Transcript NewLifeAudio-SecondWind_69634

Physician-Assisted Suicide
WV Wednesday
Jon T. Holmlund, M.D., M.A. (Bioethics)
July 15, 2015
[email protected]
Blog: Bioethics@TIU http://blogs.tiu.edu/bioethics/
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Contains images from internet: slides for personal educational use only, not for dissemination
“That to make sure of life eternal is the one necessary
business that we sons of death have to do in this world,
and without which all our time here is worse than lost,
every enlightened mind will easily acknowledge; this
present life being, by the rule of it, appointed but to this
end, to be preparation time, spent in a continual care to
make ready, that we might have a good meeting with Him
who shall be seen in this air one day.”
Jonathan Mitchell, in a preface to Thomas Shepard’s The
Parable of the Ten Virgins (1659)
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The “Phases” of Bioethics
STAGE
EXAMPLES
ISSUES
EVANGELICAL STANCE?
Bioethics 1.0
“taking life”
Abortion
Euthanasia
End-of-life care
Who is human?
Who is alive?
Can human life be
deliberately taken?
Christian alternatives
Culture war
“Call your congressman”
(Largely settled positions)
Bioethics 2.0
“making life”
Bioethics 3.0
“faking life”
In vitro fertilization
Genetic diagnosis of
embryo
Sperm/egg donation
Surrogate moms
Cloning (“2.5?”)
Reproductive freedom
Making child to order
Re-defining the family
“Making vs begetting”
Children as gifts vs
projects
Unease and alarm
-BUTFreedom or acceptance in
some cases (IVF)
Synthetic biology
Cybernetics
Other emerging
technologies
Scope of human
dominion
Human nature itself;
changing or even
supplanting
Huh?????
(Need for pastoral input in
some personal choices)
(Arcane matters for
experts; far off from
common lives)
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Nigel Cameron in Human Dignity in the Biotech Century, pp. 26-27
The Christian’s “gospel orientation”
The Indicatives
•
•
•
•
•
then
Redeemed by Christ
Death defeated
New creation
Liberation from sin
Future conformity to Christ’s
likeness
• “The aroma of Christ”
• “Aliens and strangers”
The Imperatives
•
•
•
•
•
•
•
Great Commission
Love
Gratitude
Justice
Mercy
Reverence
Humility
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Some Christian Basics
• Death is a defeated enemy
• God is sovereign over our lifespans
• “To be absent from the body is to be
present with the Lord”
• “It is appointed unto man once to die…”
• Compassionate, energetic care for the sick
and suffering is good
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“I’m not afraid of death. I just
don’t want to be there when it
happens.”
Woody Allen
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“Things get worse, then you
die?”
Pain,
Difficulty
breathing
Two Better Images of Dying
• Snow melting in the spring . . .
• Taking a car trip on the interstate . . .
Emanuel LL, et.al. http://www.medscape.com/viewarticle/716463_2 accessed 7/13/15
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A Point of Broad Agreement
• People have the right to limit the amount of medical
treatment they receive
– Achieve treatment goals (disease control, survival)
– Avoid undue burden
– Palliation—control of symptoms, not disease
– Maintain comfort and dignity
– “Quality of life”
• Controversies on the margins!
– e.g., artificial feeding/hydration
– Determining when someone has died
– “Vegetative state”
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Palliative (best supportive) care
• Refers to proper treatment of pain,
distress, dysfunction, etc.
• Essential to good medicine
• Individualized
• Sometimes the most effective treatment
• Getting better
• In the very last days: hospice
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The doctor should/will…
• Guide us through what to expect
• Help us deal with decisions and practical
problems
• Treat pain and other symptoms effectively
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“We may withhold treatment,
but we never withhold care.”
Robert Orr, M.D.
