“Thinking about Death” was the title of my Feb. 23 blog post, and it was partly about what I am calling “death control.” Since that is such an important, and controversial, issue, I am writing again about that matter.
Death
Control is Not Euthanasia
First,
it is important to note that “death control” is not euthanasia, which is
illegal in every state in the U.S.
One page on The CompassionAndChoices.org
website (see here) states this
clearly: “Medical aid in dying is fundamentally different from euthanasia.”
Here’s why:
Euthanasia is an intentional act by which another person (not the dying person) administers the medication. In contrast, medical aid in dying requires the patient to be able to take the medication themselves and therefore always remain in control.
Thus,
if used soon enough, MAID (medical aid [or assistance] in dying) can be used by
people suffering from cancer, ALS, MS, or other progressively debilitating diseases—but
not with those suffering from acute dementia. (This latter is a very sticky
issue that I will think/write more about later.)
Death
Control is Not Suicide
The
term “physician-assisted suicide” (PAS) has long been used, and terminally ill
people who have taken means to end their lives have often been said to have
committed suicide. But increasingly, that is being seen to be a
negative/judgmental term that should be avoided.
Citing
the same CompassionAndChoices webpage, many leading medical organizations “have
all adopted policies opposing the use of the terms ‘suicide’ and ‘assisted
suicide’ to describe the medical practice of aid in dying.”
Here
are some differences between MAID and suicide (h/t to suicideinfo.ca):
**
Suicide is often carried out alone and in secrecy, leaving loved ones with devastating
grief; MAID involves decision-making informed by medical personnel and usually includes
loved ones.
**
Suicide is usually due to mental pain: distress, loss of meaning and purpose in
life, and psychological burdens considered too heavy to bear any longer; MAID
is chosen by those whose death is apparently inevitable in a matter of several
weeks or a few months because of serious physical illness.
**
Suicide is often carried out in violent ways (such as by self-inflicted gunshot);
MAID uses non-violent means provided by trained professionals.
So,
What is Death Control?
Death control means terminally ill
people having the right to choose ending their life at the time and place of
their choice—and with grace and dignity. Making such choices legal and practicable
is the purpose of these organizations:
Compassion &
Choices
Death with Dignity National
Center
Final Exit Network
Among
other things, these organizations are seeking to increase the number of states
where MAID is legal, and that is a good and important work. Several states are
considering such legislation at the present time; sadly, Missouri is not. (See this map for the situation in all states.)
Last
week there was an intriguing obituary in a New
York newspaper: “Martha Schroeder died with dignity at home on the afternoon of
February 25, 2021. She was 90 years old. Her fear of losing control to dementia
and blindness was peacefully put to rest.”
Although
there is currently a MAID bill before the New York legislature, assisted death
is not yet legal in that state. But if, and when, such legislation is enacted,
in N.Y. and states across the country, perhaps an increasing number of
obituaries will report people dying with dignity—and by MAID.
Such
death control seems to be a desirable, humane, and compassionate way to deal
with the lingering suffering of terminally ill patients and the futile expenses
of keeping people alive in spite of an extremely low quality of life.
For
all of us, death is inevitable. But since for many terminally ill people death
with dignity is something that can be controlled, why don’t we actively seek to
make that a possibility for those who desire to make that choice?
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Good blog, Leroy. If pressed, I would come down on the right of any adult to choose suicide. That could allow, perhaps, to reduce some of the more gruesome suicides. I think one could argue that we already have a kind of de facto controlled death when the terminally ill are fully drugged up against pain.
ReplyDeleteThanks for your comments, Anton.
DeleteWhen I decided to use the logo from the Last Exit organization, I wondered it that would imply approval of suicide for anyone who wanted to make that choice. Emphatically, I do not approve of suicide, for as has often been said, suicide is a permanent solution to a temporary problem.
Suicide is the second leading cause of death for people between the ages of 15 and 34. Those under 18 are not yet adults, but the number, and the recent increase, of suicides by young adults is alarming. If among other things, suicide (as I said above) is due to distress, loss of meaning and purpose in life, and psychological burdens considered too heavy to bear any longer, then family, friends, and society at large need to work to help those suffering from that distress to overcome their problems rather than to end their lives.
