Dr. Clifton is a Catholic neurosurgeon who works frequently with people who have head injuries or are dying. His wife, Karen, has helped to supply many practical needs for Casa Juan Diego over the years, and currently provides sandwiches for the men on the streets.
Mrs. Amy Santiago was 80 years old and lived independently in her small home in a Houston suburb prior to the hospital admission for a stroke. She and her husband had built the home and reared their son in it. Their neighbors, now mostly widows, had lived there as long. She and her friends often played dominos. It had been two years since her husband had died. Her 50-year-old son now lived in California. He worked hard to support his three children and was able to provide modest support for his mother after her husband’s death. His mother knew her son was now facing a difficult time financially. His company had downsized, and he had been forced to accept a lower salary at a time when he had one child in college and two others soon to go.
The stroke occurred one evening with immediate loss of use of her entire left side followed by loss of consciousness. Her only warning was an unusual headache lasting several hours. She did not remember the first week in the hospital. When she became aware, she found a feeding tube in her nose, a catheter in her bladder, and little feeling and no movement of her left side. Although the left side of her face was paralyzed, she soon began to eat with assistance and could talk with little difficulty. She was unable to sit up or get out of bed without assistance. She rang her call button with her right hand but could not get help for at least 30 minutes. When she had soiled herself on two occasions, she felt particularly degraded at being stranded in bed until the nurses came. She became quite depressed as days passed without any return of her left side. Her son had been there when she became aware and had been consulting with the physician about the rehabilitation phase after a stroke and long term care issues, but later he had to return to work. Her physician, a pleasant, communicative young man came to see her daily. He told her that in two weeks she would go for an extended stay in the rehabilitation facility prior to discharge. When she would be discharged was never discussed and she hated to ask. Twice daily the therapists came and got her out of bed. Mrs. Santiago became aware from their conversations that their efforts were to allow her to sit independently and eat independently and that they had no e xpectation that her arm, leg, and face would return or that she would walk in any fashion. She became increasingly depressed by the third week. The therapists had told her that a nursing home was probably her only long-term option. She began to consider whether her house would have to be sold and would the nursing home be in California or Texas? How would such care be paid for? The neighborhood had gone down, and the house would not bring much. When her son came back she asked him these questions. He said that he had found a nice nursing home near their house in California. He estimated sale of the house would provide at least two years of care there. She feared that after that there would be no more money unless one of the girls quit school. When her young physician began to explain the option of a painless death, she became further depressed at the thought. She felt powerless and so began to consider this option. She could not bring herself to ask how it was done. When she brought the issue up with her son, he firmly rejected the idea at first. As the physician began to answer more questions about prognosis, she and her son began to discuss the matter. Finally, overcome with sadness, she insisted that euthanasia was her choice. Another physician she had not seen before talked with her about euthanasia and seemed to want to be sure that her mind was made up. This nice young woman was smartly dressed in the same uniform as her doctor. The doctor had been right. There was really no pain associated with her death. Just insertion of an intravenous line and then she lapsed into unconsciousness just like when she had the stroke.
Euthanasia and God’s Will
The Church has spoken unequivocally about euthanasia as she believes God has spoken unequivocally. In the Gospel of Life (Evangelium Vitae) Pope John Paul II has stated: “I confirm that euthanasia is a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person.” The Holy Father continues, “In its deepest reality, suicide represents a rejection of God’s absolute sovereignty over life and death as proclaimed in the prayer of the ancient sage of Israel: “You have power over life and death; you lead men down to the gates of Hades and back again” (Wis 16:13). Jesus set the example by completely submitting himself to his Father’s will in both the time and terrifying manner of his own death” (John 13:1). When suffering is unavoidable, it may have a purpose known only to God and is to be endured with faith and hope. “I kept my faith even when I said, “I am greatly afflicted” (Ps. 116:10). Suicide or murder are not the ways out. Some people of faith might debate or question the Church’s interpretation of Scripture and its position on involuntary euthanasia. When a disabled or ill person is killed without their consent, involuntary euthanasia, the moral position of the state or physician doing the killing is more serious (Evangelium Vitae). Few who accept Christian or Jewish theology would seriously debate its perfidy.
