A problematic new end-of-life medical form is rapidly gaining ascendency in U.S. healthcare. It is called the “POLST” document. (In my own state of Colorado, it’s called a MOST document.) The acronym stands for Physician Orders for Life-Sustaining Treatment….
The POLST-type legislation removes the condition that a patient is terminally ill or diagnosed in a PVS before a refusal order is actionable. In other words, the new law permits any adult patient to refuse any treatment at any time for any reason in the event they lack decisional capacity; and health care professionals, directed by a doctor’s medical order, ordinarily would be (and are) required to carry out the order. Although the law for strategic purposes is rhetorically formulated as bearing upon end-of-lifemedical decisions, it sets forth no requirement that a patient’s refusal of life-support must be limited to end-of-life conditions.
This would seem to not so much be legalizing euthanasia, but instead legalizing suicide by ommission.
Patients are permitted to sign a form saying that they do not wish to be resucitated or given any intervention including antibiotics or food and water, without necessarily having a life impairing disease. They are allowed to sign, and then stop eating and drinking and not be recussitated.
Suicide is, of course, a sin (self killing). Frail individuals can also be coerced into committing suicide (or at least signing). However permitting patients to legally “force a physician to do nothing” is a moral problem, not a medical problem. The church would do better to preach to her flock rather than to government.
The article makes ridiculous assumptions. Anyone should be allowed to die when their physical body is no longer able to survive without medical assistance, so long as the person in question, desires God’s will be done. If someone doesn’t want to take his heart medicine any more, so be it. Respect the rights of individuals to make decisions regarding their medical care. For example, I think the CA POLST document (http://www.scanhealthplan.com/documents/cme/CA-POLST-form-web_english.pdf) is too wimpy in that medical personnel are given the right decide what “comfort” care is, absent explicit instructions, ie providing oxygen. If a person decides the time has come, and God has too (which is to say, the physical body in question is dying on its own), why should some else have any right to make any intervention at all, just because a third person doesn’t like some transient symptoms occurring on the way to final repose? There should be another box on the CA form in the Orders B section which should state no medical intervention whatsoever should be performed.
Senior Priest, did you read the article? I ask because it specifically makes clear that the patient is not dying. So your comment that they should be allowed to die ‘when their physical body is no longer able to survive without medical assistance’ is inappropriate. I imagine a scenario like this: a patient has Guillain-Barre syndrome. This brings paralysis and the patient can no longer swallow. Normally a stomach peg would allow food to be ingested. With intensive care the patient with this severe illness will recover, usually completely. But wait! Under the law as described here the medical and nursing staff cannot give support because the patient signed one of these declarations. No feeding or even hydration can be given because the staff would be committing a felony. The patient of course for the time being cannot speak to cancel the document. And so a person who probably wanted to live is condemned to die even although a full recovery is possible. How wise – how Christian – how moral – is that?
Brugger makes a good point. This type of document is bound to wind up in a court case someday, with some doctor’s you know what in a sling, and make some attorneys a boat load of money.
I personally believe the ethical issues raised by POLST-type legislation to be very disturbing. I agree with most of what Mr. Brugger says about it. But it is nonetheless legislation tailor made for the modern conservative philosophy that health care, like any commodity, should be regulated by the free market.
If you believe life sustaining health care is not a right, and morally can be withheld from a person who can not pay for it; you cannot logically object to POLST-type legislation. Each person must have the option of saying, Doc I would like the cancer taken out but the cost of the operation would bankrupt my family so I will have to forgo it. You further need a way to enforce your decision after you slip into incapacity.
One cannot intellectually maintain the argument it is suicide to refuse treatment that will save your life, but not murder to withhold treatment that will save the life of another.
