Metanexus: Views. 2002.10.09. 3409 words Concerning the issue of euthanasia, today's columnist, Jeff Dahms, writes that "[f]ew areas of the science religion interface are as difficult as this. Because euthanasia is a daily fact of life in every major hospital in developed countries around the world. It also routinely takes place in local hospitals, hospices, nursing homes, and our own homes. And, the Netherlands not withstanding, most everywhere it is illegal. What is going on?" Yes, what is going on? To illustrate an example of the subtle dilemma which is euthanasia, Dahms tells the following story: "I'd like to begin by recalling my first encounter with explicit euthanasia as a young resident. Apprenticed to the chief of surgery, we came to the bedside of a fifty year old man with metastatic liver cancer who had reached the stage of mental disconnection with the world around him. Very extensive testing and cross checking supported the diagnosis and other specialist colleagues had been consulted. There was the likelihood of an extended period of suffering before death. The surgeon said from the end of the bed, 'His lungs sound a little congested to me' and indicated that I should listen examine the man's chest. Naively I reported that his lungs sounded clear to me and the clearly disappointed chief told his obviously slow witted resident to listen again. Finally catching on I started to report that maybe there was just a little noise in one lung when the surgeon interrupted my first sentence with the diagnosis of pneumonia. 'Painful thing pneumonia' he said to the nurse with us who also clearly understood what was going on, and gave instructions for a powerful morphine infusion to be started late that evening. The surgeon then proposed I contact the man's wife, suggesting that she might like to visit early that evening. She was a member of the hospital's board, and I was to tell her of this 'complication,' the 'treatment' and the risks of sudden death from the treatment and our intention to start the morphine late that night." Dahms goes on to observe that the only thing more peculiar than the incident itself was the fact that everyone-the doctors, the nurses, and the wife of the patient-all knew their roles and played them. And this is not an uncommon practice of the human psyche, as you will see upon reading the today's column, Euthanasia - As good as it gets? Today's columnist, Jeff Dahms, is a physician-surgeon and research scientist associated with Sydney University's teaching hospitals. His scientific interests are in mind/brain evolution and the philosophy of science, particularly in the fundamental areas of physics and biology, and in relational areas such as the science religion discussion. -- Stacey E. Ake =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-= Subject: Euthanasia - As good as it gets? From: Jeff W. Dahms Email: Some time ago our hospital ethics group convened to consider yet again the impossible question of euthanasia. Instead of the usual formality of just drafting vague hospital policy the group was invited to contribute to rethinking the fundamentals. The discussion included unusually open consideration of what actually goes on in the hospital setting and a variety of proposals for how we might handle the issue better. It seemed that this explicit backgrounding might be of interest to the Metanexus group. Additionally some of the rethinking significantly reconfigures the field and would benefit from the technical skills and wide ranging views of 'Metanexans.' Few areas of the science religion interface are as difficult as this. Because euthanasia is a daily fact of life in every major hospital in developed countries around the world. It also routinely takes place in local hospitals, hospices, nursing homes, and our own homes. And, the Netherlands not withstanding, most everywhere it is illegal. What is going on? Don't ask don't tell First it is hard to get the facts and we all collude in this. By unconscious social consensus we seem to have adopted a 'don't ask don't tell' approach to what really goes on. Clinicians talk in vague generalities and the community is quite happy not to press the matter. It is very discomforting for all of us to square up to the issue so it is kept in that big mental box labeled, 'Things we'd rather not admit, think about, know about etc' Surveys under anonymity of doctors around the world show a significant fraction admit to the practice. If the police or a legal body are approached about a particular doctor who has admitted the practice in one of these surveys they will reply that 'no one has lodged a complaint.' Nobody really wants to know. Denial is not necessarily always a vice and sometimes an under rated virtue but it does make it very hard to understand some important things in life and do them better. It depends on what you mean by euthanasia For a start euthanasia is almost never labeled as such. We tend to think of gross interventions - turning of life support machines, giving lethal injections of a drug and so on. These are quite infrequent of course and ending a life is rarely as dramatic or explicit. Much of it is buried in routine clinical decision-making, for instance: * How quickly the resuscitation team