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Belmont Principles
(the “secular” approach)
• Autonomy—People have a right to make
their own decisions
• Nonmaleficence—Limit burdens of
treatment
• Beneficence—Relieve suffering, pursue
patient’s best interests
• Justice—No favoritism or discrimination
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Two Ticklish Terms
• “Futility”
– Problematic if used too aggressively by authority
figure
– 3 reasonable requirements for “futility”
1. Ineffective: won’t change disease course
2. Non-beneficial: unable to satisfy patient’s good
3. Disproportionately burdensome
• “Quality of Life”
– Problematic mainly when used to justify a wrong
like unjust taking of life (abortion, euthanasia)
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Physician-Assisted Suicide (PAS)
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Definitions
• Physician-assisted suicide (PAS)—also
called “physician-aid-in-dying”
– Intentionally helping a patient to terminate his or her life at his or
her request. (MedicineNet).
– Facilitating a patient’s death by “providing the necessary means
and/or information to enable the patient to perform the life-ending
act.” (American Medical Association)
• Euthanasia
– The practice of intentionally ending a life in order to relieve pain
and suffering. The word "euthanasia" comes straight out of the
Greek -- "eu", goodly or well + "thanatos", death = the good
death. (MedicineNet)
• Note some slip in “allowing to die”—NOT a reasonable part of the definition
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Two comparisons
Killing ≠ Allowing to die BUT Withholding =
Withdrawing treatment
• OK to not treat
sometimes
• Generally better to
try, and withdraw if
– Grave situations
doesn’t work
– Proper decisionmaking process
• ACTIVE taking of life
is impermissible
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The “Rule of Double Effect”
Aquinas and other Roman Catholics
• Morally acceptable to do something that has
both good and bad effects if ALL are true:
– Act inherently good or at least morally neutral
– Agent intends good effect
– Agent does not intend bad effect even if
foreseeable
– Good effect not achieved by means of bad
effect
– There is a morally grave reason to allow the
bad effect
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PAS and Euthanasia: Current
Landscape
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Countries where euthanasia is
legal
• Netherlands (2002)
• Belgium (2002)
• Canada
– Quebec Law 52 (2014)—allows euthanasia for people insured in
Quebec
• Colombia—”terminal illnesses” only
– No opt-out for conscience
– Catholic Church has threatened to close hospitals rather than be
complicit
• Luxembourg
• Japan—local court cases open the door
• Surreptitious practice in other countries?
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Additional foreign countries
where PAS is legal
• Switzerland
– “Suicide tourism”/Dignitas
• Canada (nationwide)
– 2015 Supreme Court Decision
– Suspended 12 months to give gov’t an opportunity to
write laws/policies
• Debated/on fringes in some other countries
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Euthanasia in the Netherlands
2010 data reported in 2012
• Total deaths: 136,058
• “Explicit intention of hastening death”: 4,360
(3.2%)
• Euthanasia: 3,859 (2.8%)
• Assisted suicide: 192
• “Ending of life without explicit request”: 310
• 2012: 4188 deaths (include 42 dementia, 13
severe psychiatric problems
• Failure to report about 20% of the time
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Sources: Holland reports; Lancet 2012
Practices in Flanders, Belgium, in 1998, 2001, 2007, and 2013.
Chambaere K et al. N Engl J Med 2015;372:1179-1181.
The Groningen Protocol
(Netherlands)
• Termination of the life of a child (<12 years old) is
permissible if 4 requirements are met:
1.
2.
3.
4.
The presence of hopeless and unbearable suffering
The consent of the parents to termination of life
Medical consultation having taken place
Careful execution of the termination
• 22 cases claimed 1997-2004—all infants with spina
bifida and/or hydrocephalus
• “Update” due
• Assertion: more abortions, less euthanasia since
protocol adopted
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Pediatric Euthanasia in Belgium
(expansion of law in 2013)
• 16-doctor panel to review requests
• Death expected in a “short time;” child experiencing
“constant and unbearable physical suffering”
• Child understands what he/she is doing and assents (!)
• Parental agreement
• Request in writing
• Emotional support for all
• Supposedly no cases, yet. Are they being reported?
