Centerfield

I agree. I don't think that it is necessairly a dangerous slope. With the medical advances that have been made in the last 100 years, the time has come for us to address the true "sanctity" of keeping someone "alive" via feeding tubes, etc.

As an Oregonian, I find the attempts by the feds to continually pursue this law a bit perplexing.

I blogged on this today:

http://www.preemptivekarma.com/archives/2005/02/dr_assisted_sui.html

(You all probably won't agree with part of it...which is why I post it here...I hope you'll consider challenging me at PK)

Since the SCOTUS has already rules this a state's rights issue...I'm wondering how much of an uphill climb this will be for the AG.

Speaking as a physician assisted suicide scares me. Set aside the "legality" of suicide. By what training/expertise do physicians come to "assist" in suicide. Now terminal care/comfort care is (IMHO) very much in sync with our training.

Slippery slope is a well worn term but here's a common "slippery slope" case: "Mr. Jones has metastatic CA and now has significant new problem. He's delirious and he's clearly expressed a desire for no "heroics". His family and Power of Attorney let you know he was interested in assisted suicide. How does the physician proceed, provide only comfort care or actively hasten his death? I hate to say it but often proxy decision makers have personal reasons why a quicker death may be "better" (i.e. the burden of care, witnessing the "suffering"). This seems like a slippery slope to me.

Chris, I think a doctor's perspective is invaluable. I understand what you are driving at in being concerned about the issues that arise for a doctor. Certainly any such changes in or new interpretations of the law (regarding the controversial claim of the right of people to retain individual agency over their inevitable demise) should include addressing both the professional and spiritual views of medical professionals.

Might you be willing to say more? Surely you know what you want for yourself...maybe you've talked about it with other doctors regarding the spiritual side of what they want for themselves. What about patients? What do they seem to want? Seems to me, naively, that some people want a "soft landing," continuing to live as long as they can live with consciousness and minimum pain. Hard to define. Others want a quick exit at some equally ill-defined point when it can be judged that the game is up. Do people need to think about this more, or less?

An aside: I'm wondering what doctors are saying about the semi-cynical, possibly misleading, but very entertaining new TV drama House, about a head diagnostic doctor who is very cynical and indeed misanthropic, but portrays a singular skill at diagnosis. Have you seen it?

I think there are a couple of issues here. First, it seems to me there is a significant difference between assisted suicide and simply not performing heroic measures to keep someone alive. I think assisted suicide is a much more dubious practice, especially given what I understand is the progress that medical science has made in pain relief (although the DEA may be rolling that back). It seems to me terminal patients in great pain are susceptible to influence and we need to be quite careful in starting down this road. (Although I will say, whatever happended to federalism?)

I think it's a different issue with respect to such things as feeding tubes, etc., where the person would clearly die without assistance. I frankly find it appalling the way that Jeb Bush and others have used this issue for political purposes. It seems to me that the conservatives have made respect for life almost a fetish to the point where no one can simply die in peace. Now I am hearing conservatives tout the idea that advances in medical technology raises the prospect that persons whose brains have been essentially shut down could be cured. There is, of course, no scientific evidence of this. I think this makes a mockery out of the idea of death with dignity and also the idea that death is something that is part of life. I think what Jeb Bush did with Terri Schiavo in Florida was a disgraceful imposition of the state into a family's intimate affairs.

bk;

Might you be willing to say more? Surely you know what you want for yourself...maybe you've talked about it with other doctors regarding the spiritual side of what they want for themselves. What about patients? What do they seem to want?

Research, (unfortunately I can't cite the specific article) indicates that patients at the end of life are most concerned with pain control and abandonment. With good pain control the desire for assited suicide drops dramatically. If we got a lot better at end-of-life care the desire for assisted suicide would likely drop significantly. And by the way, we ARE getting better at end of life care (but we have a long way to go).

I know the Netherlands experience gets over cited but its still useful to point out their experience with an alarming increase in the number (based on survey) of non-consensual assisted suicide. (i.e. everyone agreed the best route was assisted suicide, they just forgt to ask the patient.) I think we need some hard barriers to prevent us from slipping "down the slope" because to often everyone else's interests, the tired family's; the frustrated physician's, and the "in the red" insurance company's interests; encourages a quick, easy and peaceful solution.

Thanks Chris, those are all really good points. Since I have a psych BA, i suspected that pain management and an emotionally supportive network would be key elements. Erickson describes the typical emotional conflict people experience in the last stages of life as one of generativity vs. despair. My sense is that suicide tends to be an act of despair. Pain and lack of the presence of friends and family are generally the physical and mental sources of despair, respectively.