is called to a cardiac arrest and then how long they work, even what drugs are administered. * How the young motor cyclist with horrific head injuries is triaged and first treated in the emergency room, * When antibiotics are administered and critical biochemical imbalances rectified in the patient in extremis. * What tests are ordered or not even what routine monitoring is to be done. The general point in the above is that modern medicine deals with very complex networks--interdependent body systems, pharmacological and mechanical support systems, diagnostic and treatment and management systems. Clinicians like everyone else have value systems and there are endless ways for these values to be expressed clinically. It is so routine in fact that few clinical people even focus on it consciously. If you ask them about euthanasia, even in privacy, the will often deny it first up. This is not a conscious covering up. We have very good evidence of the power of unconscious influences on clinical decision-making. Witness the multiple studies showing the enormous difference race makes to treatment. This does not come about because the medical establishment is riddled with conscious race bias. Question these clinicians and you will hear only the most high-minded sentiments. The race bias, that they do not even know about and would be extremely embarrassed to discover, is so powerful that it can radically alter decision making. The compassion of euthanasia is much easier for many doctors to admit at least to themselves, so there is no difficulty in granting it a very powerful unconscious influence. The reality is that there is an infinitely divided grade of euthanasing, ranging from gross acts like turning of life support systems to the subtle completely unconscious determinants of who gets what operation. Active and passive euthanasia .....and just wars. When the subject arises outside the clinical setting, discussion will usually turn first to the idea of active versus passive euthanasia. This philosophic distinction has the archaic ring of scholastic ideas like just wars. I think the idea was very dubious a thousand years ago but it is simply a self-calming psychological convenience in the twenty first century. In the modern complex clinical setting hinted at above there are myriad ways to 'actively' engineer the end of a life 'passively.' Is intentionally failing to monitor the potassium level of a vomiting elderly patient with terminal cancer and a poor heart and thus greatly increasing the likelihood of a cardiac arrest active or passive euthanasia. We still reach for the idea because it seems to allay some of the psychological discomfort with what we do, not because it has any technical meaning. Moves to legalization...the slippery slope and the dead end road. Moves to legalize euthanasia have an odd social history. When the Netherlands recently made this move the press in Germany and Britain were outraged at the decline of civilization being wrought by the Dutch. Interestingly the rates of euthanasia in both Britain and Germany are actually higher than in Holland. Doing it is OK. Legalizing it is immoral. The issue seems to be treated somewhat like prostitution. None are particularly interested in this regular fact of life - until it is proposed that we legalize it. Governments with a few exceptions oppose legalization even though population surveys often find substantial majorities in favor of same. There are passionate euthanasia support societies and religious groups who vehemently oppose it on their own religious grounds. In summary here are the major issues * Euthanasia of every degree of is common and universal ranging from the fully conscious occasional throwing of a switch to the unconscious determining of subtle clinical decisions. * We mostly refuse to focus on what is going on and allay our discomfort with really overt action with notions like active and passive euthanasia. * In spite of the above many people are unable to die their death of choice and suffering great pain and indignity. * Legalization is a hard road and there is no consensus on whether we should go down it. * There is widespread feeling that individuals and relatives are the ones who should be making the choices (clinicians should not be 'playing God') yet there is concern about the 'slippery slope' to awful abuse of any legalized system. So is there some way of working with these seemingly impossible dilemmas? Let me begin with my conclusion and then work towards supporting it. The view is not conditioned by any religious conviction. We should keep euthanasia broadly illegal and actively practice it with an overseeing judiciary for the necessary checks and balances. Introduction to Human Psyche 101 To help explain this apparent contradiction I'd like to begin by recalling my first encounter with explicit euthanasia as a young resident. Apprenticed to the chief of surgery, we came to the bedside of a fifty year old man with metastatic liver cancer who had reached the stage of mental disconnection with the world around him. Very extensive testing and cross checking supported the diagnosis and other specialist colleagues had been consulted. There was the likelihood of an extended period of suffering before death. The surgeon said from the end of the bed, 'His lungs sound a little congested to me' and indicated that I should listen examine the man's chest. Naively I reported that his lungs sounded clear to me and the clearly disappointed chief told his obviously slow witted resident to listen again. Finally catching on I started to report that maybe there was just a little noise in one lung when the surgeon interrupted my first sentence with the diagnosis of pneumonia. 