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US States where PAS is legal
• Oregon—Death with Dignity Act (1997)
• Washington—WA Death with Dignity Act
(2008)
• Vermont (2013)
• Court Decisions Permitting PAS in:
– Montana (Baxter v Montana, 2009)
– New Mexico (2014)
• Numerous other states have considered or
are considering legislation
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Oregon’s Law
•
•
•
•
•
•
•
•
•
•
•
Oregon resident
Two oral requests separated by 15 days
Written request with 2 witnesses
Two doctors determine diagnosis, prognosis, and decision-making
capacity
– Psychiatric evaluation for depression or other mental illness
Doctor must inform patient of alternatives
Doctor must ask patient to inform next-of-kin
Surrogates may not request on patient’s behalf
Patient can rescind request
Doctor writes prescription, leaves the rest to the patient
Doctor must report prescription to the state Health Authority
Pharmacists must be told whether drug was used
Source: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/faqs.aspx
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The Oregon Data
• 105 deaths in 2014—compared to 33,391 total deaths in
2013 (appx. 0.3% of all deaths)
• Totals since 1997:
– 1327 prescriptions
– 857 deaths
• Most common reasons given by patients:
– Loss of autonomy (91%)
– Unable to do things that make life enjoyable (87%)
– Loss of dignity (71%)
Source: Oregon DWDA 2014 Annual Report
http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf ,
Accessed 7/13/15
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CA SB 128: “The End of Life
Options Act”
• Modeled after Oregon Law
• Underlying disease listed as cause of death
• California Medical Association dropped opposition
– AMA, World Medical Association still opposed
• Passed State Senate 23-14 (party-line)
• Stalled in Assembly Health Committee
– Justice concerns among Democrats from rural districts
• Dead for this year
• Court cases pending (like Montana/N.Mex.)
• Future ballot initiative?
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Brittany Maynard Video
https://www.youtube.com/watch?v=Mi8AP_EhM94
Note: “Compassion and Choices” originally known as
“The Hemlock Society”
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Kara Tippetts Video
http://www.krdo.com/news/terminally-ill-mom-assisted-suicide-isntthe-answer/29024550
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Arguments for PAS
• Autonomy—keeping control. “It’s my life.”
• Patient, not doctor or others, decides whether suffering
is unbearable.
– “Arrogant doctors” refusing patient requests
• Fear of loss of dignity or prolonged dying process.
• “Freedom from prolonged pain and suffering is a basic
human right.”
• Process can be controlled. Oregon shows it is not
getting out of hand.
• Opposition seated in “dogma of the Catholic church”
• Sanctity of life is subjective
• Line may not be bright; “double effect” is a charade
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Canadian Supreme Court
(Carter v Canada)
• “It is a crime in Canada to assist another person in
ending her own life. As a result, people who are
grievously and irremediably ill cannot seek a physician’s
assistance in dying and may be condemned to a life of
severe and intolerable suffering. A person facing this
prospect has two options: she can take her own life
prematurely, often by violent or dangerous means, or
she can suffer until she dies from natural causes. The
choice is cruel.”
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Two aspects of dignity
1. Fundamental: all people share, cannot
be lost or denied
2. Realization of human excellence
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Counterarguments
• Autonomy and rights are not absolute; right is to care, not
exercise of any and all means to end pain
• Decision will not be autonomous for some
• “Arrogance” does not apply: doctor’s calling is to care for
suffering patient
– Issue is nature of medical calling
• Good care upholds patient dignity
• Slippery slope is real—especially if sanctity of life is relative.
• What “dogma” is referred to? Mightn’t it be right? Or a
matter of principle and conscience?
• “Sanctity of life” also goes to the core of physician’s calling.
• Hard cases make bad law
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• “Double effect” still meaningful w/r/t intent
What do Californians Think?
Field Poll, 2005
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Gallup US Poll 2015
http://www.gallup.com/poll/183425/support-doctor-assisted-suicide.aspx, accessed 7/13/15
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http://www.gallup.com/poll/183425/support-doctor-assisted-suicide.aspx, accessed 7/13/15
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Physicians’ Attitudes
Medscape, 2014
• 21,000 MDs (17,000 US, 4,000 Europe)
Question
Should PAS be allowed?
