From Today’s Christian Doctor – Summer 2010

I visited a couple in assisted living at a Christian facility that has residential retirees, assisted living, and skilled nursing modules. In the lobby I met the chaplain, and we talked a bit about life in this community. He brought up the fact that he will frequently hear residents wonder why, “God hasn’t taken me home yet?” This led to a discussion of end-of-life issues, and his wondering what difference, if any, there was between terminating care or treatment and letting someone take their life or intentionally ending their life.

Since such a question might have been deemed inappropriate a few decades ago, it is enlightening to take a brief look at how we could arrive at such a conversation. At thebeginning of the last century, there was very little that physicians could do to change the course of disease. Most people died at home. By the end of the 20th century, one’s life span had increased 50 percent. It is estimated that around 85 percent of those who died did so in a hospital.^{1, 2} The reason for this was the tremendous advancement in medical technology which allowed us to keep people alive despite the presence of trauma or diseases which would, in an earlier era, have taken the patient’s life earlier on. In that sense, medical technology is both a blessing (because of the lives it saves and prolongs) and a curse (when the lives it prolongs degenerate through diseases such as cancer or Alzheimer’s).

In the case of Karen Quinlan (1976), the NJ Supreme Court case declared she had the constitutional right to die. This “right to die” movement was aided by both the presence of procedures and technology that prolonged the dying process and the high cost that this placed on the patients, family, and society. In 1990, the Supreme Court, in the case of Nancy Cruzan, implicitly sanctioned the use of the advance directive. The state of NY in 1994 concluded that patients should be allowed to refuse life-sustaining medical treatment, but that physician-assisted suicide and euthanasia should not be allowed.

In this context the plea for patient autonomy enters the discussion. Dr. Robert Orr states, “The dominant principle in secular medical ethics today is autonomy.”³ But it is not often differentiated (as Dr. Orr has explained) into “negative autonomy rights” (right to refuse treatment) which are nearly unassailable and available to all patients, or “positive autonomy rights” (a demand for treatment). For instance, one cannot demand antibiotics for a viral infection or narcotics for a mild headache. But it is here, in the pressing for positive autonomy rights, that we see the point of the physician-assisted suicide wedge being hammered in. There is a fundamental difference between allowing (at their request) patients to die by withholding or withdrawing medical treatment, and hastening death by intervening with drugs or devices. The Hippocratic Oath gives no mandate for treating the terminally ill, but it does prevent us from assisting in a person’s suicide or performing euthanasia.

What are the underlying fears? One might expect that the patient’s primary fear would be the “fear” of dying in pain. However, the main reason given by patients in the Netherlands for seeking death is “loss of dignity.”⁴ All but one of the twenty-three persons who were reported to have used Oregon’s assisted suicide law during its first year wanted suicide not because of pain, but for fear of losing functional ability, autonomy, or control of bodily functions.⁵

Can these fears be addressed? Ever since Cicely Saunders founded the first modern hospice in England in 1967, there has been steady progress in our ability to alleviate end-of-life pain or suffering. Dr. Joanne Lynn, director of George Washington University’s Center to Improve Care of the Dying says, “People find it hard to believe, but almost all patients can be kept conscious and out of pain. The rest can be kept sedated and out of pain.” She noted that “the literature on end-of-life care is replete with the incorrect assumption that terminal illness defined retrospectively carries no distinction from terminal illness defined prospectively.”⁶ The February 2009 Bulletin of the American College of Surgeons devoted a six page article to encouraging the training of surgeons in palliative medicine.

Society has a fear that the cost of care will outstrip the financial resources that the patient, family, or society as a whole will have. “There are currently 36 million Americans older than 65 years; 90 percent have one chronic illness, and more than 77 percent have two or more chronic illnesses. By 2030 it is expected that the number of older Americans will have more than doubled to 70 million — or one in every five Americans.”⁷ It is estimated that up to 31 percent of Medicare beneficiaries undergo surgical procedures in the last twelve months of life.⁸

Then there are those of us who fear that if physician-assisted suicide and euthanasia become legal, as it has in Oregon, Washington, Montana, the Netherlands, and an Australian province, there will be abuses, and the “slippery slope” phenomenon will take place. A 1990 survey of the Dutch experience found that out of 129,000 deaths during 1990, 2,300 were requests for euthanasia, 400 were physician-assisted suicide, and 1,000 were euthanasia without explicit request. In nearly half of the involuntary cases, physicians did not consult with family members but took it upon themselves to perform the procedure. The Dutch found that more requests for hastening patients’ deaths came from family members than from patients, and that family members and healthcare providers often pressured patients to request death.⁹There have been many studies dealing with end-of-life issues, and an overwhelming conclusion is that a desire for hastened death is tantamount to a diagnosis of depression, or at the very least a “cry for help.” Yet, in Oregon, the frequency of psychological consults dropped steadily from 35 percent to 5 percent.