Immorality and Public Policy
Efforts to legalize euthanasia in the United States are well under way. The debate will be about civil liberties. The fundamental limit on civil liberties by society at this time is to prohibit any act by an individual or group that directly harms another person or persons. Within this definition lies a lot of latitude. For example, what is a “person” and what is “harm?” When there is a question between a civil liberty and probability of harm, the civil liberty has usually won. An example is the unrestricted availability of sexually explicit material to minors on television and the internet. So the debate goes, is sexually explicit material really harmful. The jolting reality of legalized abortion in America up to the moment of birth makes the point that personhood is relative. The fetus prior to his/her first breath has not been defined as a person, or if so, as a potential person, or a marginalized person. The civil liberties of the fetus at all stages of development have been placed at the disposal of the woman bearing the child. Primacy is being placed on preserving the civil liberties of members of society who are not vulnerable. The point is that arguing that euthanasia is immoral and a violation of God’s will is unlikely to have a substantial effect on the debate about legalizing euthanasia in the United States. The proponents of legalized voluntary euthanasia will argue that it is a new civil liberty, a new right that affects no one but the patient making the decision of suicide. What is being dressed up as a new human right may become the right of society to further eliminate the vulnerable. The reasons for this are not immediately obvious, are not plainly discussed, but are particularly compelling.
Management of Technology
Physicians and patients share the ability to control pain and to control use of technology without deliberate actions taken to kill the patient. Much has been made of patients with cancer who live their last days in agony. However, pain of almost any degree is controlled at least when the pain is time-limited by an impending death. At times large doses of narcotics may alter the patient’s sensorium or even depress respiration to such a degree that an imminent death occurs. sooner. Newer techniques of narcotic infusion in the cavities of the brain or spinal column relieve pain effectively in many patients without drowsiness. More physician education is probably needed to assure that appropriate technology is applied. It is of interest to note that while pain management has dramatically and consistently improved in recent years, discussion about legalizing euthanasia has increased, indicating that social and political forces may motivate the debate as much as a concern for relief of pain. Withdrawal of disproportionate care is balancing the treatment to the disease and is not euthanasia. Death is not certain. Physicians now have the ability to permit a dignified, comfortable death without the chilling act of killing the patient. All hospitals and all religions permit, even encourage, “discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome” (Second Vatican Council). An example of this is the case of a fifty-year-old executive who acutely became comatose from a large hemorrhage in the brain. The man ran his own business and said many times that if he were ever rendered unable to live independently, he would prefer to be allowed to die. In some patients it is possible to discuss with the family at the time that the probability of death is certain with no chance of any quality survival. In this circumstance, surgery for a blood clot, using a ventilator to support breathing, or medications to support blood pressure are never instituted in the first place. It is frequently not evident in the first hours after a stroke or brain injury what the long-term prognosis is to be. It was not clear in this case at the time of the stroke that the prognosis was very bad. The patient underwent surgery, was placed on a ventilator and supported with intravenous fluids and medications for blood pressure. After three days it became evident from imaging studies and neurologic examination that this patient could not regain consciousness or sentient behavior. The tube in his windpipe was removed as was the ventilator, and he expired within hours with his family in attendance. The decision to withdraw care not proportionate to the expected outcome may not always be made immediately after onset of an illness. In cases of chronically vegetative patients not requiring life support, the judgment is often made that treating repeated pneumonia with antibiotics is disproportionate care. Patients may expire of the infections they are prone to. The ability to control pain and to balance the treatment to the disease is available to physicians and patients now without the chilling act of killing the patient.
One of the great risks of euthanasia is that what appears to be a rational decision may not be rational or independent. The first reaction to any loss, whether of a family member or a limb, is depression. Acceptance only comes later. A decision made in a depressed state may not be the same decision made after the loss has been accepted. Acceptance of an illness or loss occurs at different times in different people. An example is patients with spinal cord injury. Many times young doctors have said to their colleagues about quadriplegia (paralysis of arms and legs), “Do not treat me if I ever come in like that.” It is true that in the first weeks after spinal cord injury in young men, many have wished for death. Yet within one month they all begin to fight. In the end, almost no one wishes for death after the fact of quadriplegia is accepted. On the contrary, these young people accept on a daily basis what seems inconceivable. They work and take joy in aspects of life which those without disability consider given. Their injury creates individuals of uncommon determination and equanimity. Life is viewed from a different perspective, but it is no less valuable. The very circumstances in which euthanasia is considered are circumstances of depression when rational, informed decisions are unlikely to be made.