What you point out in your last sentence is true, I think--but that doesn't take into account the inordinate expense of keeping terminally ill people alive. (At the end of the comments section of the Feb. 23 blog post, two medical doctors wrote about that issue.)
Vern Barnet, another local Thinking Friend, sent me the following pertinent email:
ReplyDelete"The MAID term you use that we also used locally in our interfaith panel was Medical Assistance in Dying -- Folks might be interested in the video [accessible at the following link].
https://www.cres.org/programs2021.htm#210214MAID
Here are comments from Thinking Friend Truett Baker in Arizona:
ReplyDelete"Very informative and well-crafted blog about 'death control.' Enjoyed the links also.
"There is nothing honorable and dignified about suffering to death. I completed Unit 1 in Clinical-Pastoral Education at Herman Hospital in the Texas Medical Center in Houston as part of my degree requirements at Midwestern Baptist Seminary. This was the first year that seminaries made this course a part of the required curriculum.
"Part of the training including serving as a chaplain in the hospital. I will never forget Mrs. Ault, a devout Catholic, who was my first patient. She was dying of cancer and medications didn't diminish her pain. I prayed for her and tried my best to console her. She asked over and over why God was permitting this unrelenting suffering as she had trusted and worshiped Him all of her adult life. I had the good sense not to remind her that the Bible taught that suffering built character or other such glib and hollow responses. This was repeated day after day.
"In one of my supervisory sessions, I cried as I related my visits to my supervisor and explained that I couldn't go back again to her room, which always smelled of death. He reminded my that just my presence was a blessing to her and I continued to visit her until she died. That experience began my interest in 'death with dignity and compassion.' Over the years, since 1962, that experience has developed a strong conviction that voluntary, planned death, whatever it is called, should be an option for some people."
Leroy, this subject takes more than 600 words, and I appreciate you have devoted 2 blog posts to it already, and a 3rd may be in the works.
ReplyDeleteI really don’t like the label, death control, but otherwise I agree with most of what you have written. Birth Control is a world-wide problem, since climate change and over population are on a collision course, along with over extraction, over production, and over consumption. Death control, as you use the term, is really only a first world problem, it seems to me. The third world experiences death much the same as the whole world experienced it throughout history, up until modern medicine, which is largely confined to first world countries and communities.
If mortality were better recognized in first world cultures, and the priority of extending youth and middle age to the maximum were deemphasized, I think much of our dilemma about death would become moot.
Here is an example: ventilators. With our current pandemic, there has been a boom in ventilator use and production. An early goal of public health was to “flatten the curve” to relieve pressure on ICU’s and shortages of ventilators. Then, when the vaccines were approved for emergency use, elderly were the first recipients, since they were the most susceptible to hospitalization and death. The urgency to get herd immunity was/is to eliminate the spread of the virus and minimize its mutations which may have greater potency, evasiveness and infectiousness. Minimizing the need for and use of ventilators has been an underlying goal.
Just as nuclear weapons are available but we hope no one will ever use them again, so ventilators are available but we hope to minimize their use.
Are there other weapons systems we should minimize? Poison gas comes to mind. Long range artillery and aerial bombing of civilian areas comes to mind. Likewise, are there other medical procedures, bio-engineered devices, medications we should minimize? Opioids come to mind. Electro-shock therapy, unnecessary hysterectomies, unnecessary c-sections come to mind.
Now we are getting into the weeds. What about pacemakers? This is a question close to my heart, since I have been referred to a Cardio EP for determining whether I fit the criteria for a passive pacemaker.
When I reflect on the facts that I have already outlived my father’s lifespan by more than four years, and that I can be physically active each day as much as I want without the pacemaker, my intuition is to not pursue the pacemaker option. I know many friends and family members who have received pacemakers and I don’t want to question their decisions. And I am not saying I will not change my mind in the future. But it seems to me, if eventually we may choose palliative care and hospice, and will sign do-not-resuscitate orders, isn’t it logical to decline certain medical tests and procedures and devices before we get to those end-of-life decisions?