'Painful thing pneumonia' he said to the nurse with us who also clearly understood what was going on, and gave instructions for a powerful morphine infusion to be started late that evening. The surgeon then proposed I contact the man's wife, suggesting that she might like to visit early that evening. She was a member of the hospital's board, and I was to tell her of this 'complication,' the 'treatment' and the risks of sudden death from the treatment and our intention to start the morphine late that night. More surprising to me than the fact that this that this was happening was that everyone knew their role. The patient's wife accepted the story and the plan at face value, though clearly understanding at the same time what was going on, as she had wide hospital and medical experience. Here is what really happened. The clinical decision was taken to end that man's life. It was done publicly in the hospital environment with no one in the slightest doubt about what was taking place. A legal form was constructed for the decision using the pseudo diagnosis and treatment. The patient's wife was informed of this face value decision in such a way that she could intervene if she wished. Most importantly I realized she was not asked to make the decision. It gave her a way of agreeing without actually being responsible. This piece of theatre demonstrated a number of things that are rarely if ever raised in considering the issue of euthanasia. There are many circumstances where there is time, the relevant technical understanding and the 'emotional room' for the patient or a relative to make the critical decision. There are also many circumstances in which at least one of these is absent. Let me illustrate the idea of 'emotional room' with a somewhat extreme example to make the point clearly. There are birth defects that leave the newborn with part of the brain outside the skull and one of the Faustian consequences of modern medicine is that we can now keep such infants alive almost indefinitely if enough effort is expended. Consider the consequences in a legalized system of euthanasia of formally asking the new mother to make the decision about the life of this infant. She can decide that the infant should die and live with that decision and the endlessly recurring thoughts of 'Maybe they would have found a cure,' Maybe I could have coped...and so on. Alternatively she can decide to try to carry the burden of coping with such an infant with no real knowledge of what is actually entailed and then fall apart under the shear weight of the impossible task. In such a scenario the piece of theatre above provides a way out. It is a way to choose but not be ultimately responsible. The way it is set up is that a formal statement is made that we are planning to do so and so. It both informs the relative and opens the way for them to intervene if they really wish but we are not explicitly inviting that intervention. They can then go along with what is being done without actually authorizing it. They were never explicitly asked. Logicians may perfectly well object that this is nonsense - of course the person is still choosing and is therefore still responsible. But let me report from the field that Aristotle hasn't got it all down - the human psyche is well adapted to splitting like this. Usually this feature is one of humanity's serious psychological disabilities but in these cases the marvelous irony is that it is a huge blessing. To my continuing great surprise people from all kinds of backgrounds quickly grasp what is going on and play their parts as if individually scripted. Only junior residents seem a little slow at catching on. The other scenarios where patient/relative involvement is not meaningful are obvious - speed of decisions needed, technical understanding required and so on Patients and relatives obviously should have maximal determining input but the realities of both the human psyche and the speed and complexity of modern medicine mean there are many circumstances where this cannot or in some cases for deeply human reasons should not be done. All of the above are actually arguments against legalization. Legalization closes the very important psychological loophole that has enabled many to make it through the night. The explicit nature of the decision-making rules out the compassionate theatre above. Legalization also means group decision and time sometimes is of the essence. And finally legalization means limited specification in a world of the infinitely variable. So who will guard the guards? Is this just a 'brave new whatever' proposal to hand over our lives to a techno-elite. For there are real upper limits to patient and relative decision-making, and we are better off simply admitting this rather than faking it as we