Would you give life-sustaining therapy
if you considered it futile?
2010
Yes
No
46%
41%
2014
Maybe
Yes
No
54%
31%
20%
30%
Is life sustaining treatment being
withdrawn too soon?
Maybe
50%
86%
Is it right to provide intensive treatment
to a newborn who will die soon or
survive with terrible quality of life?
30%
Would you perform an abortion if it
were against your personal beliefs?
44%
15%
Should late-term abortions be legal?
25%
33%
30%
40%
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Problems with a “right to die”
Leon Kass: Life, Liberty, and the Defense of Dignity
• “A right in aid-to-dying will translate into an obligation to others to
help kill.”
– The state; bureaucrats?—MDs and others “pushed”
– If you have a right to be made dead, that does not give you the
right to oblige me to kill you.
• There will be “no way to confine the practice to those who knowingly
and freely request death.”
• “The medical profession’s devotion to heal and refusal to kill—its
ethical center—will be permanently destroyed…here is yet another
case where acceding to a putative personal right would wreak havoc
on the common good.”
• “Right to die” is incoherent: rights assume life and choices; being
made dead obliterates both.
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“Four myths about doctor-assisted suicide”
Ezekiel Emanuel, MD, NY Times 2012
Myth
Reality
Pain is the motivator
Psychological distress is: depression, loss
of autonomy/control—PAS “looks less like a
good death in the face of unremitting pain
and more like plain old suicide.”
High-tech medicine is the driver
Individualism/glorifying personal choice is:
euthanasia has an ancient history
Everyone will benefit
A few well-off benefit; the poor and
marginalized are the most likely to be
It’s a good, quick death
A lot of things can and often do go wrong
(e.g., vomiting) and death can be protracted
His conclusion: “we should focus our energies on what really matters:
improving care for the dying.”
http://opinionator.blogs.nytimes.com/2012/10/27/four-myths-about-doctor-assisted-suicide/?_r=0,
Accessed 7/14/15
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http://www.creators.com/editorialcartoons/steve-breen/32310.html, accessed 6/15/15
Examples of the slippery slope
• Belgium:
–
–
–
–
44 year-old transsexual with botched surgery
45 year-old identical twins going deaf and blind
Frank Van Den Bleeken (murderer/rapist)
Elderly couples if healthier spouse prefers death to widowhood
• Oregon Health Plan offering to pay for euthanasia
instead of cancer chemotherapy
• Other non-terminal illnesses—dementia, mental illness
• “Organ Donation Euthanasia” (Netherlands, Belgium)
• Victims of assault
• Pressure from family (1 in 5 patients; Theo
Boer/Netherlands)
• Patient pushed by daughter (Kate Cheney/Oregon)
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Two specific worries
• “Terminal sedation”—drug (narcotic) sedates and
relieves pain but stops breathing
– Rule of Double Effect vs misapplication (euthanasia)
– Almost all pain controlled without suppressing
breathing
– Concern is patient consent
• New French bill would allow “deep sedation” without consent
• Sense of dying of thirst (withholding feeding tube)
– Sense of thirst mainly from mouth/tongue
• Keep moist
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Hospice and Euthanasia/PAS
are NOT compatible
Hospice is about living, PAS and
euthanasia are about dying
Some PAS advocates try to
conflate the two
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10 Characteristics of a Good Death
John Dunlop, in Why the Church Needs Bioethics
1.
2.
3.
4.
A good death is the culmination of a life lived well.
A good death affirms the values of the person.
A good death follows a change in longings from earth to heaven.
A good death minimizes suffering when possible and affirms
dignity.
5. A good death comes after closure with family and loved ones.
6. A good death uses medical technology appropriately.
7. A good death does not involve euthanasia or assisted suicide.
8. A good death involves resting in Jesus.
9. A good death brings people to God.
10. A good death brings glory to God.
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The Medieval Ars Moriendi
• 5 temptations
1.
