Withdrawal of care and assisted suicide: the case of Charlie Gard

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Kenan Malik writes in the New York Times in support of Charlie Gard’s parents, presenting a secular, utilitarian argument for the continuation of the child’s treatment.

In the article, Malik draws attention to a contradiction between the State’s position regarding Gard and its position regarding a patient with a terminal neurological condition who wishes for assisted suicide.

The practice of withdrawal of care is often invoked in the debate over assisted suicide.  Proponents of assisted suicide make an “equality under the law” argument: since we allow the death of patients by withdrawing intensive care, shouldn’t we also allow patients to commit assisted suicide?

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Compassionate care in 2017

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A 90-year-old mother is in the hospital for a stroke.  Her son gave me the following details:

Two months ago, mom was admitted to the hospital for dehydration.  At baseline she had mild dementia and chronic atrial fibrillation.

She recovered well.  Before discharge, the primary care physician convinced the family to change her status to “hospice,” arguing that she would get better, more appropriate, and more comfortable care.  Her blood thinner Eliquis was discontinued for being “too risky.”

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The body language of assisted suicide

What the verbal request fails to reveal

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Laws that allow assisted suicide restrict the provision of “aid-in-dying” drugs to patients whose mental status is not impaired and who are capable of sound judgment.

Medscape recently featured a video interview of Timothy Quill, the palliative care specialist and long-term assisted suicide activist.  He is interviewed by the ethicist Arthur Caplan, and the two discuss the psychological evaluation of terminally ill patients who request physician-assisted suicide (PAS).

Several points made by Quill caught my attention.

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Should assisted suicide be legal in a free society?

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Abigail Hall Blanco, a research fellow at the Independent Institute, recently wrote a piece entitled “Assisted suicide is a personal choice” in which she defends the position that assisted suicide should be legal in a free society.

Before discussing this piece, it is important to clarify what Blanco probably means when she asserts that assisted suicide is a “personal choice.”  After all, the statement may seem like a triviality: all humans are persons, and therefore all human choices are personal choices.

I suspect that what Blanco means to say is that assisted suicide should be legal because it is a free choice that only affects the person making it.  In that sense, the subject and object of the choice are both the same person: The choice begins with the person and the effect ends in the same person.

Having made that clarification, let’s examine the three arguments Blanco makes to support her position.  These arguments are counterpoints to claims allegedly made by opponents of assisted suicide.

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On the deactivation of implantable devices

Tough ethical questions

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There is an interesting thread on Twitter generated by a BBC article relating the case of a British patient who was granted the right to have her pacemaker deactivated.  Dr. Wes Fisher was interviewed in the article.

The question posed is whether this constitutes assisted suicide or not.  Dr. John Mandrola pointed to the position document of the Heart Rhythm Society regarding such cases and seems firm that pacemaker deactivation is not euthanasia.

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The brave new world of contemporary bioethics

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A few months ago, I tweeted that today’s ethicists sometimes serve the function that sophists used to fulfill in Ancient Greece: to provide moral cover for the powerful.  A “consensus statement” issued last week by a committee of philosophers and bioethicists  brings some pertinence to my comment.

These international scholars–all from prestigious Western institutions–had met in June in Geneva, Switzerland to take up the question of conscientious objection in healthcare.  Here are the first five points of their ten-point statement, published on the Practical Ethics blog of the University of Oxford philosophy department:

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The mother of all medical errors

Iatrogenesis in perspective

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A study published a couple of months ago in the BMJ  made headlines for claiming that medical errors are the third leading cause of death.  As expected, the reactions were swift and polarized.

For some, the study confirmed that the self-serving healthcare system is utterly careless about the welfare of patients.  For others, the claim was complete hogwash, based on faulty methodology designed to justify further regulatory oversight.

The two positions are not necessarily mutually exclusive.

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The pharma-fed doctor

And the foundation-fed healthcare journalist

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In his recent article “Feed Me, Pharma,” ProPublica’s Charles Ornstein has been calling attention to studies showing that the prescribing decisions of doctors are linked to the amount of money that drug companies can bestow on them, usually in the form of meals, travel expenses, tuition support to attend courses, and so on.

I find nothing surprising about that, and Ornstein need not be so scrupulous when he clarifies that “the researchers did not determine if there was a cause-and-effect relationship between payments and prescribing.” To deny that perks have a causal effect on physician behavior invites improbable considerations.

In fact, the data suggests that doctors are particularly easy to manipulate. One of the researchers interviewed by Ornstein was “surprised that it took so little of a signal and such a low value meal [to influence doctors]” A Chick-fil-A is all that it takes!

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In defense of the employed physician

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I wish to make one clarification and one prediction regarding employed physicians.

The clarification is this:  There is a common misconception that if healthcare operated under free market conditions, it would primarily be a cottage industry of solo practices and of small physician-owned hospitals.  Such operations would not develop the capabilities of large healthcare entities that we commonly associate with central planning.

In reality, however, the opposite would be the case.

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Practicing medicine for the common good

Beware of the fallacies of Spaceship Earth ethics

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In a recent New England of Medicine article titled Considering the Common Good—The View from Seven Miles Up,” Dr. Martin Shapiro tells a story that serves as a parable for a more general point:  Instead of only considering the best interests of individual patients, American physicians should adopt “a more communitarian approach to decision making” and consider “the implications of individual clinical decisions for other patients and society as a whole.”

The parable is as follows: two sick patients are aboard an airplane, each which his own physician.  The first one is terminally ill and on his way home; the second one has a grave illness but stands a small chance of surviving.  A decision to land midway must be made in flight, and it pits the interests of one against those of the other.

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