Will this solve the whole problem of death? Of course not. There are a lot of scenarios I can imagine: a young person is in a serious car wreck, or a person under 50 gets a stage 4 cancer diagnosis, or a budding athlete suffers a series of concussions But there are a lot of older folks like me who have had a full life and can decline some of the wonders of modern medicine. Will that shorten their/our lifespans? Probably. But they/we may be able to experience natural aging and a more “natural” death thereby.
Thanks for posting these thought-provoking comments, Phil. I want to respond by referring to just two of the matters you broached.
DeleteFirst, I hadn't thought about "death control" being primarily a "first world" problem, but you are probably right about that. But that is mainly the audience I am writing for. Unfortunately, I have very few Thinking Friends who are not in the "first world."
Then the matter of pacemakers: I certainly would not be in favor of a person who was terminally ill getting a pacemaker, but as I understand it, primarily it is people who are likely to live many more years with a pacemaker who have that operation. There are two such instances in my close family.
June's mother had a pacemaker/defibrillator implanted in the last decade of her life, but she enjoyed a fairly high quality of life until shortly before her death at the age of 93 in 2008. We were certainly glad to have had many good times with her after we came back to the States from Japan in 2004, and it would have been a real loss if she hadn't done what she did to extend her quite normal life during those years.
My mother's younger brother was born in 1933 and had at least two pacemakers during the last decades of his life. He lived a very "normal" and active life until shortly before his death in 2016. It would have been tragic if he had not had that extension of his life, which was much appreciated by his six children, many grandchildren, and even a few great-grandchildren who knew him before his death.
I am still in favor of death control as I have explained it above, but I certainly do not think there is any reason to refuse medical help like that received by a pacemaker in order to extend one's "normal" life, especially for the sake of one's family.
Here are substantial comments received from Kevin Heifner, a social media acquaintance for some time but now, I'm happy to say, a Thinking Friend. Kevin is a medical doctor and lives in Arkansas.
ReplyDelete"Thank you Dr. Seat for your thought-provoking commentary. I’m going to respond to several points sequentially without a lot of forethought from a position of 'practical ethics' as I see some of this as a physician.
"1. I agree with your first two main points, that death control is neither euthanasia nor suicide. You make this case well and I have nothing to add, other than to support your contention that how any term is employed may be manipulative. We see this commonly in political language and often underestimate the power of words to frame an argument, often from the outset and incorrectly. In this instance the use of the term 'suicide' is incorrect and unhelpful for a more reasoned and productive discussion.
"Not only the use of this term but our acceptance of its usage at the outset should cease. Once the narrative is framed in this manner, it makes it much more difficult to move forward. We see this commonly not only in this discussion, particularly in political matters, where the assumption made is simply accepted as fact. So that is a problem one. False statements and incorrect positions should be called out immediately or else further discussion is based on an untrue premise. I know this is not really the point of the post. But I think it is extremely important that we recognize this in all of our philosophical discussions.
"2. The main thrust of your comments is about death control. I don’t see much issue or even controversy here. Here’s why. We practice death control every single day and have throughout the era of modern medicine. I’m not trying to make a cute point here so let me give you a real world example.
"One of the most common, almost daily, scenarios that physicians face is along these lines.
"We will have an exceedingly ill person in the ICU setting who carries a prognosis which is as close to 100% fatal as human reasoning will allow. In other words this is a person that every physician on the planet recognizes stands no chance of survival. It is extremely common for us to hear comments from the family along the lines of 'Grandma said she would’ve never wanted to be kept alive by machines. She wanted to be given a reasonable chance. But do everything you can to help her. We know she’s in God’s hands and he will call her home whenever he wants.'
