Methods: A confidential survey was sent to 1600 critical care nurses in the United States asking them to describe anonymously any requests from patients, family members, surrogates or physicians requesting assisted suicide as well as their own unilateral practices.
Results: 1139 nurses responded (71%). Of these 852 nurses (17%) reported that they had received requests from patients or family members to perform euthanasia or assisted suicide. 129 of these (16% of that group) reported that they had actively engaged in such practices. An additional 35 (4%) reported that they had hastened a patient's death by pretending to provide life sustaining treatment ordered by a physician. The method of euthanasia most frequently reported was administration of high dose opiates to a terminally ill patient.
Conclusion: Nurses in the USA are actively participating in euthanasia far more frequently than previously surmised.
Comment by D. Crippen:
My first response to this paper was to speculate that the nurses were semantically confusing euthanasia with palliating discomfort during the withdrawal of futile life support. "I got an order to give the patient a lot of morphine after the ventilator was withdrawn...ergo, I killed the patient". However, on carefully re-reading the way the information was obtained, I really think these nurses were bumping off patients with intent.
If this is true, and I am prepared to argue that it is for a moment, I don't believe that nurses offing terminal patients is the real issue. The real issue is: In our era of high quality critical care, why do nurses feel the need to assist in putting patients out of their misery? Could it be that critical care physicians, in the aggregate, are remiss in dealing with death and dying in the ICU effectively? Or that there are not enough medical directors in places providing care to critically ill patients? Food for thought.
Malcolm Fisher:
I think your view is correct and when looked at in the context of the SUPPORT study understandable. A nurse in Melbourne is in jail as we speak for allegedly removing a patient from a ventilator without the medical knowledge or input .I do not believe this is good care.
There was a remarkable paper in J Cardiovascular Nursing 1988:3:47-56. by Majorie Stenburg called The responsible powerless" which wrote of the converse--nurses being asked to implement end of decisions without having input into the decision making, which is an reasonable way to treat professional colleagues, friends,or both. It seems to me that the results of this study suggest a similar attitude problem.
I am reminded of the first Apache II study in which communication between nurse and doctor was a major factor separating units with good and bad outcomes.. It further seems that if the processes involving a peaceful death in Intensive Care are discussed with patient,family,doctor,and nurse and they all agree on a management plan frankly and openly, and that an environment is created where nurses feel comfortable with and empowered to raise questions regarding the appropriateness of continuing care that nurses would have no need to covertly kill.
I have been down the covert paths as a powerless resident. It is a lonely and hazardous path and not one I would choose for myself or my colleagues. In ICU society's apparent tolerance of the withdrawal of futile machinery and second effect drugs mean that in 1996 there are better and more honest ways of achieving death with dignity.
In dealing with the uncertainties and the burdens of end of life decision making the whole team needs each other in decision making , management and support. The whole process is about looking after one another; patient ,nurse, doctor,and relative. We should all be on the same team as we have the same goals. There is no place for the soloist, medical or nursing. Indeed collegiatedecision making is a patient's right as collective wisdom-albeit a crudetool-is the only opportunity patients get to have our prediction's accuracy increased.
SCCM responds:
"SOCIETY OF CRITICAL CARE MEDICINE TO CONVENE NATIONAL CONSENSUS CONFERENCE ON "CARE DURING THE LAST DAYS OF LIFE"
Critical care specialists respond to New England Journal article citing critical care nurses involvement in active euthanasia or assisted suicide
WASHINGTON, DC (May 22,1996) -- John W. Hoyt, M. D., president of the international Society of Critical Care Medicine (SCCM), said today that an article in The New England Journal of Medicine (May 23) about the participation of critical care nurses in euthanasia and assisted suicide indicates that "nationally we have a serious problem that must be addressed," and announced that SCCM will implement a three-part program including a national consensus conference on "care during the last days of life."
"While the editorial accompanying the article in The New England Journal notes that there are questions about the study's design and presentation of results, the article makes it clear that a significant problem exists," said Dr. Hoyt, who is chairman of the Department of Critical Care Medicine at St. Francis Medical Center in Pittsburgh. "The SCCM does not condone the actions of health care professionals as described in the article. These acts violate the ethical norms of our profession." "However, it is apparent from the survey cited in the article that there are situations in which critical care nurses feel that they must take these actions. While there are questions about the actual statistics, the fact remains that euthanasia and assisted suicide are happening, and this is unacceptable."
Dr. Hoyt and Connie Wallock, M.S.N., past member of the SCCM goveniing council, said that the SCCM's action program includes two other initiatives, in addition to the national consensus conference, which will bring together medical and health organizations, patient and consumer advocacy groups, and government and public policy bodies to address care at the end of life.
First, this week SCCM will contact 12,O00 critical care specialists across the country to ask them to lead a frank and open discussion at their hospitals about care for patients during the last days of life. Secondly, SCCM will work with the major national hospital organizations to expedite adoption of a multidisciplinary team model of intensive care unit management, and to ensure that every hospital has an ethics committee accessible to health care professionals, patients and families, which will help address the situations described in the article.
The Society of Critical Care Medicine represents physicians, nurses and other health professionals caring for patients in intensive care units worldwide, according to Ms. Walleck, who is a partner in Critical Care Management Consulting in Albany, NY, SCCM was founded to ensure that critically ill patients, including those in the last days of their lives, receive the highest quality of care in the most humane manner. Dr. Hoyt added that while SCCM's primary focus is on care provided within hospital intensive care units, the factors that can lead to euthanasia and assisted suicide are broader, extending to all segments of society.
"As a society, Americans are still very uncomfortable discussing and dealing with the issues surrounding death and dying. Public opinion about what is appropriate and acceptable during the last days of life remains uncertain and shifting; there is inconsistent use of advance directives and living wills. This absence of solid public opinion is reflected in the lack of a clear-cut national public policy. In state legislatures and courtrooms across the country, widely divergent decisions are reached on a case-by-case basis."
The absence of an expressed national consensus certainly affects health care professionals and organizations, Dr. Hoyt said, "and even we have not yet come to grips with all of the issues." He cited lack of understanding and consistent adoption of effective pain management guidelines as one example, as well as the fact that not all hospital intensive care units are organized according to the ideal model for patient care.
"The best model for an intensive care unit is a multidisciplinary team approach, led by a critical care physician present full-time in the ICU, with the physicians, nurses, pharmacists, therapists and other health professionals working together and fully involving the family and patient. In this setting, where health professionals are communicating with and supporting each other, where patients and family members are involved and informed, it is far less likely that anyone would feel the only option waseuthanasia or assisted suicide," Ms. Wallock said.
For the past 25 years, SCCM has been working with hospitals to encourage the adoption of the multidisciplinary team approach to ICU management. "This model meets the key goal of all involved in the health system," said Dr. Hoyt."It ensures that the patient receives the optimal care, in the most humane and respectful manner. "Unfortunately, not all hospitals have adopted this model, so there are too many situations where care is fragmented, where patients and families are afraid and uninformed, and where the nurses at the bedside may feel they have few options."
The end result of all these factors, Dr. Hoyt concluded, "is a health system that is not functioning the way we believe it should for patients at the end of life. So we must take action." He said that the SCCM program will begin immediately, "The letters to critical care specialists are being sent this week, asking them to take the lead in reviewing policies and procedures at their hospitals. The goal is to create a climate within intensive care units where no professional, nor any family member or patient, would feel that euthanasia or assisted suicide is the only solution."
He also noted that he has already sent letters to leaders at the American Hospital Association, the Catholic Health Association and the American Association of Medical Colleges, asking them to work with SCCM to expedite the adoption of the multidisciplinary model of intensive care unit management at all U. S. hospitals.
"There is no better time for this discussion than now," said Dr. Hoyt. "American hospitals are currently going through massive re-engineering programs, in an effort to maintain quality standards while simultaneously reducing health care costs, and the intensive care units, with their high cost structures, are certainly part of this change. The multidisciplinary team model can help address the cost issue, while preserving and enhancing the quality and dignity of patient care."
Ms. Walleck stated that plans are underway to convene the national consensus conference (a traditional process within the health care field used to develop common agreement on medical care issues) on care in the last days of life. The conference will be hold this fall in Washington, D. C., and will bring together leaders of medical and health organizations. government and public policy bodies, and consumer and patient advocacy groups. (EDITORS: Preliminary list of those to be invited is attached.)
"In article after article, speech after speech, we've all given lip service to the fact that end of life issues are complex, complicated and disturbing. The time for action is now. When a survey, no matter how questionable the methodology, finds that health professionals and patients and families are turning to euthanasia or assisted suicide because they feel there is no other option, then it is imperative that we act," said Dr. Hoyt.
"The Society of Critical Care Medicine is, by our explicit mission, the organization most suited to begin the process of identifying, addressing and developing a national consensus on these issues. Our patients and their families count on us. They come to us at their most vulnerable time, and trust us with their lives. We owe it to them to address the end of life issues in a responsible, collaborative way."
Mike Rie:
Thank you Ellen Rosen for this timely info. Don't destroy the tape! I listened and was chagrined to see the naievite of SCCM inrrunning a national press conference. This was a lenghty presentation that will not get much press play i n my view.
Major issues
Kelly Randolph:
This is lip service on a "problem" that has existed for a long time. Dr. Hoyt says: "The fact remains that euthanasia and assisted suicide are happening, and this is unacceptable." Is this an expression of personal opinion or professional ?
Secondly: "SCCM will work with the major national hospital organizations to expedite adoption of a multidisciplinary team model of intensive care unit management, and to ensure that every hospital has an ethics committee accessible to health care professionals, patients and families, which will help address the situations described in the article." This will NEVER happen. Anyone of you who have ever worked in a small comunity hospital know that team models of management are expensive-- ruled out. And aren't ethic committees mandated by JCAHO already?
Similarly: "SCCM was founded to ensure that critically ill patients,including those in the last days of their lives, receive the highest quality of care in the most humane manner." There are those that feel that euthanasia/assisted suicide are part of the humane care model. "This absence of solid public opinion is reflected in the lack of a clear-cut national public policy. The best model for an intensive care unit is a multidisciplinary team approach, led by a critical care physician present full-time in the ICU, with the physicians, nurses, pharmacists, therapists and other health professionals working together and fully involving the family and patient." . yes, utopia. I have heard of it but never been there myself.
"The goal is to create a climate within intensive care units where no professional, nor any family member or patient, would feel that euthanasia or assisted suicide is the only solution." I'm having trouble imagining any unit where a patient would be made to feel that suicide is their only "hope".
"American hospitals are currently going through massive re-engineering programs, in an effort to maintain quality standards while simultaneously reducing health care costs, and the intensive care units, with their high cost structures, are certainly part of this change. The multidisciplinary team model can help address the cost issue, while preserving and enhancing the quality and dignity of patient care." How can the multidisciplinary team model address cost issues? The more people that are involved with a process, the more it is going to cost.
