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Volume 55, No. 1 January 1999
THE END OF LIFE
Until recently, a very few Americans knew in advance the precise time and manner of their death: those who were on death row, awaiting their date with the executioner.
There is in fact only one way in which any physician can know with certainty the time of a patient's demise. Most physicians can probably recall one or more patients who defied their prognostications, living months or years longer than expected, and sometimes even making an astonishing recovery.
The key to understanding the "end-of-life" campaign is to recognize that "end" is not just a noun, but also a verb.
"To end life" sounds less harsh than "to kill."
The idea is to end life before it becomes not worth living (lebensunwertes). The Oregon physician-assisted suicide law arbitrarily defines that point to occur no sooner than six months before the projected time of natural death.
At the actual end of life, the physician has a corpse, not a patient. At that instant, an absolute, irreversible, natural change of state makes all the AMA's Education of Physicians for End of Life Care (EPEC) materials utterly irrelevant.
The transition point under discussion in this campaign is not death, but rather the point when a particular life reaches a zero or negative value. Then one would no longer wish for a person to live long and prosper, but for the nonperson to die more quickly so that the collective can prosper more.
This point is relative, not absolute like death-and so are the ethics invoked in determining it.
The ethics are supposedly multicultural: "Dan Callahan, director of international programs, races out of the building for the airport. Once again he is off to a conference abroad to work with members of one of his international committees on the goals and values of contemporary medicine in an increasingly interdependent world," reads a Hastings Center fundraising letter. Yet the whole agenda begs the questions at the heart of the world's cultures: Why did Egyptians build pyramids? Why did Christians bury suicides at the crossroads? Why did Hamlet pause and ask: "For in that sleep of death what dreams may come?"
End-of-life "choices" may be presented as "options": even if the manner-of-death decision forecloses other possibilities (such as stepping back from the precipice at the last instant).
But avoiding the issue is not an option, given the pervasive nature of the supposedly multicentric campaigns by the new AMA Institute for Ethics (focusing on end-of-life care, genetics, managed care, and professionalism), the ACP/ASIM Center for Ethics and Professionalism (including the same foci), the Robert Wood Johnson Foundation "Last Acts" program, and so on.
A number of techniques are helping to win acceptance for the physician as killer:
- Desensitization (watch Doctor Death
kill a patient on national television-rather like forcing medical
students to watch pornographic films);
- Surveys (like one distributed by the
American Academy of Neurology, which helps frame the questions as
primarily legal rather than moral and shows that more and more
physicians are moving toward acceptance of euthanasia);
- Incentives (win a grant, or attend a
Saturday morning seminar and get a great parking place for the
football game that follows, or engage in the activity that gets
the highest reimbursement under the proposed new AMA/HCFA E&M
Documentation Guidelines);
- Punishment (in addition to nonpayment,
"regulatory requirements...expose providers to significant civil
and criminal sanctions for failure to comply with `medical
necessity' requirements," noted a memorandum from System
Integrity Office at Providence Health System-and how could futile
care be medically necessary or appropriate?);
- Semantics (the Oregon Department of
Health defines assisted suicide as a form of "comfort care");
- Interactive propaganda and peer
group pressure (once physicians complete their
continuing medical education, they are urged to "share" with
others who missed the opportunity -the "train-the-trainer"
process); and
- Control of the data (death certificates in Oregon are deliberately unclear in case of physician-assisted suicide, and there is no way of knowing whether certain groups are disproportionately affected-Medical Economics 5/11/98).
The difficulty of obtaining reliable data on euthanasia is eloquently shown by the Dutch experience. It is said that more than 60% of Dutch cases of euthanasia are unreported, in violation of their own guidelines. Involuntary euthanasia is not legally sanctioned in the Netherlands; however, euthanasia there is always voluntary by definition, even when done "without explicit request." (See JAMA 1997;277:1720-1722, 278:817-818, and 278:1492-1493).
The logically consistent endpoint of this discussion is the view of Australian philosopher Peter Singer, recently appointed Professor of Bioethics at Princeton's University Center for Human Values. Singer has been denounced by Catholic bishops, prominent rabbis, and parliamentarians of Helmut Kohl's Christian Democratic Party (who compared him to Hitler's henchman Martin Bormann). He cannot speak on the Continent without being assailed by disabled protesters (Wash Times 7/6-12/98). Singer does not believe that the concept of a moral right is helpful or meaningful. He judges the value of any action by whether it increases the sum of pleasure in the universe, as by removing "miserable beings."
In Singer's view, it is the failure to accept killing that is horrific (Wall St J 9/25/98).
The outcome of this culture war is not yet determined, but the end of the Hippocratic tradition could be at hand.
Collectivist Morality
From the two central features of every collectivist system, the need for a commonly accepted system of ends of the group and the all-overriding desire to give to the group the maximum of power to achieve these ends, grows a definite system of morals, [which] differs from [ours] in one point which makes it doubtful whether we can call it morals; that it does not leave the individual conscience free to apply its own rules and does not even know any general rules which the individual is required or allowed to observe in all circumstances....