The problem here may be one of degree… But Grandma has long since been kept alive by machines and we are continuing to do so, against her expressed will. For some reason, and I guess it’s just what we’re made of as humans, it is difficult for families to move from the general to the particular. And to point out the obvious: without the artificial support of our magical machines and devices, God would have called Grandma home weeks before. The problem as a physician becomes when we do so much, and I think often overstep our bounds, I feel like we’re putting up hurdles for God to jump over. But God is going to always win that race.
"As to the term and concept of death control: this is actually what we do every single day in medicine. There really isn’t anything, other than perhaps codifying this in a legal format for protection of physicians, that is unique about this concept. Many of the routine things that we do now are in fact 'death control. Daily, common measures and orders we carry out in hospitals. Although I think physicians in general do a good job at attempting to extend the good life rather than prolong suffering, we can certainly do better. Allowing individual patients greater access and ability to control the outcomes of their own care, by strengthening the types of measures that we are already doing, is a very good thing.
“'Death control,' as you define it, is medically correct, empathetic, and moral."
Thanks, Dr. Heifner, for your lucid comments and for helpfully amplifying the main points of this blog article. I much appreciate you taking the time to write such beneficial comments.
DeleteI would like to say something about "Death Panels." Remember those from ACA debates a decade ago? My family felt the lack of one the last few years as my mother experienced increasing dementia that finally took her life in 2019. The lack of Death Panels came in because she had four serious trips to the hospital in those last years, and our family, especially my father, were flying blind concerning how to handle each crisis, for none of the hospitalizations were directly concerned with dementia.
ReplyDeleteMom fell and broke a leg in 2016. The doctor inserted a new metal ball into her hip joint, and attached her femur to the ball. That seemed reasonable enough. A couple of weeks into rehab, she was back in the hospital for emergency treatment of a stomach ulcer. She finally made it back home from rehab, although her dementia was noticeably worse from the anesthesia. About a year later, she fell again, and broke her hip. The doctor said there was too little bone left to fix it, but said she might recover on her own, especially since the hip broke over the metal ball joint, which would guide the healing without locking up. Then days later the rehab nurse found evidence of internal bleeding, so back she went to the hospital for the fourth time. A scan was done to see if she needed cauterizing of another ulcer. Instead the doctor found a large section of her stomach was dying, and she would need major surgery. The doctor was confident he could do the surgery, and said her death would be "gory" if surgery were not done immediately. As best I could make out what she was saying, I do not think she wanted a major intervention, but the doctor had my father at "gory death." Did I mention the lack of Death Panels? After surgery, a different doctor making rounds gave the dementia prognosis speech, but it was too late.
My mother went from rehab to Medicaid bed where a little over a year later she mercifully died. Did I mention the lack of Death Panels? Where was a dementia manager for an aged person with any admission to a hospital? Perhaps they could have helped with one other problem in her hospitalizations; she repeatedly ripped IV's from her arm. During the very first hospitalization the doctor ordered an all-night companion to make sure she did not do it again. The next time they just redid the IV, even after we told them what happened the first time. Did I mention the lack of Death Panels?
Now the doctors in hospitalizations three and four did their work as they saw it, she actually did walk again, indeed, she became the terror of the dementia unit, coming up behind wheelchair bound patients and pushing them on joy rides. She lived over a year, finally dying after a time on hospice. Thank God for hospice. Still, did I mention the lack of Death Panels?
Thanks for your comments, Craig, and for sharing your personal thoughts and feelings about your mother at the end of her life. My mother also had increasing dementia during her last years, and, perhaps later this month, I am hoping to write more about the sad situation of people suffering from acute dementia. Maybe Death Panels are what is needed in such situations. That is something I want to research and think about more, so thanks for heading me in that direction.
DeleteI was happy to receive the following comments from Dr. Fred Heifner, another new Thinking Friend who is commenting for the first time. This Dr. Heifner, whose doctor's degree is a Th.D. earned at New Orleans Baptist Theological Seminary, is the father of Dr. Kevin Heifner, the medical doctor whose comments are posted above. Fred, who is my age, still teaches at Cumberland University in Tennessee. Here are his comments:
ReplyDelete"Thanks for the provocative articles on death control. I do like the distinction you have made between the concepts of death control and euthanasia. When I have dealt with euthanasia in ethics, I have made a point to indicate that euthanasia is not limited to a single definition. Although it is often thought about singularly, there is a distinction in voluntary euthanasia, involuntary euthanasia, and nonvoluntary euthanasia. Voluntary euthanasia falls more closely to MAID, medical aid in dying. Serious consideration needs to be given to death control, dying with dignity, and MAID for some carefully defined categories. Thanks for your focus on this issue."