"The time for action is now. When a survey, no matter how questionable the methodology, finds that health professionals and patients and families are turning to euthanasia or assisted suicide because they feel there is no other option, then it is imperative that we act," Does that mean national legislation?
"The Society of Critical Care Medicine is, by our explicit mission, the organization most suited to begin the process of identifying, addressing and developing a national consensus on these issues." Are we really silly enough to think that there will ever be national consensus on this issue?
"Our patients and their families count on us. They come to us at their most vulnerable time, and trust us with their lives. We owe it to them to address the end of life issues in a responsible, collaborative way." Bingo. Now weíre back where we should be, the patientís choice. There will never be national consenus on this issue. It cuts across many cultural and religious barriers. National legislation will not solve this "problem". Educating the public is a lofty and admirable endeavour. However, educated people are not so easily herded in the same direction as they were when they were "naive".
Abortion is a perfect example of a national policy that legalizes a procedure, but has its opponents as well. There is no clearcut national opinion on abortion, and euthanasia is the same type of situation. In a country where almost any medical tx imaginable has been made available, coordinating the death process scares the heck out of us. Our pets easily receive a more coordinated death than grandma can. How can we as health care providers advocate against euthanasia without it being a conflict of interest? Is not more revenue generated by prolonging life?
Political talk is not the cure here. Tolerance is. And mandating a national consensus or policy against euthanasia is going down a road weíve been down before with the abortion issue. Morality should not be legislated. Legislated morality is mandated morality, and that is intolerance. An educated consumer is the cure for this ìproblemî. We must learn to tolerate the patients wishes, at any cost.
John Hoyt:
Kelly, I am very disappointed that you have misinterpreted the press release from SCCM. We have no intention of a legislative fix. This is a patient/family and nursing and medical issue. We intend to have a concensus conference with nursing, medical, hospital, ethics organizations represented. We will include patient advocacy groups such as AARP because we agree that patient choice is the issue. Your level of cynicism surprises me. SCCM will not change the world I agree but we can at least begin a national dialogue on death and dying in the critical care setting.
Malcolm Fisher:
Kelly Randolph writes in response to John Hoyt and Connie Walleck's Press Release. Much good sense plus
If you really believe that that efficiency ,trust,expertise,collegiality,and the concept of Doctor,nurse ,family,and patient working together are "Utopia" you need a job shift. People are moved to be solo executioners,almoners,euthanasists, by seeing untreated and unrecognised suffering and being powerless to make changes for the better. A collaborative process to provide a peaceful death for patients who are going to die is a reality in many units. The situation described in NEJM is about lack of leadership ,collaboration and process. I come back to my favourite lines from Professor GR Dunstan. "You should not judge an Intensive Care Unit by the number of survivors, as though each death was a medical failure. You should judge it by the quality of survival of those who survive, the quality of the dying of those in whose best interests it is to die, and by the quality of the relationships involved in each death." It is feasible and not hard. Connie Walleck is correct.
Morality should not be legislated. Legislated morality is mandated morality, and that is intolerance. An educated consumer is the cure for this "problem". We must learn to tolerate the patients wishes, at any cost. Now we hit Utopia. Knowing the patient's wishes is the hard part because of drugs,diseases equipment, fear, and suffering and uncertainty over whether wishes expressed in the living are relevant to desires when the blow torch is on the belly.
Will a national policy really 'cure'us of this 'problem'? SCCM already has a Mission Statement about how units should be run and what intensivists should do. If this was implemented and if more US units had a trained, committed,empowered, Intensivist as director, and this Director understood the lessons of the original Apache study, and developed processes that empowered beside nurses and involved them in decision making processes I think your problem will be solved.
Kelly Randolph:
In response to Malcolm Fishers points.... I think that these are geat ideals, ones which early on in my career I strived for. I know view that period as very niave on my part. I now believe strongly that there are small institutions out there that DO NOT tolerate any strong physician leadership. The only thing tolerated is a strong CEO. Coordination of care by a competent director is seen as loss of control by some. I am only stating what I have seen, heard, and experienced.
There are units out there that have never heard of SCCM or Apache. These concepts and ideas are beyond the grasp/reach of some community hospitals, for various reasons. The desire for strong Intensivist leadership has been voiced here on numerous occasions, by many different nurses. Empowerment is a word here........
Mike Rie:
Kelly Randolph is a seasoned critical care nurse who I corresponded with last winter when we were going through the excess death rate at Vermillion Indiana Hospital in the ICU and the public investigations and actions that flowed therefrom. Kelly is not at that hospital but has worked in Indiana at least until this new job move reported on the list. I want to support some of Kelly's ideas because I believe they are right for the secular diverse pluralist democracy in my homeland. The ethos of society is different in Indiana from Southern California or the Bronx. Maybe the ethos of a white anglo Australia permits a homogeneous one flavor ethics ice cream in Oz but"it wont play in Peoria" to quote John Ehrlichman of Watergate fame.
This national consensus approach of SCCM flys in the face of the Guide Approach or Houston procedural approach. Kelly is right on center when he says that "you cant legislate morality" Fire up the situation with centralized power brokered neofascist vision of the good beatified ICU and we can have bombings moved from abortion clinics to the ICU. The isssue of euthanasia mercy killing is not new. Corporate control of proffesional values under managed care worries me a lot more.
Now I also want to agree with Malcolm Fisher's quotes from the Professor Dunstan. Must have been a sage. But we have too many secret chaotic monetary, moral and legal issues hitting us all at once in the USA that will more likely come to closure locally than nationally. I think it most hypocritical and immoral that SCCM advocates unitary standards of care in an explicitly multitiered system. Futile care limits can be imposed through the pocket book more peacefully that through the government. Americans don't like big government in their health care and are prepared to accept A Gospel of Inequality to preserve that. The SCCM press conference set the wrong tone, CNN squealched Hoyt interview and USA Today has the predicted headline "1 in 5 ICU Nurses Help Patients Die". Paradoxically I think the best service SCCM provided thisissue was to bury it by oafish PR. We will need at least two weeks of media surveillance to get the full outcome.
Dick Burrows:
News review - american nurses admit to euthanasia etc etc. This seems to be following a predictable line. There was one slight difference though and I'm not sure how important it is or even if it is just me reading between the lines. Previously these events were slanted to indicate a revulsion for such behaviour. The subject was reported rather flatly. Is the news media becoming more agreeable to euthanasia or reflecting an unspoken agreement to it by the public???
Stephen Streat:
The NEJM homepage //www.nejm.org doesn't yet have the 23rd May edition abstracts and hey snails are really slow across the Pacific so I have not read the article but here are a few thoughts: As expected this is being reported as "Nurses Kill Patients In Critical Care Units" - as an example I will include tomorrow the verbatim text of the teletext broadcast on NZ TV.
CNN reports the NEJM paper prominently on their homepage //www.cnn.com but there is no comment from SCCM so far there. I have been working so have not been home to see CNN international (Could John Hoyt have made it to an interview with Larry King ?).
Here are a few comments :
Although SCCM is an international organisation (as the lead in to the press release states) it is not clear to me that this finding (if a survey result can be thus dignified) is an international problem - at least not in the way it is defined in the US.
I agree with FL that the "principle of double effect" is likely to operate commonly even when the perception of the person (nurse) involved may be that what they have done constitutes "assisted suicide" or even euthanasia. These matters are not as clear cut as they may seem at first glance.
There is to my mind crucially the issue of "intent" - is this addressed in the NEJM article - was it the intent of the nurse to deliberately hasten the end of the patients life or was this an inevitable accompaniment (and an all-too-visible, memorable and guilt-provoking effect) of the use of sedative or analgesic medication to relieve pain and suffering which could not be relieved in any other way ?
Some months ago I saw on TV here a cinema verite documentary made in Amsterdam (in Dutch with English subtitles and voiceover) about physician-assisted suicide and watched it (with my wife) very carefully. It concerned an elderly man with motor neurone disease, his wife and their general practitioner. All of the processes involved in the euthanasia saga (which took place over several months) were shown clearly, unambiguously and explicitly in a sensitive and matter of fact manner (including the final lethal injection of sedative and neuromuscular blocker and the patients death and the reporting of the death to the equivalent of the coroner or medical examiner). Having worked in critical care for most of the last 20 years this simple documentary dispelled any minor lingering confusion that might have existed in my mind between compassionate palliative care during fatal critical illness and euthanasia or physician-assisted suicide. The doctors intent in the act appeared quite different to me from anything I had seen and although many of our Dutch colleagues may be able to rationalise the deliberate ending of life at a given mutually agreed time (I quote - "let him finish his port") as "compassionate palliative care" if I imagined myself in the shoes of the doctor in the documentary I would not (yet) be able to perform that rationalisation...
I have personally been involved in many situations when patients have been given large amounts of sedative, anaesthetic or opioid medication by nurses and by doctors and I can honestly say that never have I seen that done with the INTENT TO KILL the patient. Because of our regional neurotrauma/neurosurgical role there are about 60 patients per year who die in this department after treatment is withdrawn because of severe brain damage short of brain death and many of these - but not all by any means - are given opioids to alleviate respiratory distress after withdrawal of mechanical ventilatory support. Under many even more terrible and vexing situations (eg awake locked-in syndrome, completely denervated GBS with sleep-wake EEG, awake mentally incompetent adult with C1 transection) I have seen patients removed from ventilatory support and given sufficient medication - including total intravenous anaesthesia - to alleviate respiratory or other distress but never with the INTENT TO KILL the patient, always with the INTENT TO PREVENT OR RELIEVE SUFFERING during an asphyxial or agonising dying. Convince me that this distinction was made and was able to be made by those nurses in the survey who said they had performed euthanasia.
I accept that those of us who work in intensive care units have historically lacked leadership in dealing head-on with these difficult issues. I venture to suggest that in countries where a long tradition of full-time Intensivists exists - eg Scandinavia, Australia and New Zealand, parts of western Europe - that these issues are often addressed very well - free of the awful US shackles of ethics committees, consumers rights advocates and that most destructive force against "best-clinical-practice" namely fear of litigation.
I appaud the suggestion that SCCM take a lead in discussing these issues widely in hospitals but I am cynical enough to think that clinical practice in the US is so tightly (and often subtly) constrained by political, economic and legal forces that such discussions are unlikely to lead to any substantive change in practice - either in terms of furthering the "ideal staffing model for intensive care" or in dealing with what I think is the real iceberg of which this paper alludes only to the tip - widespread use of futile and inappropriate and callously prolonged intensive therapies for hopelessly ill patients....