often do now. I think there are ways to handle the abuse of power issues - stronger requirements for shared clinical decision making coupled with informed judicial oversight. Keep euthanasia vaguely illegal. When one may be called to legal account for these decisions one will check and double check and check again, involving as many as possible in the decision. What happens at the moment is that the police and the judiciary completely informally act as the systems overseers. There is the initial decision by the police about whether to even pursue a case. Some years ago in Australia there was a case just like the one cited above concerning the brain damaged infant. The mother had informed her fundamentalist religious sister of what had taken place and the sister went to the police. Their response was to suggest that she work it out with her sister and a counselor and perhaps discuss the matter with the relevant religious minister, judging that this was not a police matter. The sister was very persistent and finally persuaded a lawyer to raise the paperwork forcing the police to act. When the matter finally came before the judiciary it was very quickly 'decided' in favor of the mother and the doctor. A judge with a wide view of how the system works made sure that it worked. What should we be doing then? Euthanasia is a fact of life but there are many problems with how we are going about matters. Many needing/asking for help are not getting it. The covert nature of how the system works means that clinical and legal decisions are wildly variable. I do not believe that the solution to the problem of under provision is to legalize euthanasia. Nor is the solution to the problems of abuse to attempt to eliminate the practice. We need to start by openly discussing what is actually going on. Then we can begin to consider the way the various parties to process might improve their act when we have a concerted vision of how the system could work. Some of these issues more applicable in some countries than others. Here are some changes that we might consider: 1. The legal system The proposal needs a self aware legal system sophisticated enough to play its role consistently. Their role is to make sure that the maximum amount of choice is being given to patients and their relatives consistent with the above principles. Their job is also to keep the pressure on the clinical team - to make judgments about outcomes, defending clinicians where good outcomes are being achieved and prosecuting where someone is going beyond the pail. This seems inordinately subjective but there is often surprising legal unanimity in spite of this. 2. Advocates of legalizing euthanasia The advocates of legalizing euthanasia need to give the system enough room to work. Dr Kevorkian is not being helpful. No formal system can cope with the complexities of the issues both technical and human and much that is good about the current arrangement will be destroyed in the process of legalization and the necessary constraint and formalization. The attraction of legalization is that it takes care of the obvious end of the spectrum - terminal people who wish for a death of their choosing - but with very considerable unanticipated consequence for the rest of the community's needs. 3. Advocates of eliminating euthanasia People with religious convictions that would interfere in the lives of others might well do to spend some time doing volunteer work in the scenarios they purport to understand. When things get tough enough we are all the same and make surprisingly similar decisions though we rarely think so in advance. The difficulty is that at a distance from life one can hold any untested convictions, and worst of all impose those convictions on others actually immersed in the problem. We may be deciding for others now but it is likely it will be our turn tomorrow. 4. Clinicians Clinicians will have to learn to live with hard choices giving as much decision making to patients and relatives as possible but in the end having to make many solo calls. It is no help to pretend that we are doing anything other that what we are doing. Medicine includes euthanasia, and it is philosophic pedantry to pretend otherwise. No committee is going to shoulder the responsibility of these decisions. Even an ambiguous legal system is necessary to give the system both its edge and its flexibility. If we'd rather a comfortable life of self-surety than perhaps politics was meant to be our calling. =-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-= This publication is hosted by Metanexus Online . The views expressed here do not necessarily reflect those of Metanexus or its sponsors. To comment on this message, go to the browser-based forum at the bottom of all postings in the magazine section of our web site. Metanexus welcomes submissions between 1000 to 3000 words of essays and book reviews that seek to explore and interpret science and religion in original and insightful ways for a general educated audience. Previous columns give a good indication of the topical range and tone for acceptable essays. Please send all inquiries and submissions to Dr. Stacey Ake, Associate Editor of Metanexus at . 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