Slouching Towards a Duty to Die
Miguel A. Faria, Jr., M.D.
Such human weeds clog up the path....We must clear the way for a better world; we must cultivate our garden.
Margaret Sanger (1883-1966)
Founder, Planned Parenthood
An article in the New Oxford Review illustrates how " 'a right to die' easily becomes 'a duty to die' once society labels some lives as not worth living." Two case histories were briefly outlined. In one instance, Harold Cybulski, visited by his family while in his hospital bed in Ontario, Canada, wakes up from a coma just as his physicians were about to " 'pull the plug and let him go.' As the grieving family filed in, Cybulski's two-year-old grandson ran ahead crying, 'Grandpa! Grandpa!' Grandpa Cybulski opened his eyes, sat up in bed, and reached down for the little boy."
In another instance, 83-year-old Marjorie Nightbert had suffered a stroke and impaired of swallowing and possible aspiration, required a feeding tube. Her brother who had durable power of attorney instructed her doctors to withhold feedings. As Mrs. Nightbert starved, she began to request and a nurse gave her "a little milk." For this offense, the nurse was reprimanded. After fourteen days without food and water, a pro-life activist heard of the affair and brought the case before the state protective system and the attention of a judge who ruled in favor of the patient. Unfortunately, at a final hearing a different circuit judge ruled that Mrs. Nightbert was "not competent to ask for food" and ruled in favor of her brother. Mrs. Nightbert, unlike Grandpa Cybulski, died after another torturing two weeks of starvation.(1)
And yet, mounting stories such as these, article after article, in the medical literature have subtly and not-so-subtly extolled the virtues of utilitarian (collectivist) ethics in its various incarnations, e.g., population-based medicine,(2) shared ethics,(3) futility of care,(4) distributive ethics,(5,6) and the like. All of these proposals seek to submerge the heretofore supremacy of the individual-based ethics of Hippocrates for a collectivist (authoritarian) ethic in which the physician is no longer beholden to his individual patients, but to the greater, collective good of society. This is necessary, we are told, because physicians must participate in the allocation of scarce and finite health resources (i.e., rationing). And if we have learned anything from recent history, particularly these closing days of the 20th century, it is that death is the ultimate and most efficient form of rationing.(7)
Increasingly, physicians and hospitals are being pressured to ration health care for the elderly and the seriously ill. And private insurers and managed care companies following the lead of government agencies are participating in the "rational" allocation of resources. In New York, administrators at Calvary Hospital, which administers a hospice run by the Dominican Sisters of Hawthorne for terminal cancer patients, received a notice from third party payers that insurance payments would be terminated if patients "live beyond expectations."(1)
The New Oxford Review article also quoted the Wichita Eagle that reported: People in the United States' hospice programs are not dying fast enough to satisfy federal government auditors. Washington is conducting special reviews of hospice records and calling for repayment of money spent under Medicare for patients who lived beyond the expected six months after they had enrolled for hospice care....A dozen hospice programs have been notified by the Inspector General's office of the Dept. of Health and Human Services that they improperly spend $83 million caring for people who lived more than 210 days after enrolling for hospice care.(1)
And yet, physicians serving on ethics committees in various specialties have been coaxed, persuaded, or pushed to legitimize medical care rationing under the concept of the duty to die --- in the name of the proper or rational allocation of finite resources or veiled in more euphemistic terms such as "futile care" or "end-of-life" care initiatives, leading to the same ends.
Last year, a colleague who served on the medical ethics committee of his internal medicine subspecialty group asked me to comment on guidelines written on the initiation, continuation, and withdrawal of intensive care. I found that the material he sent me led subtly from the rational allocation of resources to euthanasia. I warned him against participating in what I perceived to be a potential societal trend in which physicians were becoming instruments to carry out a social agenda leading to the de facto rationing of medical care and deciding God-like who lives and who dies. And indeed, some ethicists, such as Dr. John Hardwick of East Tennessee State University, have dropped all pretenses about these proposals and had gone ahead enthusiastically and approvingly and called this issue an agenda leading up to "a duty to die."