I suspect that it is precisely because patients and their families do not trust us that this issue has surfaced so indirectly. They do not trust us to realistically (not coloured by the rose-coloured glass of contingency fees, practice bonuses or best practice risk-management) appraise the situation, realistically deliver the news that further intensive therapies are medically inappropriate and will be withdrawn and that the patient will continue to be cared for closely and humanely during whatever process transpires.
Kelly Randolph:
Stephen Streat says....." I appaud the suggestion that SCCM take a lead in discussing these issues widely in hospitals but I am cynical enough to think that clinical practice in the US is so tightly (and often subtly) constrained by political, economic and legal forces that such discussions are unlikely to lead to any substantive change in practice- either in terms of furthering the "ideal staffing model for intensive care" or in dealing with what I think is the real iceberg of which this paper alludes only to the tip - widespread use of futile and inappropriate and callously prolonged intensive therapies for hopelessly ill patients...."
I couldn't agree more with this, I just couldn't get it out without a good dose of cynicism. I have lots of experience with discussion. It has never led to anything other than more paperwork and tracking models....etc. Adjusting staffing levels to meet this goal would be out of the question in my experience. Expect to make do with less. This is very troubling to those of us having never experienced utopia..... :)
David Crippen:
There is much difference between Stephen's hospital where he has the tactical authority to "say no" to accepting patients that he feels, in his considerable judgment, will not benefit from "critical care". Stephen has been granted the mantle: "arbiter of public resources" by the same folks who came up with a NATIONAL BALANCED BUDGET!!!! Do you get the flavor that these folks have at least part of their act together? I can assure you all that he uses it wisely, frequently avoiding prospective patients guaranteed to create problems of life support withdrawal. Stephen is an outstanding role model for his unit's "critical care team", some members of which include nurses. He provides effective leadership in dealing with death and dying and his team responds to that leadership. There is no incentive to murder patients because they are invariably dealt with in a humane, compassionate and effective manner at the end of life.
Conversely, we in the great land of plenty continue to put it all on credit cards, then pay the bills by withdrawing from other credit cards. There are no contraindications to ICU admission; people simply get what they desire. I do NOT have the authority to say no to resource allocation I know with a reasonable degree of certainty will not be used wisely, and will necessarily proliferate warm corpses in my ICU. When that happens, the political situation that mandates " ethics committees, consumers rights advocates and that most destructive force against "best-clinical-practice" namely fear of litigation" does not work in favor of physicians taking an aggressive stance to effectively deal with it as Stephen does routinely. I hazard a guess that MOST ICUs in the USA do NOT have effective leadership of a "critical care team", necessarily promoting inconsistent quality of care, and setting the stage for frustrated nurses to off patients growing mold in ICU beds.
I, too, sincerely applaud Dr. Hoyt's clear leadership on this matter. It would have been only too easy for the SCCM to duck and run. I strongly believe that this issue has little to do with nurses simply offing moldy patients. This issue has to do with how critical care teams function and who is providing leadership. I think that a big consortium to sit down and talk about difficult and frustrating issues is EXACTLY the right response. I hope I get invited to put in my US$00.02 and I heartily encourage all CCM-L-ers to attend this meeting. You can be sure that I will be there, even if I have to (shudder) pay my own way. This article has identified clear problems in the way we practice critical care medicine and SCCM has risen to offer some leadership. I know of no better way to change things that don't work than to establish potent a consensus of how it ought to be. Kudos to them.
Dick Burrows:
If we do it well; earn credibility by communicating from go and being there trying to make the patient better day and night, and create an enviroment where people are treated with respect and allowed an opinion there is no need for the processes I find offensive. Most relatives who come into a unit anxious and looking for a job description.They get the latter from the way we care for their loved one and the way we care for them and each other. From what WE say and do. And in the eight enviroment they will become part of the team and behave inan impressive manner irrespective of ethnicity,intellingence or religious belief.
I wish this was always so. It is often the case but where it is not the case is mostly not my fault. Even when you show some people those qualities they still want your head on a platter - that's life and that's why you need some authority. Not the whole bag - just enough such that when you present the problem to other reasonable people those reasonable paople say "we say the doctors decision will hold sway even though there is never certainty that he is right" (In using the term 'he' I mean the whole bloody kit 'n caboodle of doctors & nurses - especially those who are intimately concerned with the patient. Most people can deal with dying. It is suffering they find difficult. As Woody said "I'm not worried about dying - I just don't want to be there when it happens"
Malcolm Fisher:
Mike Rie writes: "The ethos of society is different in Indiana from Southern California or the Bronx. Maybe the ethos of a white anglo Australia permits a homogeneous one flavor ethics ice cream in Oz but"it wont play in Peoria". I Could not agree more. I call this Shadbolt's Law--a great faith in our society that the law may fix social and ethical problems, Child pornography-outlaw it. Kids smoking toacco and other drugs. Outlaw it. Then it will go away. Ha Ha.
Soon we will outlaw poverty and unemployment. The law becomes a means of escaping the real issues and the only effective legislation in this area I know of were the English laws in the 1800,s making kids go to school instead of down the mines. Go looking for the words "love, suffering,dignity" in law books. Good luck. Aftyer Sanckiewick, Arnold Relman wrote that the law has no idea of the complexity of medical decision making. Decisions about deathj and dying in ICU should be made at the bedside by a team of family,patient(if possible) doctors and nurses. Such decisions being made by solo euthanasists, ethics commitees or courts are a failure of the best processes. If we do it well; earn credibility by communicating from go and being there trying to make the patient better day and night, and create an enviroment where people are treated with respect and allowed an opinion there is no need for the processes I find offensive.
Most relatives who come into a unit anxious and looking for a job description.They get the latter from the way we care for their loved one and the way we care for them and each other. From what WE say and do. And in the eight enviroment they will become part of the team and behave in an impressive manner irrespective of ethnicity,intellingence or religious belief. As Dick Burrows said: "Most people can deal with dying. It is suffering they find difficult.".
Stephen Streat:
When FL was down here a couple of weeks ago we had a one-day conference and one of the topics was "Limitations on therapy and withdrawal of intensive therapies - the US and the NZ viewpoint". FL and I did the neccessary Laurel and Hardy routine. Very interesting. I spoke about the concept of "reasonableness" as the glue which binds decisions about limits and withdrawal to one's own societal (yeah Dick I hate the word too) values. This seems so obvious as to be trite but still - to paraphrase - what is reasonable in one society, at one time, for one patient is not necessarily reasonable in another, at another time for a different patient.
It is not reasonable to expect that every patient will survive. Commonsense tells us that about 15% of all-comers will die in ICU. I think it is not reasonable to expect that every patient will (should) receive every conceivable therapy that might be efficacious - however remotely. For example we do not refer (="fly 2000km") every patient with fulminant liver failure to Australia for liver transplant. We do not refer patients that we think are likely to die even if transplantation is done. As a result we have excellent survival for transplanted FHF. It is unreasonable to refer every (any IMHO) 75 year old with awful ARDS for consideration of ECMO but the odd otherwise fit teenager will do very well and it is reasonable to try.
Our society and the profession in NZ accept that resources are limited and should be delivered preferentially to those persons most likely to benefit. Implicitly (so far), we have been delegated responsibility for rationing decisions. As an interesting aside - in the most recent NZ Government Budget last week (Budget surplus 3% of GDP = tax cuts + debt repayment + increased social spending) some of the increased funding for health was tied to the development and actual use by healthcare providers of explicit rationing criteria based on individual clinical need (encompassing both degree of severity and extent of anticipated benefit). This is an accepted and normal part of medical "reasonableness" in NZ.
We distinguish three categories of limitations - 1) reservations - admitted with a metaphorical red warning flag saying "trial of intensive therapy will not be continued indefinitely", 2) Specific limitations eg "Not for angiotensin infusion" or "not for renal replacement therapy" (yeah I hate that term too) and 3) Withdrawal of intensive therapies. We (the Intensivists) decide to admit a patient with "reservations". We (the intensivists, the patients are our patients remember) decide on specific limitations on therapy in consultation with other medical teams and withdrawal of intensive therapy is a process that requires consensus between the critical care team, other medical teams and the family. We seek the families consensus - we do not ask their permission. Sometimes this takes time.
Within this framework we consider consensus decisions made from differing points of view (eg intensivist, neurosurgeon, family) as our best evidence of "reasonableness" within our societal context. Our society does not require, demand or insist on viewpoints from non-clinical committees, patient advocates, nurses, lawyers and the courts - these are (currently at least) thought "unreasonable". Clearly evident consensus at the time is an excellent defence against (later, much later) legal or other action. It also helps to share the burden and is part of what Malcolm calls "looking after one another".
We do not ask our nurses to be part of these processes as a routine as we take the view that when matters of "prognosis" are involved that they are not "expert witnessess". (As an aside we would probably have a lot more withdrawal of therapy if the nurses did it by themselves ;-). When the situation is however more fraught and decisions are being made which involve more questions of values than prognosis then the nurses are often involved - we value their viewpoint but we do not burden them with the "responsibility". Similarly to the situation with the patients family - we seek the nurses agreement in matters of withdrawing intensive therapies but do not ask their permission (usually they say something like - "Why didn't you do this yesterday ?").
Simon Finfer:
Although Australia is predominantly "white anglo" it is also a multicultural society fortunate enough to be almost bereft of the historical baggage that dogs Europe (see the former USSR and Bosnia) and to a lesser extent North America. Prior to the introduction of Medicare, Australia had essentially a private health system. The Labour Government took the bull by the horns and introduced the socialised medicine that the USA (or its lobby groups and power brokers) fears, and, although under the same resource pressures as every technologically advanced health care system, the system works. At least so it seems to a first generation immigrant like me, who came to enjoy a quality of life that wasn't on offer in my homeland, the opportunity to allow my children to grow up in a society free from riots and gross social inequality, and to practice medicine (especially critical care medicine) the way I think it can and should be practiced. In the last I was fortunate to join a system and team where others had already done all the hard work and got the system running.
If the USA is afraid of big government in health care, is it interested in good outcomes for its citizens when they go into hospital, and into Intensive Care Units? Assuming it is, and assuming that the ICU where the Intensivist as co-ordinator of care working with a team all heading in the same direction is the best model to provide these outcomes (disagree if you wish), how do you get to that goal? I am nowhere near arrogant enough to suggest I could answer that question. But the tale of what has happened to Private ICU in Australia in the last 2 years might be of interest.
Private hospitals have many ICU beds, in general they were operating on the American model (or the model that is often perceived as American from abroad, given that Mike Rie is right to remind us that talking of the USA as one homogenous mass is a gross oversimplification). Patients were admitted at the behest of a doctor, often a surgeon, usually following elective surgery, and care was fragmented with multiple consults by single organ doctors (the SODS) all looking after their bit but no one looking after the whole. No one person knew what was going on and so communication with nursesand families was understandedly fragmented and poor. The health insurers were unhappy. ICU rebates of $1800 per patient day were being paid to hospitals on dubious grounds. The government was unhappy. Health insurers were putting their costs up and people were dropping out of insurance and putting additional pressure on the public system.