On 26 June 1997, the US Supreme Court upheld the NY state laws against assisted suicide. It made clear, and upheld, the distinction between assisting in suicide and withdrawing life-sustaining treatment. The court highlighted three issues of critical concern: pain management, patient control over life-sustaining treatment, and the recognition and treatment of depression. Finally, the court felt that the debate over physician-assisted suicide and euthanasia should continue in the legislative process.

Hence there will be ongoing and persistent attempts to introduce PAS legislation in your state and mine. In 1996 and again in 2009, physician-assisted suicide legislation was introduced in New Hampshire where I practice, and I felt it was incumbent upon me to step forward and speak truth into the obfuscation foisted upon the public by the promoters of PAS.

Much of the appeal of their arguments came from heart-wrenching stories of patients suffering needlessly at the end of their lives. Following the principle that it is better to light one candle than to curse the darkness, I went, on both occasions, to testify about the dangerous public policy that the proposed PAS bills would create. After my testimony before the Judiciary Committee, one legislator told me that because of my testimony, the panel had decided to take PAS off the legislative agenda.

You and I need to take the principles of the imago dei and convert them into compelling public arguments. We need to work toward affordable healthcare for all. Our neighbors, friends, and chaplains need to hear the compelling arguments for adequate pain control, support of advance directives, and durable power of attorney for medical care. We need to advocate for the diagnosing and treatment of depression. This calls for family and society to be physically and emotionally present for the elderly, the sick, and the dying.

Should we ignore this responsibility (in reality, a privilege), the infirm and elderly will come under undue pressure to end their lives. This pressure will come from financially burdened or selfish families or from a patient’s fear of being alone, a burden to others, or that he or she may experience a loss of control. We will be seduced by the idea of a painless death, but will have to live with the abuse and selfishness of family and society as we try to save money and avoid responsibility. The Hippocratic Oath prevents us from abusing our power over the vulnerable and exposed. We voluntarily set limits on our conduct, remembering that our primary service is to the sick, not to their family or the national deficit, nor to the hospital or the nursing home.

Respected physician-ethicists (Gaylin, Kass, Pellegrino, Siegler) have stated that, “Neither legal tolerance nor the best bedside manner can ever make medical killings medically ethical.”¹⁰ Dying is part of living. We cannot heal or comfort by making nil. The physician-euthanizer is a deadly self-contradiction.

When you think of the unbelievable change in the “doctor/patient” relationship physician-assisted suicide creates, and compound that with the loss (as a physician) of your right of conscience to refuse PAS as treatment, the practice of medicine will, at the end of life, change from compassionate caregiving, to balancing the financial books of the nursing homes and hospitals. We cannot stand by and let that happen. The debate will not be in the courts, it will be in the public square. Each of us needs to be knowledgeable enough to explain in basic terms why PAS is bad public policy. One very helpful way to understand how to prepare yourself is to participate in the media training course offered by CMDA. Then, when you meet the chaplain, your neighbor, colleague, or your state legislator, you will be able to change their minds and hearts on this issue, before it is too late.

Bibliography

¹ Freis, James, “Aging, Natural Death and the compression of Morbidity,” NEJM 1980: 130-135.

² Vladeck, Bruce, “End of Life Care,” JAMA (1995): 449.

³ Orr, Robert, Medical Ethics and the Faith Factor.

⁴ Medical Post, 16 March 1999.

⁵ NEJM (18 Feb 1999, Vol. 340, Issue 7.

⁶ Larson, E. & Amundsen, D. A Different Death, 248-9.

⁷ Bulletin American College of Surgeons (February 2009).

⁸ Health Serv Res. (2004:39:363-375).

⁹ Larson, E. & Amundsen, D. Op. Cit., 234-235.

¹⁰ JAMA (1986:2139).