The staircase or slippery slope surely leads to a "Logan's Run" scenario. [for the unfamiliar, Logan's Run was a sci-fi flick in which people all got euthanized when they turned 30]. I think we can find some middle ground where we are flexible about what happens based on each individual's needs. These need to be given pre-eminence to the exclusion of insurers and even exhausted family to some extent. IMO, it s.b. the patient's decision, whenever possible, presuming sentience/sanity.

MWS,

From what I've read isn't the Schiavo case a little more complicated then that? From what I've read, Bush got involved at the urging of Schiavo's PARENTS....who have maintained the claim that Schiavo's husband (who has power of attorny) is actualy acting in bad faith, representing his own interests and not acting according to what Terri's would be. In fact, they've also alleged that Michael Schiavo (who is living with another woman by which he has 2 children) is actualy responsible for the origional injury which placed Terri in her current condition. I have also read some stuff to support the idea that such allegations are not completely baseless. Police have been unable to make a detertermine of the cause of Terri's origional injury (which occured when the couple was alone in thier apartment). A medical examination of Terri have revealed evidence of past untreated injuries which were "consistant with battery" and the sole source for the claim that Terri would not like to be kept alive under such conditions is the uncorroborated testimony of Terri's husband, Michael, who has testified that Terri made a private verbal statement to him indicating such.

I don't know what the real truth is here. But this is NOT example of a case where a patient is being kept alive clearly against their own wishes and that of the family. This is a case where the actual wishes of the patient are very much in doubt.... the family is very much at odds with each other about whether to terminate.... and there are very serious doubts about the credibility and motives of the person who has authority to make such a decision. In other words, there is no call to lambaste Jeb Bush for intervening..... he very well could be preventing a murder from occuring.

Cenge, those are all good points except for the last. If you ask me Schiavo is already dead for all intents and purposes, regardless of whether her husband had some role in her condition or might be acting in bad faith.

I understand that some might disagree, and point out that Schiavo's parents may draw comfort from keeping what's left alive. And who knows, maybe she is alive in some meaningful sense, but I doubt it. My best guess is that Elvis has left the building.

Cengal;
In my experience there are few end-of-life cases where everything is neat and clean. The best surrogate decision makers are people who are close to you. People who are close to you likely have their interests intertwined with yours. I don't know the details of possible domestic violence in the Schiavo case but if she expressly stated she didn't want such life-prolonging measures then her surrogate decision maker, regardless of his/her moral standing, should appropriately try to have them stopped.

A couple more comments after I read an article about the latest developments of the Schiavo case

"The Schindlers know Terri wouldn't want to be killed by starvation, which is a horrifying death," said family attorney Barbara Weller.

Not true, hospice physicians and nurses's experience tell them its a painless and "easy" death

After three witnesses made statements, the court found clear and convincing evidence that Schaivo didn't want to be tube-fed

See my previous post. This is compelling evidence to pull the tube

Research, (unfortunately I can't cite the specific article) indicates that patients at the end of life are most concerned with pain control and abandonment. With good pain control the desire for assited suicide drops dramatically. If we got a lot better at end-of-life care the desire for assisted suicide would likely drop significantly. And by the way, we ARE getting better at end of life care (but we have a long way to go).

I don't think you'll find a single assisted suicide advocate that isn't in favor of better pain management. We're not there yet, obviously. Assisted suicide should remain an option for those individuals who choose it. There is no more heinous intervention by government than to keep people from making the end of life decisions of their choosing. Especially under circumstances like this.

The Oregon law has safeguards to keep things like non consensual suicides from taking place. There are very specific standards that must be met. This is the law that's being heard by SCOTUS, not the Netherlands law.

This isn't about forcing people against their will to take their lives to save money or make a doctor's patient load lighter. It's about allowing individuals to choose what they want for themselves.

Chris, I agree. However, what is to stop an unethical surrogate decision maker from completely fabricating the story of the patients consent for thier own selfish ends?

I have no problem with such decisions when it's clear that is what the patient wants. However, since the decision is irreversable and involves ending some-ones life I want a pretty high standard of evidence applied when determing what some-ones wishes are/would be.

In particular, I'm concerned (as we all should be) when such decisions are based solely upon the uncorroborated testimony of an individual who has serious credibility issues and a clear conflict of interest.

Again, for what I read of the Schaivo case... the only evidence for Terri's wishes about tube-feeding was Michaels uncorroborated claim. Now if there are other credible witnesses then that would be a different story....however that contradicts the sources I read.