Enter ANZICS, the government and the health funds. Fees are negotiated for specialists looking after patients in ICU. BUT they must be present in the ICU for the whole working day, and not on call for any other hospital or service. The health fund will only pay the ICU rebate to the hospital if it has a full time ICU director who is a recognised ICU specialist, the ICU must have full time dedicated specialist cover, and the patients' admission to, and continue stay in, the ICU is certified justified by the ICU specialist. Result: Private hospitals falling over themselves to appoint ICU directors and specialists to survive. Much grumbling by SODS over loss of income which is now dying down, better care and co-ordination of ICU care for patients, families and nursing staff. No increased cost to government (which pays 75% of the specialists fees for private patients) as one ICU specialist patient day charge = 3 specialist consultations, which is less than the SODS were charging anyway.
Moral: (from rose tinted specs of first generation pommie immigrant in Utopia) Forget the consensus conference, find a way to make it look financially attractive to whoever it is who wields the power and the cheque book. The British version of The consensus conference is the interdepartmental working party, those who have seen "Yes minister" will know what I mean, the outcome is often the same.
Mike Rie:
Simon Finfer's post was educational, entertaining and brings up another central Hegalian thread that was missing in the SCCM Press Release. MONEY!! Hegal in the Philosophy of Right says that money is the constant and universal mode of exchange. Corrollary: When you cannot express your morality in money it is of a meager and unsatisfactory kind. Now this cozy scenario about Australian private critical care sounds like Papa Doc Malcolm and the Australian Critical Care mafiosi won out over the vision of the SODS. I am sure that SCCM leadership understand that and Malcolm Fisher gave a nice talk about that at the SCCM meeting in San Francisco in l995. Sounds utopic and I would enjoy living under such a yum yum tree and putting back a few pints with ye mate. But in the longterm you have to invite Adam Smith to the pub as well.
Simon, I think you do not appreciate that we are having to undergo painful downsizing of an overly bloated hospital system where everyone wants to be a professional survivor. As the resources tighten in the US scenario we are all considered excess providers that have a duty to die in the market place before our patients do from mediocre declining standards of care or "Conflict of interest Sellouts" who will commit shabby care to keep employed. To me American Medicine is in a somewhat similar situation to that of German Doctors in the early 1930s. This is a side issue but avery important issue to the nurse euthanasia issue that sparked all these posts in the last few days. Americans don't give a rats ass foreveryone's ICU outcomes- primarily their own.
I think all the non US people on this list might enjoy reading Democracy in America by Alexis De Tocqueville written early mid 19th century. Not much has changed. I am saddened by the backward looking political process advocated by SCCM leadership to achieve what we would all regard as a desireable end point. I fear the ostrich's pulseoximiter will show severe desaturation and cellular decomposition without successful accomplishment of mission. Focused controversial targeted strategies with local events are the better approach in my view. We will evolve from a new strum and drang that will be quite different than Austra lasia.
Rolando Berger:
On 5/23, among other things (with which I do wholeheartedly agree), Malcom Fisher wrote: "Decisions about death and dying in ICU should be made at the bedside by a team of family, patient (if possible), doctors and nurses. Such decisions being made by solo euthanasists, ethics commitees or courts are a failure of the best processes".
I agree in principle but disagree on such a "blanket" indictment of ethic committees. What Malcom describes as "patient, family, doctors, and nurses" is the best ethics committee one could want in these cases. You can call it a "team" if you wish, but a rose by any other name.........
What must be understood is that the concept of "group decision making" in these matters is central to preventing abuses, safe-guarding for major errors in judgment (however well intentioned), eliminating (as much as possible) the need for "solo euthanasists", and reassuring society at large of the seriousness, compassion, fairness, and care with which these decisions are made. We can drop the term "committee" if one prefers, (it does tend to convey an air of bureaucracy), and replace it by "team", or "decision group", or whatever strikes our fancy.... but the concept remains the same: not one person's opinion and ethical values will empower her/him to unilaterally direct the destiny of everyone else.
A common problem in these discussions is failure to agree on an uniform terminology. An ethics committee does NOT mandatorily imply a free-standing, "not-connected-to-the-patient's-case" group of suits, clergy, and lay people. Of course, some "traditional" ethics committees are just that, and I agree with Malcom Fisher that THIS TYPE of ethics committee is a joke. However, this is not the only type of ethics committee there is. At our two local VA Medical Centers, (for out-of-towners, these are Federal Goverment Hospitals for veterans of the armed forces), ethics committees (when one is needed) are constituted by what Malcom described as a "team". We only add to that team a legal counsel to answer questions about legality (if needed) because this is a crucial issue in the USA, and pretending that it is not is naive and counterproductive.
Likewise, if requested by the team because of significant disagreements or problems, we provide a MD with expertise on ethical issues to act as moderator/mediator, but NOT TO MAKE THE DECISION INSTEAD OF THOSE CARING FOR THE PATIENT. Experts in different fields can be called in consultation to provide the "team" members, (I won't say committee so Malcom is happy), with specific technical information that may be needed to arrive to a more intelligent and well-informed decision in a given case. Neither the moderator, nor the legal counsel, nor any expert consultants called in on that case, are empowered to make the final decision. The "team" does that I would like to think that, hopefully, through such a process we will have no need for "solo euthanasists". Malcom Fisher is right: must people can face death O.K..... but the dying process (read "suffering") can loom as an unendurable agony and a truly terrifying ordeal for many.
Jack Havill:
We in ICU often withdraw treatment to prevent suffering etc knowing that the patient will die as direct result of our action e.g. stopping the respirator. The euthanasia doctor gives a direct injection at the request of the patient to prevent suffering and the patient dies. As far as I can see, the only difference is a subtle difference in intention. The actions are the same in that they will have the same result -death.
David Crippen:
I must take issue with Jack. I think the difference is more than subtle. The Principle of Double Effect allows one to increase the intensity of palliative efforts at the expense of hemodynamics and respiratory function, but it is not a license to perform an intentional act calculated to hasten death. If I give a patient 40 meq of potassium chloride intravenously, suffering is certainly curtailed, but the patient succumbs as A DIRECT result of my actions.
However, If I give the patient just enough morphine sulfate to palliate pain and discomfort, and he succumbs because the debilitation from his disease process will not allow him to buttress his ventilation function against the effect of narcotic, then the patient dies as a result of his untreatable disease process, not as a direct result of the narcotic.
I think this is far from a subtle difference in intention.
We have mostly faced up to the problem that some patients would be better dead as do their NOK etc, but are not capable of taking the next step to put a rational, well protected, adequately safeguarded process into place to cause the death. Instead we dissemble and fudge the issues and give big doses of narcotics to save suffering which are enough to cause death in themselves anyway without respiratory support.
The concept of euthanasia is superficially satisfying but if implemented, brings with it inherently dangerous and uncontrollable excess baggage. The burden of proof to establish hypothetical consent for euthanasia is very difficult or impossible to ascertain. The authority base of who will be in charge of determining when euthanasia is indicated is too broad to be workable. Many patients seeking euthanasia have treatable depression. The one current advocate in the United States, (Kevorkian) a non-practicing pathologist who never saw a live patient in his entire career is held up as the butt of jokes wherever he goes. And so ad infinatum. Active euthanasia has been specifically prohibited in virtually every code of law for 3500 years, even in Holland where it is condoned, not legalized.
The reality is that euthanasia need rarely be considered in actual practice. In fact, there are effective and socially acceptable methods of insuring that suffering does not occur during the natural course of an illness.
Dick Burrows:
I will take issue with both of you. If the intent is the death of the patient then removing the ventilator is euthanasia just as is the administration of a large dose of whatever. In that sense there is no difference. The difference is one of a psychological attitude, which has been given legal standing, that one is passive (act of ommission) and the other is active (act of commission). Clearly intent is far easier to prove if the act is one of commission.
The double intent is only allowable because you are reducing the patient's pain by injection of an analgesic. If you intend to kill him you are wrong but right if your intent is simply to relieve his pain. Shame, if it happens to do 'im in as well. The real issue surrounds the fact that the ONLY way to ease suffering is through the death of the patient. It is granted that depression pain etc etc must be treated first until there are in fact no options left other than death.
Some people may well be able to bear the cross of their suffering with a serenity the like of which the rest of us can only wonder at. Many will bear the suffering because society tells 'em to bite on the bullet - it's the necessary martyrdom that you need to enter the kingd.... blah blah. Others are saying 'enough let me off". The problem comes with too many subjective aspects which are impossible to measure - "quality of life" What the hell does it mean? It's one area where we don't even let the patient make up his own mind - unless he does it by himself of course - and spreads his brains on the wall with 12 bore. Plench in the way of definitions which are abstract in the extreme but we'll really only be able to tackle the issue when we start to address the subject openly and without euphamism - that I agree with.
John Hoyt:
I predict that the USA will run into the brick wall of euthanasia and never cross that line as a society no matter how the current reasoning seems foggy to some. There is a substantial religious majority, particularly Roman Catholic, in this country that sees the difference we have discussed as very real and any attempt to make the next step, that active euthanasia relieves suffering, will lead to a political and religious stalemate similar to the abortion issue in the USA. Watching this issue (euthanasia and physician assisted suicide for clear cut medical reasons) unfold in the USA will be absolutely fascinating. Knowing the dark and evil side of human beings as I do and fearful of the slippery slope I will take my side in opposition to euthanasia.
Jack Havil:
To David Crippen and John Hoyt: You would probably agree that there are occasions when by withdrawal of a respirator certain death will occur whether palliated by morpine or not??? I would agree that the patient actually dies of the disease process and see the logic of that but nevertheless what we do quite clearly precipitates death on certain occasions. Every man and his dog on the street can see that. We cloud the actual process by appealing to our honourable feelings. Don't get me wrong I believe in honourable feelings! I think the intention of the clinician is crucial but an honest practiser of euthanasia also has honorable intent - to relieve suffering. At this point in time, even the patient has a say in that process of true euthanasia which is not possible in many intensive care situations.
To Dick Burrows: Could you tell me the subtle difference between a positive action ( commission )and a negative action ( ommission )? Is it the whether the ET tube is pushed or pulled? Or is it whether the ventilator switch is up or down? Or is it intent of the intensivist? Or is it the result of the action?