After reading the "Ethical and Moral Guidelines for the Initiation, Continuation, and Withdrawal of Intensive Care of the ACCP/SCCM Consensus Panel," and responding to their call for input from members, Dr. Jerome C. Arnett, Jr., an AAPS physician and Medical Sentinel editorial board member, wrote to Dr. Alan Goldberg, president of ACCP (June 4, 1999), expressing his concerns: "The recent changes in our professional ethics undermine our ability to care for our patients. It must be addressed not only by individual physicians, but also by those organized groups which represent us." Dr. John G. Weg, chair of the ACCP Ethics Committee, responded for Dr. Goldberg. He wrote that the Consensus Panel, in an article in Chest, "affirms our role as the patient's advocate and specifically deplores ending life 'on grounds of the need for distributive justice (use of funds saved by very expensive life support for one individual to improve the health care of others) or more blatantly offensive, to reduce health care costs' "(8)
Unfortunately, Dr. Weg's statement contending the doctor should be the patient's advocate flies in the face of those points underscored by the ACCP/SCCM Consensus Panel. Take for instance the question asked in point #8 of the decision-making capacity (DMC): "Is it better not to institute intensive care for a patient who is likely to die or to instead initiate and then withdraw care when its futility is established?ª(9)
The fact is that just posing such a question even in such subtle terms, raises the point of whether Hippocrates' ethics are still relevant or whether the Oath and tradition of Hippocrates should be replaced with the collectivist, ethics of population-based medicine.
Interestingly, Dr. Leo Alexander, an eminent psychiatrist and Chief U.S. Medical Consultant at the Nuremberg War Crimes Trials, in his classic 1949 New England Journal of Medicine article described how German physicians became willing accomplices with the Nazis in Ktenology, "the science of killing." This was done, we learn, for the good of German society and the improvement of "the health of the German nation."(10) And in this light, Dr. Alexander addresses the critical question: "If only those whose treatment is worthwhile in terms of prognosis are to be treated, what about the other ones? The doubtful patients are the ones whose recovery appears unlikely, but frequently if treated energetically, they surprise the best prognosticators." Once the "rational allocation of scarce and finite resources" enters the decision-making process in the doctor's role as physician, the next logical step is: "Is it worthwhile to do this or that for this type of patient?"(10)
Dr. Weg quotes Dr. Arnett the ACCP/SCCM "Consensus" Panel of 1990 (The Chest Foundation, http://www.chestnet.org): "We must not allow the difficulties of moral decisions at the bedside to divert us from the problem of macro-allocation at a national level. Only by being effective at the national level and by making changes in the structure and financing of health care can we prevent or avoid the occurrence of difficult moral choices at the bedside." Although Dr. Weg's quotation of the panel's statement is ameliorated by his mentioning their call for physician's role as patient advocate, their remarks are only illusory. For in the same breath the panel states, "But a physician may have to act under reasonable restraints imposed by society."(9) Likewise, Dr. Weg mentioning the ACCP's stated position about the "physician-patient covenant" and the "primacy of benefit for the patient" may be hollow and, unfortunately, subject to the transformation of medical ethics to fit the times.
Physicians must place the patients' interests above the cost considerations of third party payers or their own monetary benefit. Likewise, physicians must place the interest of their individual patients above that of the collective be that the health care network, or some "greater good" of society. To do otherwise is the first step down the slippery slope of euthanasia --- rationing by death.
Under the utilitarian ethics of rational allocation of resources and the "benefit of society," Hitler issued his first order for euthanasia in Germany on September 1, 1939. Yet, the road to active euthanasia had been paved before the Nazis came to power in Germany. German physicians in the Weimar Republic, as early as 1931, had openly held discussions about the sterilization of undesirables and euthanasia of the chronically mentally ill. So when the Nazis came to power, groups with humanitarian sounding names were set up for "health" programs under deceptively euphemistic terms.(11) And so, even before the Final Solution of the Holocaust was officially implemented, 275,000 German citizens had been put to death. Thus, Dr. Alexander wrote "from small beginnings" the values of an entire society may be subverted, and "it is the first seemingly innocent step away from principle that frequently decides a life of crime. Corrosion begins in microscopic proportions."(10)
The move to transmute our traditional, individual-based ethics of Hippocrates
into the utilitarian ethics and the rational allocation of resources is
the first step down the slippery slope of determining who lives and who
dies --- rationing by death.
1. Collison J. Just a human weed? 'Grandpa! Grandpa!' New Oxford Review,
April 1999, pp. 23-25.
2. Population-based ethics. AAPS News 1999;55(7):1.
3. Kirn TF. Tavistock Group Proposal - 'Shared ethics' for all providers, a Quixotic quest. Internal Medicine News, March 1, 1999, p. 5.
4. Bay Area Network of Ethics Committee (BANEC). Conflict resolution guidelines. Western Journal of Medicine, May 1999, pp. 287-292.