2.
3.
4.
Lack of Faith
Despair
Impatience
Spiritual Pride or
Complacency
5. Avarice (Greed;
clinging to family or
property)
• 5 Christian graces
1.
2.
3.
4.
Reaffirmation of Faith
Hope for Forgiveness
Charity and Patience
Humility and
Recollection of Sins
5. Detachment
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“Given the opportunity, I would support laws [to allow
PAS as in Oregon]…[but t]he fact that, by 2012, one
in thirty-five Dutch people sought assisted suicide at
their death is not a measure of success. It is a
measure of failure. Our ultimate goal, after all, is not
a good death but a good life to the very end. The
Dutch have been slower than others to develop
palliative care programs that might provide for it…we
damage entire societies if we let providing this
capability [for PAS] divert us from improving the lives
of the ill. Assisted living is far harder than assisted
death, but its possibilities are far greater, as well.”
Atul Gawande, M.D., Being Mortal
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“I will neither give a deadly drug to
anybody if asked for it, nor will I
make a suggestion to this
effect.” Hippocratic Oath
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[With Hippocrates, “f]or the first time in our tradition
there was a complete separation between killing and
curing. Throughout the primitive world the doctor and
the sorcerer tended to be the same person. He with
the power to kill had power to cure…He who had
power to cure would necessarily also be able to kill.
With the Greeks, the distinction was made clear. One
profession…were to be dedicated completely to life
under all circumstances, regardless of rank, age, or
intellect—the life of a slave, the life of the Emperor,
the life of a foreign man, the life of a defective
child…but society is always attempting to make the
physician into a killer—to kill the defective child at
birth, to leave the sleeping pills beside the bed of the
cancer patient. [It is] the duty of society to protect the
physician from such requests.”
Margaret Mead
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Will Doctors Do It?
Tom Garigan, “The Physician’s Imprimatur,” Bioethics@TIU 7/13/15
(http://blogs.tiu.edu/bioethics/2015/07/13/the-physicians-imprimatur/)
• We assume physicians are highly ethical; if their
expertise and judgment are involved, a moral
imprimatur is applied.
• So it was claimed for abortion—but an industry
arose
• So it may be for PAS—most MDs will say no, but
some will exploit
– Health/hospital systems may have some say…
• In fact, doctors are not ethical because they are
doctors, they are ethical because of what they
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do and not do
“What do you think are the best ways to
approach [PAS] with sensitivity and grace while
upholding the importance of the imago-dei in all
humans?”
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Some approaches
• Answer testimonials with testimonials
• Realize that people’s fears of loss of control and dignity,
and of suffering, are ministry opportunities
• Encourage excellent care at the end of life
• Prepare for our own deaths and be willing to talk about it
– Cf “Death Cafes” http://deathcafe.com/
• “At a Death Cafe people drink tea, eat cake and discuss death. Our
aim is to increase awareness of death to help people make the most
of their (finite) lives.” (From the website)
– Don’t be flip or smug
• Civil but forceful public policy advocacy
– Californians Against Assisted Suicide
http://noassistedsuicideca.org/
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“No one wants to make suicide easier for the depressed: many will
recover and enjoy life again. But mental pain is as real as physical pain,
even though it is harder for onlookers to gauge. And even among the
terminally ill, the suffering that causes some to seek a quicker death
may not be physical. Doctor-assisted death on grounds of mental
suffering should therefore be allowed.”
The Economist
“Euthanasia/assisted suicide is not about terminal illness but a radical definition
of autonomy that endangers the weak, vulnerable, ill, disabled, depressed,
scared, grieving, chronically ill, dying, deeply dissatisfied, and perhaps most
cogently of all, the expensive for which to care.”
Wesley Smith, Human Exceptionalism blog
http://www.nationalreview.com/human-exceptionalism
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“We shall not.”
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“You know, friends, from time
to time it’s good to talk about
death.”
Dr. Edmund Clowney
Sermon on Luke 7:11-17
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Discussion
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