David Crippen:
Jack Havill sez: I would agree that the patient actually dies of the disease process and see the logic of that but nevertheless what we do quite clearly precipitates death on certain occasions. We cloud the actual process by appealing to our honourable feelings. Your humble and obedient FL sez: I think that is how the game is supposed to be played. Let me pique you with an example of at least one good reason why euthanasia won't work (IMHO).
Lets say Patient Joe Blow is terminal with a painful disease....lets say inoperable cancer of the prostate. Lets further argue that he begins to have pain and that pain is unresolved by oral medication. He has reached the point where he no longer can resolve living. Lets say that euthanasia is legal and it requires the signatures of two physicians and lots of informed consent.
So Joe lives in a community of 10,000 in the lower reaches of the upper Midwest.....no, better yet...the upper reaches of the lower South. He reports to his local physician, age 73. Last medical meeting attended 1943...Last book read....From Here to Eternity........Ole Doc Bones. "Doc...I just can't take this pain anymore. Those pills you gave me don't work. I want out before it gets worse". So the Doc gives him an informed lecture on the hazards of euthanasia, namely death, and the patient persists. OK. Ole Doc Bones gets his pal Ole Doc Adenoids, graduate of general practice class of 1934 from the State Hospital for the Blind and Criminally Insane of Lower Podunk, Slobbovia. Dr. Adenoids has a 14 word English vocabulary after living in the United States 70 years. Dr. Adenoids concurs that death is a realistic option here. Sure will make that pain stop, anyway. "Black Capsule"...down the hatch. Another satisfied customer. The patient's practitioners have done the right thing. Their mind was right. They perceived a patient suffering and they fixed it.
Now, I play John Fowles and bring you back to a fork in the road. The patient lives in the Volvo Belt of Sydney, Australia and is the private patient of one Professor Malcolm Fisher, big time critical care specialist and amiable zanie. Upon presenting to the Professor with this request, he immediately gets the big time eval which shows he is not nearly as "terminal" as he thinks. He then gets his head shrunk and discovered he is depressed; a treatable disorder, and gets loaded up with Kickapoo Joy Juice. He starts to feel better. The Professor starts the patient on his own special brew of oral pain medicine and it is another two months before pain breaks through. During that time, he sees his son graduate from Chiropractic School and do his first bone bend right there on stage. The Professor then gets the patient fitted for an implantable, epidural morphine dispenser...he then goes down the road another two months, during which time he sees the birth of his first grandson. Six months later, he lands in the hospital, where the professor puts him on a continuous infusion of morphine to palliate pain and the patient expires quietly the next day.
My point (and I do have one), is simply this: if society allows euthanasia, it will NECESSARILY allow any duly licensed medical practitioner to carry it out. I submit to you that quality control in the practice of medicine is uniformly LOUSY. If you give Professor Fisher the option of determining how to palliate the dying process, you also necessarily give the same authority to Drs. Bones and Adenoids. To me, that is the biggest problem with Euthanasia.
Malcolm Fisher:
Euthanasia is going the rounds again. It is difficult because when ever I read about it I tend to only get one side of the story. Dr Ragg, for example, gave a viewpoint in these pages a few weeks ago which defined those of the cons. And a week later Dr Auchinloss covered the pros. Let me tell you what I see as the issues and try to be a journalist not a columnist which means keeping my opinions out of it. You'll get them at the end if there is room. I have to write to space on the back page to keep things tidy.
Medicine lost the plot a little with its ability to keep people alive and the skills doctors used to have in managing patients in whose best interest it was to die were lost. By voluntary euthanasia we mean committing an act upon a patient at the patient's request which will lead to the death of the patient. The intent to end life is greater than the intent to relieve suffering. This is illegal in every Western society (including Holland) and has been found unacceptable by Government consensus in the USA and England. However, it is acceptable in Western societies to institute therapy which relieves suffering even if such therapy shortens life. This appeared at the AMA conference on Euthanasia to be acceptable to the Right To Life groups and everyone else and it can be argued as within the law in Australia on the basis that the laws about murder are not designed to cover this situation. Irrespective of legality there has been no tendency to prosecute those who practice what we choose to think of withdrawal of care or withdrawal of life support. The ethical arguments about intent and effect are complex: Some ethicists believe there is no difference but in the context of society deciding what is acceptable the difference appears apparent.
Australian society condones the taking away of life in war, and more recently in defence of property. Other societies condone it for execution. Euthanasia is probably being practised more now than in the past, and it is generally believed in the United States that partner euthanasia (not involving doctors) is more common because of the medical profession being legally restricted from helping. Assisting suicide is also illegal in Australia which is illogical as suicide per se is not illegal. If euthanasia is being practised and is acceptable to society there is a reasonable argument that it be controlled by legislation. The Con is that the law is a poor tool for dealing with abstract concepts like suffering or dignity and laws that permit taking of another's life have potential for abuse. That potential may be greater than no laws at all. No one has written a good law about euthanasia as yet.
The care of the dying is not well done overall in our community. It was not taught to most of us, and many do not know what is acceptable and what is not. Even if the care of the dying was done well there are a small (protagonists argue the size) group of patients who medicine cannot fix and whose suffering or potential for future suffering when they cannot control the situation makes death the most acceptable alternative to them. Because of another illogicality by which painful suffering can be treated but suffering which is not interpreted as pain cannot, the treatment of this group of patients appropriately and legally cannot be done without allowing euthanasia.
Most patients who request death are saying "my suffering is too great" or "I do not wish to be a burden on others". Often alterations can be found for them that are acceptable. It is often hard to determine the rationality of people making such requests. If you are more about rationality it is best to continue to treat which leaves the treatment of withdrawal option open until you can decide if the request is rational or reasonable.
In Intensive Care Units dealing with care unlikely to produce an outcome acceptable to the patient the problems are easy to deal with as our society accepts the withdrawal of artificial forms of life support like ventilators and inotropic drugs. Patients with diseases like AIDS and muscular dystrophies are more difficult because helping them today in the absence of physical pain becomes legally shaky. These people are unable to take their own lives. The Koran says: Thou shalt not take life. The Old Testament says Thou shalt not kill. So religious people have objections to euthanasia.
Now I think everyone would agree with what I have written so far. Where the protagonists disagree and the differences occur lie in simple questions. Are the introduction of laws which allow the taking of life on request likely to do more harm than good or will those advantaged by the laws be of greater numbers than those disadvantaged? And the second question is that if one person is disadvantaged are the laws acceptable.? Here the arguments become emotive. The worst scenario is involves invoking Nazi Germany. Those who do point out that the holocaust began with the mentally ill, was condoned by doctors and worked on the basis of devaluing the lives of other human beings and starting with little things. The advocates of euthanasia say that the excesses of Germany are very unlikely to occur in Australia in the 1990s. The protagonists of euthanasia point out the Dutch society has not crumbled because of euthanasia and the antagonists point out publications emanate from Holland (some emotive and some not) suggesting voluntary euthanasia leads to involuntary and financial euthanasia, the latter being where people are killed because of the cost of their treatment. This probably happens and returns us to the more good or harm arguments. The advocates of euthanasia suggest that this emphasises the need for laws and regulations and does not support a no euthanasia argument.
It seems to me a lot of the doctors involved in this, including that ones that are rushing to confess, don't really understand the difference between care of the dying and euthanasia. In AusDoc on 5th May there is an account of a SA doctor who confessed. He sedated a ventilator-dependent patient with motor neurone disease and took him off the ventilator and increased the sedation when he became restless. That goes on in Intensive Care Units everyday. The intent is not to prolong suffering by sedating. This enables removal of artificial forms of life support that the patient does not want and are not going to produce an outcome acceptable to the patient. Some would say to continue was assault. A dignified, painfree death was a consequence of good treatment. That is acceptable to everyone and is not the same as a deliberate act to take a life on request. That is what we are talking about when we talk about voluntary euthanasia.
I am anti. I believe that the harm will outweigh the good. I have no evidence to support this. I believe society has to act in favour of the sanctity of human life, and deny doctors the right to deliberately end it on request. My bias is extremely related to the numbers of people who have requested death as a way of showing me my response to their needs was inadequate, and the numbers of them who are alive and well. The responsibility of determining their rationality weighs heavy on me. And I think many doctors do not understand the difference between good care of the dying and voluntary euthanasia. My solution to the problem of the group in whom euthanasia seems the best way to go is for us to accept that non-painful suffering should and can be treated in the same way as painful suffering. I do not have sufficient faith in law to believe appropriate legislation can be framed because each case is individual. The only evidence I have to support that is that no-one has produced such laws yet. I guess that leaves me with a faith in my colleagues that may not be acceptable to a society crying out for more laws and regulations and a society that believes that legislation can solve social and moral problems which again, there is no evidence to support. The question I have no answer for is what our society should do about those whose suffering means they die alone and clandestinely when they should die with those they love around them and be cared for up to the moment of death. Even elephants provide that for their kin. And we should be able to do better than elephants.
Gary Cramer:
I think some of the opinions expressed may be missing the fact that one may judge a civilization by how it treats its citizens at the beginning and end of life and how it deals with the unfortunate and the weak and or disabled. The observations that were made in a Nov 95 issue of JAMA that half the patients able to communicate in their last three days of life reported that they were in severe pain was reported in Time December 4, 1995. One would have to be a complete idiot to trust our intensive care units to alleviate the suffering surrounding death and dying. A personal experience at St Lukes Hospital in Cleveland Ohio convinced me that the doctrine of cover your own ass was alive and well and took precidence over pain which seemed to be treated like a rite of passage.
Malcolm Fisher:
Gary, you need to start at the beginning. Doctors a hundred years ago were expert at easing the pain of death and bloody hopeless at preventing it. Along comes world war two and antibiotics and the polio epidemic of the 50,s and artificial ventilation. Suddenly the things medicine could do burgeoned and survival in chest trauma ,for example, trebled and in diseases like tetanus and GBS deaths almost vanished. With ventilators and cardiac support the range of things we could offer became vast. We entered the era of curing.We were seduced by technology. When it came to manage the dying we lost the plot. Dying meant failure Hell, Gary, the cure for cancer was around the corner. Immortality loomed. That an inhumanity hit medicine was an inevitable consequence because we had to find the limitations of the technology.We weren't really bad guys yet.
The seventies brought the complications era. We learned about the negative effects of putting tubes into people, and making them lie in bed. We bred resistant organisms and we prolonged suffering and dying. We became less seduced by technology. We still hadn't become the bad guys. In the 80's we hit the era of accountabilty and caring. The 80s pioneers-mostly from the USA- became concerned with appropriateness and suffering. Not lawyers or administrators but doctors. We relearned that we treat people not cells or cytokines. WE became interested in empowering people to make decisions, and treating their suffering and endeavouring to provide a peaceful death when cure was not possible. But by now we had to deal with unrealistic demands from patients ,lawyers, politicians, and administrators.
