking while in her coma, 'Doctor, you never say hello to me. Why do you act as if I'm not here?'" (VM)
24-4 Are many patients still PVS because of doctors' emotional hangups?
Yes. Like most of us, most doctors would rather win than lose. Most doctors feel better when they cure or improve a patient. On the other hand, when a doctor fails to improve or cure a patient, the doctor may feel that he has lost, and may lose some self esteem. When a doctor loses, and the loss affects him emotionally, he is tempted to use the same emotional defenses the rest of us use. One of the best emotional defenses is denial. To its shame, the medical profession has until recently almost totally ignored the possibility of recovery of PVS patients and has acted as if it were denying their existence.
24-5 What have many doctors assumed about PVS patients?
Many doctors have wrongly assumed that nothing can be done to help PVS patients, and that PVS patients will never improve until they die.
24-6 What has been the level of the medical research that has helped PVS patients recover?
PVS patients have recovered as a result of:
being talked to and intellectually stimulated (PD);
hearing a pep talk from a football player; (PD)
taking novocaine;
having vinegar put in their mouth.
That type of medicine could have been practiced many years ago. When we look for sophisticated research, or research using modern machinery or techniques, we do not yet find it.
24-7 What about more sophisticated efforts to understand and cure PVS patients?
There has been no significant published sophisticated effort to understand or cure PVS patients as of the printing date of this book. Good results have been obtained and published in medical journals using techniques that could have been used 100 years ago.
24-8 Have any studies shown that with slightly more sophisticated techniques, far more PVS patients can improve?
"In this paper we describe methodology and our experience with ten cases of vegetative status.
"All cases satisfied the definition of 'vegetative status' and had received medical treatment for more than 3 months prior to DCS without showing any clinical improvement.
Result:
1) There was an improvement in the EEG in nine cases out of ten cases after neurostimulation. This was in the form of appearance of more widespread a waves and was noticed between 3 to 14 days after starting the neurostimulation.
2) Four of these cases showed good clinical improvement. In the other four cases there was slight clinical improvement. They improved to the extent of following verbal orders within four months while another patient started opening eyes two weeks after starting the neurostimulation."
(IS) The article continues by listing ten improvements (in rCBF, CSF, NE, DA, POPAC, HVA, HVA, 5HITAA, 3MT, and 5HT). This article and similar articles appears to give hope of massive improvements in many PVS patients in response to only a small future research effort, if someone funds such a small future research effort.
24-9 Can PVS patients feel pain?
Based on statements of patients who have recovered, on an analysis of what still works in the bodies of PVS patients and the responses of many PVS patients to stimuli that we would feel to be painful, the evidence suggests that at least many PVS patients can feel pain. We certainly cannot know that PVS patients do not feel pain. (IL)
REFERENCES
(IL) "Can People Who Are Unconscious or in the 'Vegetative State' Perceive Pain?" Issues in Law & Medicine, Vol 6 #4 (1991) examines evidence from which it could be ocncluded that the PVS can feel pain
(IS) IGAKU-SHOIN Ltd. 5-24-3 Hongo, Bunkayo-ku, Tokyo, 113-91 Japan" reprinted from Neurological Surgery, Vol. 16, #2, February, 1988
(JP) Jennett & Plum, "Persistent Vegetative State After Brain Damage" 1 Lancet 734 (1972)
(PD) St Louis Post Dispatch, 4/14/89, p2a
(VM) Vogue Magazine April, 1988 p166
CHAPTER 25 BRAIN DEATH
25-1 What is brain death?
Brain death has two definitions. The brain can actually be dead, or it can be injured so that it only functions partially, but still is called dead.
25-2 How is brain death used by euthanasia advocates?
Euthanasia advocates define death to comprise "brain death", then define an injured brain as dead, even though in a few cases, the patient can later revive.
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