The Perversion of Medicine
The tradition of medicine is to support life and alleviate suffering of all persons regardless of their circumstances. The convicted murderer is to be accorded the same basic medical care as the saint. The Hippocratic oath and medical tradition forbid deliberate termination of life. Gaudium et Spes of the Second Vatican Council, in a reference to euthanasia and its destructive effects stated, “They (euthanasia and other acts opposed to life) do more harm to those who practice them than those who suffer from the injury. “ The ability to terminate life with consent (or without consent) will not just add a new tool to the physician’s armamentarium. The taking of active measures to terminate life will probably alter physician judgment about when and in whom to use medical treatments. Euthanasia will also inexorably lead the physicians who perform it to make value judgments about the worth of individuals. This departure from a long and clearly established medical tradition will insidiously transform the ethics of physicians who participate in it. Certainly those who do so regularly. This opinion is not just conjecture. In the Netherlands, euthanasia has been practiced since the 1980′s. If three criteria are fulfilled, physicians may not be prosecuted for homicide. First the patient must take the initiative in requesting euthanasia and request it repeatedly. Second, the patient must be experiencing suffering that only death can relieve. Third, the physician must consult with another physician who agrees that euthanasia is acceptable in the particular case. The Remmelink Commission report released in 1991 found that in 40% of euthanasia cases these criteria were not all fulfilled. In most cases euthanasia was discussed with the patient, but the patient was not fully competent to request euthanasia when the drugs were eventually administered (Van der Maas P.J. and others, “Euthanasia and other medical decisions concerning the end of life.” Lancet, 1991, 338:669-674). Euthanasia has also been offered to minors in the Netherlands. Less than 20% of euthanasia cases were ever reported to the state (Fergusson A. and others, “Euthanasia, Lancet, 1992, 338:1010-1011). The slide from voluntary to involuntary euthanasia by physicians in the Netherlands is well-documented. This occurred with no financial incentive to Dutch physicians to participate in euthanasia.
The Particularly Slippery Slope
The timing of legislation legalizing euthanasia in the United States could not be worse. Powerful new financial forces have seized medicine and changed it. The stimulus is that the cost of medicine in the U. S. has escalated out of proportion to all other aspects of the economy. Health maintenance organizations (HMO’s) are entities which have more or less been proven to stop escalation of health care costs and are, therefore, becoming the norm in financing of medicine. These companies employ doctors and contract with hospitals for medical services. Companies or individuals pay a set amount to the HMO, and for that amount all health services are provided by the HMO. An HMO’s profits are derived directly from the difference in money paid to the HMO by employers for care and the cost of care. The federal government is likely to contract with HMO’s for Medicare and Medicaid in order to set a limit on costs. Patients find HMO’s attractive in that they have no out of pocket expenses and premiums are lower than conventional insurance. For a patient, going outside of the HMO is not an option unless the patient is willing to bear all costs of care. Inherent in this concept is eliminating waste. Medical decision affecting cost of care are left to physician judgment. Physician judgment may be somewhat clouded, however, in that up to 30% of physician income is determined by how many health care dollars that doctor does not spend. HMO’s are not required to divulge to the public financial arrangements with physicians (Robert Pear, New York Times 7/8/96). The grave danger is that voluntary euthanasia, if legalized, will insidiously alter medical ethics at a time when they are already under pressure. Euthanasia that is only somewhat voluntary or frankly involuntary could well become a useful tool in controlling health care costs without ever being documented as such. The elderly disabled who are particularly at risk would become marginalized persons as have the unborn. It is a matter of curious analogy that the Nazis introduced the concepts of “unworthy lives” to the German public and medical profession by mercy killing of deformed children and the mentally ill. The words of Alexander Pope are haunting when applied to euthanasia: “Vice is a monster of so frightful mien, As to be hated needs but to be seen; Yet seen too oft, familiar with her face We first endure, then pity, then embrace.”
Mrs. Santiago’s physician was a recent graduate of a residency program and in family practice. He had little experience in caring for patients with severe injuries and had not recognized the signs of depression in her. He had competed with a large group of physicians for his position in the HMO of which Mrs. Santiago was a member and was glad to have one of the few available positions in the community. He had recently finished an organized series of lectures on cost control. Thirty percent of his and the other physicians incomes were determined by the amount of health care dollars saved that year over the actual budgeted amount. The doctor’s lack of experience, perhaps, had led him not to fully discuss with Mrs. Santiago and her son that she could probably live independently in her son’s home with modifications to the home to accommodate a wheelchair or that she could be taught over a two to three month period to transfer herself from bed to wheelchair. Mrs. Santiago would never have considered euthanasia, but distraught over financial burdens, not fully informed about prognosis, and saddened by his mother’s depression, the idea had become easier to accept. The wide acceptance and performance of euthanasia made him used to the concept.
Certainly no one would be critical. He never knew that his mother’s decision only had the appearance of free choice.
Houston Catholic Worker, Vol. XVI, No. 6, November 1996