Gary, I am sorry you had a bad experience at St Lukes hospital. We are still learning. I hope you wrote and complained so they had to rethink what they did to you and then maybe your bad experience helped others. With the best intentions in the world to make the ICU environment more human we still get it wrong. Partly because we are relearning the skills of our predecessors, partly because we have to err on the side of saving life, partly because our decision making tools are clumsy, and partly because we have to deal with the agendas of lawyers, religious fanatics, cost cutters and doctors who haven't yet made the necessary changes in attitude. Look up the SUPPORT study in JAMA and you can read about them. They are the bad guys, Gary.
You say One would have to be a complete idiot to trust our intensive care units to alleviate the suffering surrounding death and dying. Who are you going to look to, Gary.? Administrators or politicians perhaps.? They regard the ICU patient as an expense. A few extra days to allow your family and you to deal with dying is a waste of bed days to the bean counter. Lawyers?. Come on Gary. Our legal system is not about suffering and love and dignity. It is no longer even about justice. It is about winning, Gary. No more and no less. Ethicists, Gary? Ministers of religion, Gary?. They help us understand what to do but they aren't the front line troops making the decisions. They don't prescribe the morphine. Public demand Gary? The public have the majority but little power. And the public don't want their taxes wasted on the dying or the disabled until as individuals they become dying or disabled when their demands may be infinite. Our society is pretty cruel, Gary. We are a pretty selfish lot.
You see Gary, if you can't trust ICUs to deal with this you have nobody. Because nobody else can do it. And nobody else is likely to be your carer and your advocate. I apologise on behalf of my profession that we lost the plot and we are slow in learning how to look after people in whose best interest it is to die. But we really are trying and we will get it right. Mostly. Sleep peacefully, Gary, knowing that we want to do better and sleep wisely knowing that we are the only chance you have.
Avi Roy-Shapira:
In my mind, the difference between active euthenasia and the so caled double effect (giving morphine to ease the pain, knowing that it might cause death) is a matter of intent. In a utilitarian ethics, this does not matter, since the result is the same; in rule based ethics, as in the Kant model of categorical imperatives, intent is all that matters.
Those that argue that withdrawing life support, double effecting, and active euthenasia are all the same, are obviously utilitarian. On the other hand, those that distinguish active euthnasia from the other two are following a rule based ethics. Neither theory of ethics is perfect, and each has serious flaws. Therefore, one might argue either way with equal force. Nevertheless, most of the accepted moral codes in medicine are derived from a rule based ethics. Take for instance the issue of telling patients the truth about terminal illness. This is accepted today, not because it somehow leads to a better outcome, but because we recognize that patient's autonomy and right to know, are somehow more important than the consideration of what is good for the patient.
Samuel Johnson once admonished phyisicians about lying to patients: "You are not to bother with consequences, you are to tell the truth". Moreover, the utilitarian model can produce some terrible results - for example, one can justify any form of government using a strict utilitarian model, but a rule based ethics only permits democracy. My own view is that in this difficult area, following a rule based ethics, and avoiding active euthenasia, is a safer ethical stance.
BTW, The Jewish view point is very interesting. In Jewsih law, preservation of life is paramount, and no effort should be spared in trying to presrve it, without any room for quality of life issues, or patient's desires. However, the act of dying should not be artificially extended. The Talmud says that if a person is dying in the house, and there is someone outside taking down a tree, and the noise of the hammer hacking prevents the soul of the dying person from departing, one should go outside and ask the wood hacker to stop for a while so that the soul can depart in peace. This can be construed as permission to withdraw life support on dying patients.
David Crippen:
Avi speaks of "rule utilitarianism" and applies it to withdrawing futile life support. For those who don't tune into philosophy discussions much, Rule Utilitarianism must be compared to it's companion "Act Utilitarianism" for perspective.
Act Utilitarianists justify actions directly by appeal to the principle of utility. They ask the question: "what good or evil consequences will result from the act in question?". The right act is the one that has the greatest utility under the circumstances. However, the Act Utilitarian tends to play fast and loose with rules, using them as guidelines rather than absolutes. Therefore, the maxim rule: "you ought to tell patient's the truth at all times", is not unbreakable if a better deal comes along. If telling patients a lie makes for more utility, the rule can be broken. Therefore, Act Utilitarians have been castigated for substituting expediency for morality. "Sex with my girlfriend is better than sex with my wife, therefore..............."
The cure for the omissions of act utilitarianism has come in the form of Rule Utilitarianism. For Rule Utilitarians, actions are justified by appeal to rules rather than actions. Example: Don't deceive" and "Don't break promises". The fundamental principle of utility justifies the rules and then the rules justify the act. Therefore, it still isn't OK if your girlfriend makes you feel better than your wife, because the rule "Extramarital affairs are potentially bad for your health if your wife finds out" modulates it. Expediency is ruled out and fundamental principles are preserved.
I might make the argument that active euthanasia is an example of Act Utilitarianism. The act of putting a patient out of their misery justifies the tactics of the act. Therefore, a charge of expedient interpretation of morality could be levied. However, if one follows the maxim rule: "thou shalt not kill"......expanded by Hippocrates to say: "I will administer no deadly medicine...", then the rule prohibits the expedient act.
Aviel Roy-Shapira:
I think my argument was somewhat misunderstood. So I take the liberty of using some band width to clarify the argument. There are basically three major theories of ethics: the Great men theory, the utilitarian theory, and Rule based theory. The Great Men theory is the basic Greek philosophers approach, advanced by Plato and Aristotheles. In a nut shell, they argued that the Good cannot be defined, therefore one should choose a man whom one knows to be good, and follow his example. Apparently, such great man are too scarce nowadays, and this theory has fallen by the wayside. Another reason for its demise is that this theory leads to the ideaof absolute rule and totalitarianism (See K. Popper: The Open Society and Its Enemies: Plato, Hegel and Marx). Utilitarianism, advocated by J.S. Mill, basically says that ethical actions are those that advance good and happiness. Correct actions are those that have good consequences, and wrong actions are those that have bad or evil consequences. The end justifies the means.
Rule based theories, originated by Kant, argue that it is possible, using rules of inference and strict deduction ("Pure Reason") to arrive at rules, which Kant called categorical imperatives, that tell us which action is right and which is wrong, and that one should choose the right action, regardless of consequence. As I had pointed out in an earlier post, neither theory is entirely satisfactory. Therefore some ethicists have advanced hybrid theories such as rule-utilitarianism.
Rule-Utilitarianism attempts to combine both systems. The Rule utilitarian argues that respecting certain rules leads to a better overall outcome. Thus, even if it appears that a given action against the rules will lead to a better immediate outcome, society will achieve a greater overall benefit, if that action is not taken. The difference between Rule-utilitarianism and Kantianism is in how the rules are derived, but both usually lead to similar conclusions, although Rule-utilitarianism is somewhat more flexible.
Remember the scene in "Dirty Harry" where Clint Eastwood tortures the bad guy to find out where the kidnapped girl is? A strict utilitarian, or an act-utilitarian, will support Eastwood's action, since it led to saving the girl's life, obviously a good consequence. Neither Kant nor a rule-utilitarian could support Eastwood's action. Kant would not support it because not to torture is a categorical imperative. A Rule utilitarian because permitting torture in one circumstance, will cause a greater harm to society in the long run, perhaps because police will eventually start torturing innocent people.
In the Euthensia debate, some of us argued that active euthenasia, withdrawal of life support, and "double effect" are morally equivalent since the consequence is the same. Others, myself included, argued that active euthenasia is different from the other two. In my previous post, refered to by FL, I pointed out that the debate stems from different ethical stances: those that argued that the three are morally equivalent (and either condoned or disparaged all of them) were obviouly more interested in the end than in the means; those that argued that they were different, were obviously more interested in the means than in the end.
I believe that in a debate as emotional as this one, it is important to understand the basic premises that guide the debators, even if they themselves may be unaware of those premises, and take them as self evident. Recognizing the basic premises makes for a more intelligent and interesting debate.
Dick Burrows:
Not entirely sure I can agree with you here Avi. It's true that the result is the same but as utilitarianism is consequentialist in its outlook then as long as the consequence of an action is acceptable then it is OK. But you can't predict consequences that easily which is the main reason it fails. Where Kant is concerned there is a categorical imperative to act in a way that is logically and ethically correct. It is a command to the reason. In both instances the outcome is death. Whether that is a good or a bad thing is irrelevant - it is the mechanism that is open to scrutiny. Not the intent as wrong intent i.e. wrongdoing cannot be justified under any ethical code.
At the present time we have a powerful Judeo/Christian/Islamic ethic which quite simply says "thou shalt not kill" You have a duty not to kill. (according to Kant - you shouldn't need an instruction!). Although St Augustine did allow for killing provided the intent was to achieve a greater good. But you also have a duty to relieve suffering?? If you can do that by adequate pain relief etc then that is the way to go. The martyrdom which the religious ethic encourages insists that the individual suffer because "thou shalt not kill" is an order to be obeyed under all circumstances. That I do not agree with.
Malcolm Fisher:
Not much conflict between us. I guess my point is that to refer an individual to an ethics commitee of solid citizens, social workers,lawyers,and religious folk should be recognised as a failure of the bedside team/group/committee because they are medically incompetent and may be ethically incompetent. To get the Rabbi and the liberal jesuit to agree for example, is not possible. When the hospital tried to impose this upon us we just refused and said we would only comply if the Commitee chairperson talked to the family and charted the morphine. The above notwithstanding our commitee is required to look at "test" cases which are used when the IVF doctors whish to change the rules-for example whether gay couples or divorced couples should have access to IVF. I want colleagues who I respect clinically and ethically to assist me in trying to do the best for people. If you haven't fought back the tears a few times I dont think you should be on the team.
FL writes: "I applaud the suggestion that SCCM take a lead in discussing these issues widely in hospitals but I am cynical enough to think that clinical practice in the US is so tightly (and often subtly) constrained by political, economic and legal forces that such discussions are unlikely to lead to any substantive change in practice - either in terms of furthering the "ideal staffing model for intensive care" or in dealing with what I think is the real iceberg of which this paper alludes only to the tip - widespread use of futile and inappropriate and callously prolonged intensive therapies for hopelessly ill patients"....and then writes: "Then the time has come for the embodiment of CCM Physicians to land with a big wet plop right in the middle of them, start kicking ass and taking names. Maybe this is a battle that can be won by terrorist tactics, unlike dealing with huge bulletproof corporations." To that I say: Ole. Maybe the time has come to realize that there are times in life where you just have to say to lawyers and relatives making unrealistic demands the well known phrase "Go to buggery".