The principle that the end justifies the means is in individualist ethics regarded as the denial of all morals. In collectivist ethics it becomes necessarily the supreme rule; there is literally nothing which the consistent collectivist must not be prepared to do if it serves "the good of the whole," because "the good of the whole" is to him the only criterion of what ought to be done....[C]ollectivist ethics...knows no other limit than that set by expediency....
Friedrich Hayek, The Road to Serfdom
quoted in Investor Weekly 5/6/98, Prudential
Securities
W.C.A. Hospital Ethics
The attending physician's statement on a form entitled "DNR - Therapeutic Exception" reads as follows:
"I have determined to a reasonable degree of medical certainty that the patient would suffer immediate and severe injury from a discussion of CPR. I have ascertained the wishes of the patient to the extent possible without subjecting the patient to risk....I have determined that ... (a) the patient has a terminal condition; (b) the patient is permanently unconscious; (c) resuscitation would be medically futile; or (d) resuscitation would impose an extraordinary burden on the family in light of the patient's medical condition and the expected outcome of resuscitation."
Consumer Self-Help in Oregon
In the wake of Oregon's physician-assisted suicide law, Oregon homemaker Patricia Smith has written a book entitled "Ten Ways to Protect Yourself and Loved Ones from Euthanasia," $7.00 from 4-U Publications, PO Box 895, Canby, OR 97013. Topics include "How do I know if I can trust my doctor?" and "Why are living wills dangerous?"
Arbeit Macht Frei
In the last 20 years, there has been a three-fold increase in the U.S. prison population. With more than 1.8 million persons incarcerated, the U.S. has more prisoners per capita than any other country, and the population is expected to double again by the year 2005. The increase is primarily attributed to harsher sentences for first-time drug offenders. The average federal sentence for a first-time, nonviolent drug offense is longer than for rape or manslaughter (Prison Legal News, 12/98). At the same time, the number of inmates working in federal prison industries, at wages from 23 cents to $1.15 per hour, has grown from 5,000 in 1980 to 20,000 today.
While prison employment may enable prisoners to develop positive work habits and useful skills, the Coalition for Government Procurement states that prison industry often displaces other workers, destroying more than 2,000 jobs in the furniture industry alone since 1993. The government is required to give preference to goods made by federal prison inmates (Thomas Sowell, Forbes 10/5/98).
In November, representatives of the Public Health Committee of the Pima County Medical Society toured a medium-security federal prison near Tucson, where the factory produces mail bags for the U.S. Postal Service and bags for servicemen. The warden and the contracted prison physician explained tuberculosis and suicide precautions. The delegation was not permitted to interview an inmate because the appearance of access to a private physician might be perceived as favoritism and might also tend to undermine the authority of the prison physician.
The warden had no statistics on homosexual rape, one of the most dreaded risks of incarceration. He stated that many assaults were unreported because victims viewed the lockdown (protection against retaliation for snitching) as worse than continuing to live with abusive perpetrators.
A Growth Industry
In an interview with Medicare Compliance Alert editors, Wayne W. Oakes, acting chief of the FBI's health care fraud unit, was asked: "Will you ever reach a point-because you get more money every year with HIPAA-where you have enough agents?" He replied: "I don't think so because what happens here is when you fund, say 46 positions, and you use part or most of that $9 million enhancement, what happens is the cost of that agent increases each year because there are promotions involved." Also, investigations are much more sophisticated, he said. It is expensive to execute 35 search warrants in 17 states, ending up with box loads of records that have to be stored and analyzed (MCA 7/13/98).
Protecting the Public System
The main threat to Canadian medicare is not chronic deficits and waiting lists, but rather the private sector. Bill 37 in Alberta was introduced to regulate private surgical facilities that otherwise may serve to "help shorten waiting lists for some procedures the public system has trouble providing."
Bill 37 "will prohibit a private treatment facility from providing surgical services, now provided in public hospitals, to any Canadian covered by a provincial health plan." Uninsured services, now provided outside the public system, could be offered only by facilities accredited by the College of Physicians and Surgeons of Alberta and formally approved by the Minister of Health. Debate on the bill has been deferred until the spring of 1999 (see http://www.health.gov.ab.ca).
Duplication of services in the public and private sectors is considered to cause erosion of the public facilities, especially if physicians are permitted to straddle the two systems. Critics say that quality and the profit motive are incompatible goals.
If physicians are able to choose to accept more pay rather than less, "instead of the best doctors doing the most difficult work, they are doing the most lucrative work," stated Richard Plain, Vice President of the Consumers' Association of Canada (CMAJ 1998;159:551-552).
AAPS Calendar
Feb. 20, 1999. Board of Directors meeting, Dallas.
Oct. 12-16, 1999. 56th annual meeting, Coeur D'Alene, ID