5. Huntoon LR. Health care and the "distributive ethic" - "national rights" vs. socialism. Medical Sentinel 1999;4(5):177-178.
6. Kassirer JP. Managing care - should we adopt a new ethic? NEJM 1998;339(6):397-398.
7. Faria MA Jr. Transformation of medical ethics through time (Part I): Medical oaths and statist controls. Medical Sentinel 1998;3(1):19-24.
8. To Live, to keep alive, to let die. Chest 1994;106:1646-1648.
9. ACCP/SCCM Consensus Panel - Ethical and Moral Guidelines for the Initiation, Continuation, and Withdrawal of Intensive Care. Chest 1990;97:949-958.
10. Faria MA Jr. Euthanasia, medical science, and the road to genocide. Medical Sentinel 1998;3(3):79-83.
11. Faria MA Jr. Slippery slope. Internal Medicine News, May 15, 1999, p. 24.
Sidebar: The AMA and "End-of-Life Care"
The AMA has launched Patient End-of-Life Care (EPEC) initiative, intended to reach all practicing physicians throughout the country within the next two years. An AMA press release on June 15, 1998 expounds: "For decades the medical profession has focused on the growth of medical technology as a means to preserving and extending life, with death being viewed as the ultimate enemy" And if physicians feel they do not have enough expertise in alleviating the pain and suffering of dying patients: "Through the EPEC Project, the AMA is committed to equipping the physicians of America with the knowledge and skills necessary to ensure that dying patients are comfortable and that their remaining life has value and dignity"
Among the issues to be addressed by this program, we learn the physician-trainees will be: "Conducting a basic patient assessment in end-of-life care; Managing imminent dying and bereavement; Handling prognostic uncertainty; Approaching futility situations; and Responding to requests for physician-assisted suicide."
Andrew Schlafly, General Counsel for AAPS, commented: "This issue of physician-assisted suicide could ruin the medical profession...The AMA is headed towards supporting it, although covertly at first."
In a unanimous decision, the U.S. Supreme Court ruled the Constitution does not guarantee a right to physician-assisted suicide --- Vacco v. Quill (1997). Nevertheless, in another ruling, it stated that individual states must decide their individual course of actions as they continue a "serious thoughtful examination of the issue" --- Washington v. Glucksberg (1997). Thus, the door remains "ajar" as far as further court rulings in the uncertain future of the 21st century.
As readers of The New American are aware, in 1993, in his book, Setting Limits, medical ethicist Dr. Daniel Callahan, one of the most prominent advocates of the "limits of lifespan" philosophy wrote, "the place of the elderly in our society is a communal, not only an individual question." Then, in an op-ed column published in the October 4, 1993 issue of Newsweek, Dr. Callahan wrote, "Any serious health care reform efforts should rethink the efforts of medical progress...It should affect openly the need for rationing, not just as a way of controlling costs, but also as a symbol, as a need to curb our insatiable appetite for improved health care and longer lives."
More recently, the March/April 1997 issue of The Hastings Center Report, a journal covering medical ethics which, incidentally, is edited by Dr. Callahan, contains an essay by Dr. John Hardwick of East Tennessee State University entitled, "Is There A Duty to Die?" Dr. Hardwick writes, "Modern medicine and an individualistic culture have seduced many [into believing] that they have a right to health care and a right to live, despite the burdens and costs to our families and society." The professor believes that we are insufficiently statist and collectivist thus creating a scarcity of allocated resources. In his view, because resources are scarce and finite, we have "a duty to die...a responsibility to end one's life in the absence of any terminal illness...a duty to die even when one would prefer to live."
Indeed, Professor Hardwick further comments: "a duty to die is more likely when you have already lived a rich and full life. You have already had a full share of the good things life offers...To have reached the age of, say 75 or 80 years without being ready to die, is itself a moral failing, the sign of a life out of touch with life's basic realities."
Dr. Faria is a consultant neurosurgeon, Adjunct Professor of Medical
History (1993-1996) at Mercer University School of Medicine, and author
of Vandals at the Gates of Medicine (Macon, Georgia, Hacienda Publishing,
Inc., 1995) and Medical Warrior: Fighting Corporate Socialized Medicine
(Macon, Georgia, Hacienda Publishing, Inc., 1997). He serves as Editor-in-Chief
of the Medical Sentinel, the official journal of the Association
of American Physicians and Surgeons (AAPS).
Originally published in the November/December 1999 issue of the Medical
Sentinel. Copyright ©1999 Association of American Physicians and Surgeons.