I know that in the units I visit in the US most treat the dying patient as we do, openly and involving the group-nurses and family and docs-and deal with it all well and appropriately. I am also told no one in the USA has ever been sued for withdrawing care-? true. Hell,you can't even convict Kevorkian. I am against Euthanasia legislation(which is not the same as being against euthanasia) because the law is a poor tool for dealing with social and ethical issues. To the second effect and letting/die killing arguements I have a solution that works for me. We call it Ellard's Grandstand Rule. This rule says that you should always behave as though the people you admireand respect most were watching you from the Grandstand. In this context you replace trying to understand Emmanuel Kant with how you feel about the guy you observe in the mirror in the morning.
When a lawyer has tried to stop me withdrawing life support (2 times-in writing) I have ignored the request. Consequences zero so far. But i was prepared to wear the consequences. Maybe the butts to kick at are the lawyers butts.
Simon Finfer:
Let us get one thing quite clear. Medical therapy that offers no hope of improved outcome is a form of assault. When that therapy is "full bore intensive care" a la "House of God" it is also a form of torture. Now, I'm prepared to torture as hard as the next man as long as it is in the patients best interest. I won't torture them for the surgeon or the oncologist, I won't even torture them for their family. At times this somewhat uncompromising approach has caused conflict!
The lawyers have got it arse about t.., as usual (lets hear from the leagal lurkers). Withdrawing treatment to cause someone's death sounds awful, continuing treatment must be good. You and I know better. What we can do, and do do, to people can be, and is, awful. Because we do it every day we may lose sight of that. I tell families that I do not wish to prolong their loved one's dying, that I don't wish to inflict more suffering on them, never that I'm withdrawing treatment. It is not semantics, by the time we reach that point it is my honest opinion. Again I'm fortunate. If I have doubts, or they have doubts, they are most welcome to a second opinion, and they can get an honest re-appraisal from one of my colleagues, I can also get that second opinion if I need it.
We really must get away from what is causing death. It's not the issue. The real issue is the mouldy patients that FL talked about. Continued treatment without prospect of improved outcome, assault and torture. We must find a way of supporting each other to do the right thing. It's easy for me, here under the yum yum tree with Papa Doc Malcolm and the rest of the team. When we get together on an issue it's a truely fearsome sight. Those out there on their own deserve our support.
Errington Thompson:
We, as a nation, (sorry to exclude our overseas friends) have a hard time making tough decisions and sticking to them. Whether it is abortion, the speed limit, the legal drinking age or morality in the ICU, we will never reach a final decision. The US congress should pass a law banning futile care (using want ever definition they want). They should also address euthenasia. Unfortunately, this will never happen. Amercians will never make this tough but necessary decision. States will soon pass 50 individual and vastly different laws which will change every 4 -6 years depending upon which party is in office. Physicians will not have the input into this debate that we should (this is what happened with the health care debate).
So we have to spend more time out of the ICU and in the senator's office. We must push for change or no real progress will ever be made in this arena. We, physicians, must speak with a loud, constant and unified voice. Congress does not want to engage in an intellectual discussion. They want issues that will get him or her re-elected, period. So we should not fool ourselves that press releases and open debates will help clarify these issues for anyone but ourselves.
Robert Aucoin:
I have been absolutely amazed and impressed by the intellectual level and moral depth of this exchange on the right to die and who owns this right. With the technology at our fingertips we are privy to the thoughts of many learned men from around the world. There have been good, solid, arguments on both sides. I cannot begin to argue with any of you on this matter. I possess neither the eloquence nor the brains to do so. I can but offer a couple of observations:
a. Spare no expense. Go all the way. He's only two years old. I can't believe he's gone. All his blood gases and labs looked so good.
b. Get those tubes out of my son. Unhook all that stuff. Allow him an ounce of dignity in his last hours. He came by to visit us last month... to thank us again for the care we gave her last year.
Anyone who professes to have the answer is someone I would watch carefully. I've buried both my parents, a brother and half a dozen very good friends. I have not a clue of which course I would take in any given circumstance. God made me this way because it really is his business how long we stay here. The last time I tried to run His show....well I really can't go into that here. I suggest we fight for the living and pray for the glimmer of light when we are faced with the decisions of death.
Arthur Gasch:
Whether we realize it or not, or would acknowledge it openly or not, our perspectives about euthanasia are determined largely by assumptions we hold, consciously or otherwise. For example, If we acknowledge God as overseeing the universe, and presumably therefore our lives, the idea of making interventions to terminate life are ludicrous, as they preempt God and undermine his purpose. By doing so, we may be sending someone God was allowing to experience pain, as a means of initiating in them a cry to him for mercy and salvation, to eternal torment - circumventing in our free will, God's purpose for that life. If we do not acknowledge God, or believe He exists and oversees our lives, has our days numbered as the Scriptures say, and hold that there is no life after death, then the idea of watching someone suffer pointlessly causes us to view euthanasia as a merciful act.
Given this, the discussion evolves around religous and spiritual issues, whether we perceive it or not. If this is so, should we not be bound by the religious convictions of BOTH ourselves and the patient - particularly in this country which proports to acknowlege FREEDOM in religous matters for each INDIVIDUAL? Thus, following this line of reasoning, IF the patient denies God AND the practitioner denies God, THEN euthanasia is reason if the BOTH agree it is to be done. IF the patient denies God, but the physician does not, then the patient has the right to control their body and remove themselves from the care of that particular physician, seeing a Godless man to manage their death.
If the physican is Godless, and the patient is God believing, then for the physician to take the matter of terminating the patient into their own hands is a clear violation of both their person and religious beliefs, an act of murder (as the patient has committed the decision of their death to the Lord), and a violation of the freedom of religion guarenteed to everyone under the US Consititution. It is the last case in which I see the potential for abuse. If the decision is removed from the patient, and vested in either the society or managed care organization (for presumably financial reasons), or in the state, then the assertion of freedom of religion is invalidated, and the right of a person to believe in God and not be violated by the society is undermined. I agree with John Hoyt as well that the removal of support for life is not the same as the taking of life. All men die. Disease, accidents and murder are the 3 causes. Losing someone to disease or the consequences of a life taking accident is NOT the same as actively and willfully killing them by conscious action to take or terminate their life.
This I think is the core of the discussion, who decides to be God? Apparently in some units Registered Nurses decide they are God and take lives. In others Godhood is reserved for Physicians, presumably because they are smarter, richer and have finished medical school? Under managed care, the profit-driven corporation, with its financial incentives to deny care to patients, and minimize the financial costs of long-term and costly care, get to be God.
Folks, perhaps we would all be better off if the patients were again empowered to settle this religious matter in their own mind and preceed as they see fit, in this matter which is ultimately between them and the God they do or don't acknowledge.
David Crippen:
Arthur Gasch sez: "If the physican is Godless, and the patient is God believing, then for the physician to take the matter of terminating the patient into their own hands is a clear violation of both their person and religious beliefs, an act of murder (as the patient has committed the decision of their death to the Lord), and a violation of the freedom of religion guarenteed to everyone under the US Consititution".
Traditionally, our society has utilized the concept of a "commander" ("God" in the religious sense) as the ultimate issuing authority of morality. However, we must remember that each sect and locale has concepts of "God" which are mutually inconsistent and serve more to reconcile their own anthropomorphic conception of what they desire their God to be. Lacking is some universal principle applicable to all mankind, not variable from culture to culture and not dependent on acceptance by individuals to be valid. In fact, if one searches throughout the cultures of society for a universal dictum of morality, none is forthcoming. In each and every society there is varying and differing ideas about what constitutesmorality, and each of these variances is accepted as valid by those concerned.
If no unifying principle can be convincingly demonstrated, we must fall back on a variety of mutually inconsistent moral codes operating over restricted areas and limited periods, none of which would be any more true than any other and certainly none a valid basis for propagation of one code in preference to another. Even if one accepts the Biblical concept of "God" as an all-encompassing figure and ignores the sectional differences, this ultimate moral authority figure has inconsistencies which are difficult to reconcile logically. The Bible is considered to be a compendium of inviolate truisms, all of which support the reality of a personal "God" who is capable of regulating earthly activities. we must assume that such scenarios would support the "God-like" concepts of peace and non-violent reconciliation of differing viewpoints.
Biblical epics, however, in both the old and new testament are replete with examples of cold blooded murder, mayhem, deception and dismemberment directly commanded by God for varying obtuse reasons. If common sense dictates that moral codes have evolved universally to protect innocent members of society from just such atrocities, can such acts be rendered "ipso facto moral" because they are commanded by God? If God is moral, how may we tell by his actions? How is he any different then Hitler, who also had a "master plan" which required demonstratively immoral actions to achieve a "better" world? If we ultimately utilize God's commandments as the basis for the moral codes we would enforce on others, then the following paradoxes must be reconciled:
In essence, one can legitimately ask, " is an act moral because God condones it or does God condone an act because it is moral?" Either morality is defined by what God says rather than what he does. If this is true then morality is rendered subjective depending on the whim of god and can vary depending on God's mood or ulterior motives. Hardly a consistent unifying principle since any code previously defined is liable for change at any time without warning. Or God cannot violate his own moral issuance. If he does, he is evil, by definition, and his authority as a commander of moral values is defunct. Ergo: It is obvious that evil exists in the world, it must exist because God either condones it or is powerless to stop it.
In addition, Evil compromises Good, Therefore:
a) If God condones evil, then he does not live up to the quality of perfect goodness ascribed him, making him capable of imperfection. If he is imperfect, then his pronouncements on morality may be imperfect also. Simply put, He may be wrong!
b) If he desires to rid the world of evil but is unable to accomplish that goal, then he is not omnipotent. If he is not "all-powerful", then his authority is in question. He may not have the "power" to be an "ultimate authority".
Failure to resolve these paradoxes must lead to some frightening conclusions concerning God's suitability as a moral authority figure. In fact, it seems impossible to prove logically that God is not an inherently evil being masquerading as a benevolent one. Therefore, if we cannot demonstrate believable evidence for a unifying moral principle, how, then, can we convince others that our perceptions of warfare are superior to theirs.
Arthur Gasch:
David Crippen said: "If no unifying principle can be convincingly demonstrated, we must fall back on a variety of mutually inconsistent moral codes operating over restricted areas and limited periods, none of which would be any more true than any other and certainly none a valid basis for propagation of one code in preference to another. "
Even if we do, then for some euthanasia is unacceptable. My point was that for those, we should not grant you, me or the state a right to ignore their beliefs and terminate their lives for our convenience. People have committed suicide for thousands of years, both to escape physical pain, and more recently as the tragedy of our admiral indicates, to allegiate mental anguish. But helping someone to do it is wrong for some of us at least.
It seems to me that one function of a society it to protect the rights of each of us from being violated by others, and particularly to protect the rights of the helpless and vulnerable. We have failed to do that now in terms of unborn infants, who - whether it is pleasing to doctors or not, at 7 and 8 and 9 months are people, but we kill and discard them at will for the convenience of their mothers.
