Bio-ethics man to the rescue!

The issue of assisted suicide is once again making the rounds, timely in Massachusetts where decisions need to be made, as my friend Phil blogged here. I read an article by a physician, here, who discusses his own ideas although he himself doesn't give the impression that he is involved in the issue in any way other than that his own mother passed at a very advanced age with, 'the best care available'.

My ideas on these issues took a long time to form from professionally treating terminally ill patients specifiaclly in order to relieve their discomfort, the treatment of disabled children as well as personal experience both with my mother who died from ALS and the daily care of my son who is extremely physically and mentally compromised and "medically fragile".

There are a few statements that Ronald W. Pies makes which trouble me because in my opinion they are exactly the kind of subtle hidden agenda-like statements which are pushing people in a specific direction, despite that the author proclaims in the last sentence,

             "I believe this is a discussion we urgently need to have."

First and foremost I believe that ideally individuals should have the right to decide their demise. The problem with this is that when you are stuck in a medical system, such as hospital or even hospice (end of life) home care, you are possibly not capable physically of helping yourself out the door and so must rely on other people to push you through. This will necessarily burden another individual and thus we have the discussions of whether and how physicians (or any other designated medical personnel) should adopt that role. Personally I have no doubt whatsoever that the debate is being smoothed over, fast tracked, if you will, so that we are getting close to the point of having "thanaticians", trained professionals that remove the practicalities of assisted dying from the hands of the physicians, who will then collectively breath a huge sigh of relief. 

But in the mean time the discussion continues as policy is being made. There are a few issues we need to deal with though before we can actually continue this dialectic, the outcome of which should necessarily not be known.

And isn't it interesting to find that one of the most central issues surrounding people's decision making, both of informed patient as well as physician, is completely absent in the discussion?

Near the end of his article the psychiatric physician gives this issue its significant due, with this sentence, 

               "Moreover, a careful psychiatric assessment of patients requesting physician- assisted death is always indicated, because major depression may distort the patient's judgment as death approaches."

Do you see anything troubling with this statement? I do because for one thing the complex and often physiological mechanism of depression is not understood, certainly not in the case of terminal illness. There is no science to stating that a terminally ill person is depressed, not even if you make a list of fairly vague symptoms that a certain percentage of people have and go down the checklist to see which are the ones they qualify for.

But more troubling is this part,

    "because major depression may distort the patient's judgment as death approaches"

It must be major depression, otherwise it will not influence a person's outlook? This seems to lack common sense. The wording of the sentence is of course as such to have plausible deniability later on. There is no commitment on the part of the author since, it "may" distort the patient's view. He didn't say it would, just that it might. Since when would major depression not distort a person's view, especially of self worth? Isn't that what helps us define 'major depression', that distorted view?

And yet in real life, to my knowledge, rarely are full psychiatric evaluations held, only when there may be clear cut signs of apathy or obvious dementia. Otherwise these gray areas of minor depression and mild cognitive regression are combed over in the direction of competency. Even more troubling will be if finally it is decided that apathy is a natural reaction to terminal illness and thus does not qualify for inclusion in the diagnosis of depression, therefore does not require treatment. Because just to be clear we are talking about treating depression in an individual who expresses the desire to die since the one thing that is clear, people are much more apt to feel up to dealing with their condition when they are not depressed. As an aside, the treatment setting for the terminally ill, how much love and respect they are shown, the quality of the medical aspect of care and how much work is done to keep those people active and interested in life, are monumental factors in this regard.

In the article the doctor discusses ways in which people can choose to end their lives, without requiring the assistance of a physician (other than treatment of discomfort and pain). The following statement had the hair rising on the back of my neck though, 

             "Contrary to a widespread belief, voluntary refusal of food and fluids does not result in an agonizing or painful death, according to a 2003 report in the New England Journal of Medicine." 

I'm happy for the good doctor that he can look to a single report in the NJEM to convince us all of something which he obviously has never witnessed personally. By witness personally I don't mean that he may not have been a consulting physician for a patient who was undergoing this way of dying. But to sit and care for and watch  a loved one literally wither away each day, even by the hour, is a horrible and disconcerting experience. Of course some will say, 'ahh you are speaking about watching a loved one so you are confusing your discomfort with that of the dying individual. After all they are properly protected against pain aren't they?'   Well no, in actual fact you will get to see a wide degree of discomfort and pain because adjusting to the person's medical needs for pain control takes time and there are actually pains which do not respond to medication unless you completely sedate the person but in fact you are then actively assisting suicide as opposed to a simple bystander dealing only with minimizing the fallout.
The sedation allows the process of dying to go on unfettered. Consider that whereas a person who is suffering without the help of being unconscious will not necessarily say, 'this is horrible, let's speed this up' but they might actually say, 'hey, this is horrible, give me some food or water, this is worse than what I was previously going through.' So in my eyes complete sedation creates a situation, despite the person expressing their agreement to this method of ending their lives when they were lucid and coherent, where their death is actually premature, even in their eyes, had they been conscious to realize it. Because if you choose this death, of abstaining from food and water, you may think you know what you are getting yourself into but really you cannot know what it feels like until the dying process actually begins, which by the way can take a very long time. Of course the answer to this is, that abstention is the method by which a person chooses to die and the palliation is an adjunct which allows the person to choose this method without suffering, which of course everyone wants. 

In the end complete sedation occurs, although normally losing consciousness is part of the physiological reaction to the abstention, as is the medically induced aspect. The area where one predominates is again rather gray, but of course many are not interested in these subtle nuances because they have decided to die. It seems to me to be relevant though because if the method chosen, particularly if it is done to not involve a physician directly, which is the point of the article The Ethical Dilemma of Physician-Assisted Suicide, as I said above, in fact will directly involve the administering person . So then why not simply choose for sedation immediately, the effect would be the same.

There is also the issue of informed decision, where anyone with an agenda, especially physicians can be the deciding factor.

Again I personally believe we will have "thanaticians" at some point and we will all be quite used to it by then, not even raising an eyebrow. After all, for many years already physicians have been directly assisting in the euthanization of severely disabled babies in Holland, quite legally and I don't hear anyone even discussing the issue, as though it carries no importance whatsoever, no controversy. To me that attitude epitomizes why the disabled are not accepted in society. It's broken so throw it away. Is that what you teach your children when a toy of theirs breaks? Alright, I can see something in that, although personally I prefer the old fashioned kind of toys, made of wood or metal which you can play with much longer and more often than not, fix when it breaks.