April 1984 V/8
TREATING HOPELESSLY ILL PATIENTS
"Few topics in medicine are more complicated, more controversial and more emotionally charged than treatment of the hopelessly ill." So opine a group of physicians who nonetheless intrepidly attempt to offer other physicians guidelines for hopelessly ill adults in order "to come to some consensus about our responsibilities." (1) Because this document seems intended to serve as more than a guideline, its presuppositions and method deserve close scrutiny.
Presuppostions and Method
1. The panel presenting these guidelines for physicians is composed only and entirely of physicians. Have ethicists, theologians, or other health care professionals nothing to contribute? Sociological studies demonstrate that physicians have little training in ethics and hence take a pragmatic view whereby they value most an immediate practical solution. Hence, unless they have formal education in the field, experience indicates that they need the help of ethicists in order to grasp the total problem and to solve it according to principle.
2. Rather than depend upon ethical principles to substantiate their guidelines, the physicians rely upon the law or their own authority. Both the patient's right to make decisions about medical treatment and the physician's responsibility to refuse participation in suicide are substantiated by the civil law. Law should be based on ethical principles. Thus, there are more fundamental reasons than law for the aforementioned standards. Patients have a right to make decisions about their medical care because they must exercise freedom to fulfill their purpose in life. Physicians should not cooperate in suicide because human beings do not have absolute domination over their existence. Moreover, suicide destroys the bond of family and brings despair to society.
3. When the physicians reach the heart of the matter, stating the guidelines, they do not even use the law as a basis of their statements. Rather, we are asked to accept the conclusions based upon their personal authority. Hence, though they use such words as "ethically permissible" and "morally justifiable," they do not offer any reasons for their statements. Medical ethics is a philosophical discipline and in philosophy authority is the weakest of arguments.
4. Four levels of care are presented: (1) emergency resuscitation; (2) intensive care and advanced life support; (3) general medical care, including antibiotics, drugs, surgery, cancer chemotherapy, artificial hydration and nutrition; and (4) general nursing care and efforts to make the patient comfortable, including pain relief, hydration and nutrition as dictated by the patient's thirst and hunger. The spiritual and psychological needs, especially vital for dying patients, are not mentioned as part of comfort care.
5. Two types of patients are discussed: those who are competent and those who are incompetent. Guidelines for the level of care for the competent patient focus upon patient consent, relief from pain, emergency resuscitation, and hospice care. Incompetent patients are divided into patients with brain death, patients in a persistent vegetative state, severely and irreversibly demented patients, and elderly patients with permanent mild impairment of competence. Including the patient with brain death among incompetent patients only confuses the issue. Patients with brain death are not only "considered medically and legally dead." They are dead in fact. If they are not dead in fact, then they must not be declared medically or legally dead.
6. Concerning patients in a persistent vegetative state we are told that "it is morally justifiable to withhold antibiotics and artificial nutrition and hydration as well as other forms of life-sustaining treatment, allowing the patient to die." Hence, only the fourth level of care is necessary. As I have stated in a previous essay, I agree with this statement, but ethical justification should be offered. The ethical justification for withholding life-prolonging care from a person in an irreversible persistent vegetative state is because the person can no longer strive effectively for the purpose of life. All medical care which aims at prolonging life is directed to helping people achieve the purpose of life. Though physicians and other health care professionals work at the level of psychiatric and physiological function their work is ordered to the higher functions of the human person which enables the person to strive for the purpose of life. All need not agree on the specific purpose of life; we define it in different ways. But all agree that when the higher functions can no longer operate that the person no longer can strive for the purpose of life and thus there is no need to prolong life.
7. The statement distinguishes between two types of demented patients: those severely and irreversibly demented and elderly patients with permanently mild impairment of competence. For the former group only that care need be given which would make them comfortable. "If such a patient rejects food and water by mouth, it is ethically permissible to withhold nutrition and hydration artificially administered by vein or gastric tube. It is ethically appropriate not to treat intercurrent illness except with measures required for comfort." In regard to the second group, those who are "pleasantly senile," care should also be limited. In fact, if emergency resuscitation and intensive care are required, the physician should provide these measure sparingly...guided by the patient, or the patient's family, and by an assessment of the patient's prospects for improvement.
In a sense, I think that the physicians change the rules of the game when they discuss demented patients. Prior to this they discuss patients who are hopelessly ill and terminally ill and who have no potential to strive for the purpose of life. But these demented patients are not terminally ill. Nor are we sure that any individual is unable to strive for the purpose of life. Ethical reasoning also justifies allowing a person to die if prolonging life involves a grave burden in striving for the purpose of life. But this must be an individual judgment. It cannot be made of a class of people. In other words, we have to be very sure that when discussing limitation of medical care we do not neglect the weak and suffering simply because they need our help. May we allow people to die simply because "they are a burden" or are supported by public funds? In a very real sense, each one of us has been or will be a "burden" and this should not imply that we are left to die. Stating that a person can freely choose to refuse aggressive treatment that would prolong life if the person is terminally ill is one thing; maintaining that one can make that same decision for a class of people when there is still a hope or a weak potential to strive for the purpose of life is completely different.
The meeting from which the document emanates was funded by the Society for the Right to Die. While worthy of evaluation, the document should not stand as the last word on the matter.
Kevin O'Rourke, OP
1. "The Physicians Responsibility Toward Hopelessly Patients," NEJM, Vo1.310, n.125, Apr.l2, 1984; p.955-959.
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