Now apparently, desensitized by the continued genocide of that experience, we can begin to victimize the old in the name of euthanasia. Nurses, not to be outdone by doctors, in their quest for professional recognition can now apparently make the decisions of whom to kill. Why not managed care companies too? After all we are evolving a veterninary medicine system under managed care, in which doctors are financially compensated to deny care, and minimize admissions to patients - so they can increase their profits. This seems like the next logical extension. Where does it stop though?
Malcolm Fisher:
Arthur Gasch writes: "Whether we realize it or not, or would acknowledge it openly or not, our perspectives about euthanasia are determined"
No worries. For example, If we acknowledge God as overseeing the universe, and presumably therefore our lives, the idea of making interventions to terminate life are ludicrous, as they preempt God and undermine his purpose. By doing so, we may be sending someone God was allowing to experience pain, as a means of initiating in them a cry to him for mercy and salvation, to eternal torment - circumventing in our free will, God's purpose for that life. If we do not acknowledge God, or believe He exists and oversees our lives, has our days numbered as the Scriptures say, and hold that there is no life after death, then the idea of watching someone suffer pointlessly causes us to view euthanasia as a merciful act.
Arthur, I have a great deal of difficulty with God's role in all this. Indeed because I work with born again heathens I have to pay a full time non denominational pastoral officer to represent God in the unit. I guess I believe that God makes people sick and I make them better. I cannot accept the requests of relatives ,from time to time, that God wants people to suffer. Nor the Illich theory that suffering is good for you-I don't believe Illich has ever had a kick in the balls. I dont approve of the legalisation of Euthanasia because I do not believe the law is an appropriate or effective tool for guiding ethical behaviour. I am against euthanasia because I don't want to kill people. And yet 85% of my patients who die die when I am trying to provide comfort rather than cure. And the majority of the decisions involved in reaching that point are medical not ethical,and certainly not religious.
I lecture about dying a great deal to religious people. They seem pleased with the aspproach I tell them about. They invite me back. The reaon I do it is I feel a need to show them that a heathen can perform in a way acceptable to them and do it better than people who may be devout. (Indeed they don't really believe me-they believe it is God working through me.) I am prepared to usually work within the confines of the religious beliefs of my patients. My name is the Jehovah's Witness literature as one to be trusted. I am prepared to go right down to the wire with the Orthodox Jew who wants nothing stopped as long as that does not impinge on the access of those I could fix. But I wont let someone suffer for the religious needs of others nor comply with beliefs such as those who want to pray the brain dead patient back to life.
This I think is the core of the discussion, who decides to be God? Apparently in some units Registered Nurses decide they are God and take lives. In others Godhood is reserved for Physicians, presumably because they are smarter, richer and have finished medical school? I guess those of us in the front line have all thought about this. The tasks and burdens technology sent our way were not tasks we asked for. We evolve processes to do the best we can for others. I guess that is God like when I think of it.
Under managed care, the profit-driven corporation, with its financial incentives to deny care to patients, and minimize the financial costs of long-term and costly care, get to be God. That is the guts of it ,Arthur. That is what society and individuals have to decide. Who do you want to look after it-them and theirs or me and mine. Our bean counters all seem to regular churchgoers. In an intensive care unit ,it is a bit hard to empower patients to settle this religious matter in their own mind. A bit like Christ on the cross they feel a bit forsaken and want it to end. I dont know, Arthur, whether there is a better place when we die nor whether I will be allowed in.
Dick Burrows:
Another day in Paradise? Who decides to be God? Everybody does - right back to the time that Adam ate the forbidden fruit and got us all kicked out of Paradise and labelled us all with original sin! Mankind has been making decisions and playing God since he could stand on two legs and swing a club!
As regards playing God and making medical decisions one does that every time one alters the natural history of disease process. You cannot have your cake and eat it by insisting that you play God only when you stop treatment. In this sense the argument boils down to making a decision which is counter to what somebody else feels the decision should be. You play God no less so when you revive a nearly drowned child and hand a vegetable back to the parents and say "there you are I've done my bit now it's your turn"
Autonomy allows for the patient to make his own decisions which is quite right but the tragedy of the commons dictates that each individual will likely take more than his fair share - thus the need for social justice. Thus the need to make decisions. Autonomy extends sufficiently far to allow the patient to take his own life but not to involve somebody else in tha act as in euthanasia - because it is then no longer an autonomous decision. Of course one tries to give attention to religious beliefs but thens that's another debate.
Marilyn Macvey M.D:
Dick Burrows said: "As regards playing God and making medical decisions one does that every time one alters the natural history of disease process. You cannot have your cake and eat it by insisting that you play God only when you stop treatment. In this sense the argument boils down to making a decision which is counter to what somebody else feels the decision should be. You play God no less so when you revive a nearly drowned child and hand a vegetable back to the parents and say "there you are I've done my bit now it's your turn".
Dead on.(No pun intended.) I've been lurking for a few months, but now seemed like a good time to put my 2¢ in.I'm a full-time intensivist ( former Anesthesiologist, now boarded in Emergency Medicine) who work in a small ( 120 bed) semirural hospital with a 15 bed Special Care unit. We have had 24 hr coverage in the SCU for at least 15 years, provided by a well-trained core group. We act as consultants and consult on about 80% of the patients. No house staff/residents. We have admitting and discharge criteria, but these lack teeth, and when there is disagreement re who belongs in the unit,we bitch and moan, but the private docs get the benefit of the doubt (but not the last word as they will have to justify the decision to the SCU committee at some later date). The Intensivist and a ICU nurse and Resp therapist respond to all in-house "Codes", and the intensivist can also be summoned to the evaluate patients on the wards( and in the ED) if a problem is perceived. Not utopia, but we keep working on it.
But it does give us an opportunity to intervene early, and possibly forestall an admission to the unit if we think it unlikely the patient will benefit. We also have an ethics committee, made up of "neutral docs, RNs, a patient ombudsman, an attorney. We rarely use it as we find establishing good rapport with the patient and family early, and keeping them informed, and broaching the difficult questions early on usually suffices. The more difficult part is keeping all the docs involved reading off the same page. Some seem congenitally unable to accept the fact that death might be preferable to anything. If only we could get more doctors to discuss these unpleasant subject while the patient was relatively healthy, then we would have fewer *neomorts* gathering mold in the unit, adding to burden of stress on the nurses, the family and all involved. I would be very suprised if any of the RNs I work with feel as if they have taken part in euthanasia. I like to think that they would broach their misgivings as I havn't found them to be shy if they disagree with any prodedure.
Errington Thompson:
We, as a nation, (sorry to exclude our overseas friends) have a hard time making tough decisions and sticking to them. Whether it is abortion, the speed limit, the legal drinking age or morality in the ICU, we will never reach a final decision. The US congress should pass a law banning futile care (using want ever definition they want). They should also address euthenasia. Unfortunately, this will never happen. Amercians will never make this tough but necessary decision. States will soon pass 50 individual and vastly different laws which will change every 4 -6 years depending upon which party is in office. Physicians will not have the input into this debate that we should (this is what happened with the health care debate).
So we have to spend more time out of the ICU and in the senator's office. We must push for change or no real progress will ever be made in this arena. We, physicians, must speak with a loud, constant and unified voice. Congress does not want to engage in an intellectual discussion. They want issues that will get him or her re-elected, period. So we should not fool ourselves that press releases and open debates will help clarify these issues for anyone but ourselves.
Simon Finfer:
Stephen Streat is asked why he wanted to stop ventilating the patient with GB. I would turn this around and ask how would you justify continuing ventilation, artificial nutrition, antibiotics for the pneumonias etc? What benefit are you offering the person? It is only justified if you can assume the patient would request that treatment were they able to communicate. Without that consent even palpating the apex beat becomes assault, and if the patient is a woman, a serious sexual assault. In the absence of being able to communicate with the patient some societies give the Next of Kin surrogate authority (USA), others require the treating Docs to attempt to establish what the patient would have wanted, but err on the side of preserving life (UK/OZ). all reognise the right of the patient to withhold consent even to the point of death. (Advanced directives are the ideal, obviously).
At the 1994 ANZICS meet in Sydney I gave the delegates a questionnaire on continuing treatment in severe head injury if one knew with certainty what the outcome would be.We also asked what would they want for themselves in the same circumstances. 300 of 900 delegates replied. The results were presented at the 1995 ANZICS meet in Brisbane and, if I stop communing with this list, will get published one day. The overwhelming finding was that we would not wish for ourselves a quality of life that we feel obliged to preserve in our patients. If we extrapolate this to the population as a whole, unscientific, but possibly reasonable, it means we are falsely presuming consent from a vast number of patients who can not speak for themselves. To expect the family to say "don't do it, let him die", when they are going through an emotional maelstrom and clinging to any straw of irrational hope is unreasonable. Given that we can't find out what the patient wants, we are left with the question of how many people should we treat when they wouldn't want it, to avoid not treating the odd one who would. How, many guilty mando we set free to avoid jailing the innocent.
What is my point? We are certainly treating patients who would not wish the treatment if they could speak for themselves. In some cases we must justify continuing a treatment with the same care, consideration and stringency that we apply when stopping a treatment. I agree with what Stephen did. Had the patient been able to make a truly informed decision the likelihood is that he would too. He will probably send Stephen a bottle of whisky every Christmas from "the other side".
Vlad Kvetan:
(Rather than consider eutnanasia as a bedspace limiting device) I would like to suggest that 50% of patients who are identified as futile in the ICU can be identified and diverted to a paliative pathway by an intensivist working outside of the ICU. It is easier to make the decision before technology takes over.
David Crippen:
Remember that there is currently no incentive for physicians and hospitals to avoid patients what might not do well in the ICU. Reimbursing agencies pay hospitals and physicians on a per-patient basis for each warm breathing body admitted. Therefore, as more physicians proliferate the health care delivery system, and more hospital seek patients to survive, your scheme to identify them rings hollow in the ears of the marginal internist who sees nursing home patients. Each and every one of them needs a full workup and>a CAT scan every time they stare at the floor for more than ten seconds (absent seizures) or cough (pneumonia) or mumble in their sleep (mental status changes). As long as each and every one of these workups is paid for, our identifying them is a hollow gesture.
Interestingly, our visions of conserving futility has the potential to bring down the wrath of those currently making a living off the exact same patients we seek to cull out of the ICU. Paradoxically, part of our job may well be to convince these people that taking a cut in their personal resources comes with this deal that Vlad suggests and CCM-L is building. Worse, we may be in a position of having to convince ourselves. That is what I mean when I say that the CCM-L Futility project has the potential to get really hot if it ever reaches the point where anyone notices it.