Thanks, Fred, for reading and commenting on this blog article about death control. I am not sure how you define the three forms of euthanasia you mentioned. When I have taught this in ethics classes I made a distinction between two forms: active euthanasia and passive euthanasia--and I will probably be making reference to that distinction when I post, perhaps later this month, about what to do about those people who suffer from acute dementia. Perhaps you can make some helpful suggestions along that line.
ReplyDeleteBro. Leroy,
ReplyDeleteAs I mentioned in a response to your first blog on this subject, Pop (and Mom) refused any kind of mechanical help to stay alive. Their only request was pain relief. Pop needed it before dying. Mom did not. In these cases there was no thought of any attempt at resuscitation. Death was a relief for them and a result of natural processes. My father-in-law died also from a natural process what his doctors called rheumatoid arthritis of the lungs. He was in good health except his lungs disappeared into scar tissue and at 65 he was deemed too old for a lung transplant. He died at 68 basically kept as comfortable as possible. I look forward to your definition of passive euthanasia.
In my own case I have had a widow maker heart blockage repaired with a stint and survived two bouts of an aggressive form of cancer. If I had not gone through the medical procedures and instead allowed the natural courses to proceed, would I have been agreeing to controlled death or committing suicide?
Your blog has raised more questions for me than I have considered before, since I have been one that considers human life almost sacred being against abortion generally, voluntary death decisions, and capital punishment. As I have said before, thanks for your writing.
Thanks for writing again, Tom, about the perennial problem of death and how to cope with it. I think your parents, whom I respected greatly, did the right thing, at their ages, requesting pain relief but refusing any kind of mechanical help to stay alive. This is closely related to what I have called passive euthanasia. While nothing was done to hasten their deaths, which would have been active euthanasia if done by others, they did nothing to delay their deaths, allowing the "natural processes" to do their thing.
DeleteAs a middle-aged man, however, I certainly think you did the right thing to have heart blockage repaired and to do whatever you did to combat cancer. At your age and station in life, you needed to do what you did to control life, which you did, instead of seeking to control death, which, fortunately, you didn't. (Did you read my good friend Phil's comments and my response above?)
I certainly am against capital punishment, for that is the state taking the lives of others. But as you have seen in these two blog articles, I am for us humans using our God-given reason to implement death control as I am for birth control--as well as for vaccines and the use of stints, cancer treatment when likely to be of great benefit, and pacemakers, etc. At this point, I don't want to get into a discussion about abortion in this regard, and I still maintain that that issue revolves around when a human embryo/fetus actually becomes a human being with inviolable worth.
I'll keep this response brief. I appreciate the sentiments in the original post and those in the comments. I feel very conflicted about this topic as a physician. On one hand, I respect each individual's autonomy to make the best decision for themselves in a terminally ill state, which may include MAID. On the other hand, there are many tools to alleviate suffering, maintain dignity in the dying process, and choose/decline medical care according to one's wishes. I hope that all patients who are offered MAID understand fully that compassionate end of life care is available through hospice.
ReplyDeleteThanks, Ky. Your viewpoint as a medical doctor and as one deeply involved in hospice care is of considerable importance, and I appreciate you sharing that viewpoint here. Certainly, there are many things that a person contemplating MAiD must consider, and knowing that "compassionate end of life care is available through hospice" is of foremost importance.
DeleteStill, depending on the nature of the terminal illness, I'm not sure that such end-of-life care can make it possible for one to have death with dignity, and that doesn't speak to the psychological demands that those final weeks/months have on the immediate family and, as you mentioned before, to the economic costs (to someone) during the final stages.