Guillain-Barre syndrome is fatal if no intervention is performed, true. I’ve been part of the care team of a person who had it. However, if a person doesn’t want medical intervention in a case that others might make a different choice, so what? I myself would certainly want to survive a transient life-threatening condition, but others might not. I think it’s absurd that some religions forbid blood transfusions, but other people’s choices aren’t my own. The article has a very helpful link to the Compassion and Choices (formerly more lugubriously named the Hemlock Society) site, which has interesting and helpful, and what one would consider rather moderately-languaged (in theological terms, ‘nuanced’) information and forms. Whatever some people who consider themselves a moral-ethical ‘magisterium’ think, it is most certainly not suicide to allow nature to take its course. Throughout almost all human history this has been considered the will of God, and I still do.
Sorry. I didn’t answer Terry’s question. If a person signs a document which he might later regret signing, that’s unfortunate but the responsibility is still the signer’s. Life and death are important things, but they are inextricably one. However long life is extended, it’s not for very long in the scheme of things. A few years shorter or longer, that’s all. Lazarus still departed this world after Jesus raised him from the dead. We are each responsible for our choices and no one should sign such a document, ie make a decision of such magnitude, without considering the possible consequences.
A Senior Priest – I don’t know where you stand in the Anglican-Roman question. I understand the Pope has opined in the past few years that to withhold even IV fluid or enteral nutrition (given via tube) from someone (whether they desire it or not) is unethical. Someone please correct me if I am mis-stating this.
RE: “One cannot intellectually maintain the argument it is suicide to refuse treatment that will save your life, but not murder to withhold treatment that will save the life of another.”
Well of course one can “intellectually” — and rationally and consistently — maintain that it is suicide to refuse treatment but not murder to refuse to pay for life-saving treatment that other people need. The two are unconnected by the principles that make up the definition of “murder” and the definition of “suicide.”
Good grief — what are they teaching in logic these days? Under the above construction one would have to send all of one’s money to the Sudan, since it is “murder” to “withhold treatment that will save the life of another.”
Any chance at all of using just a touch of precision with language?
#8, montanan, if you ask me, in a medical situation it’s as unethical to force someone, against his will, to die who would otherwise live as it is to force someone, against his will, to live who would otherwise die.
Is it unethical to force somebody to provide the fruits of their labor to save somebody from death from a treatable condition (i.e. via taxation or by coercion -EMTALA)? Does it make a difference if the person in question does not even wish to be “saved”? What about instead of permitting that individual to send the fruits of their labor to provide food/clean water to villages in Latin America?
Having enjoyed the National Health System (despite the stories in the newspapers) before moving to the USA, I’m fervently in favor of a universal single payer health system in the US, btw, Clueless. In any advanced economy it is incumbent on those who provide medical care to try to save lives which can be saved, and want to be saved. On the other hand, as a priest I sometimes must silently endure the spectacle of family members requesting medical staff to do everything possible to save the life of a person whose death is imminent and inevitable. Many of my medical doctor friends have remarked that this behavior is really about their relatives’ fear of death trumping compassion for the dying person. The Emperor Hadrian was famously cursed by his brother-in-law (whom he executed) that Hadrian would long for death but be unable to die. This is very often the case in modern America, where death is the last forbidden subject of conversation.
“In any advanced economy it is incumbent on those who provide medical care to try to save lives which can be saved, and want to be saved. ”
Indeed. Who is supposed to pay for it? Currently our children and grandchildren who are being saddled with zero job prospects and high debt for any prospects in order to transfer “savings” to those of their “elders who can be saved, and want to be saved.”
Are those kids permitted to have any “say” regarding how much resources an “advanced economy” should transfer to the old, from the young?
Whom would Jesus indebt?
As to those “providers” again, who pays for this? Obviously not those over 65, who preferred to just run up the national credit card, instead of prepaying their debts. And when the efforts of those “providers” fail to save, who pays for that?
Right now, because the providers (in theory) CAN save they MUST save, however impossible the situation. Why does that not extend to the clergy? Churches often run food banks. Why aren’t churches REQUIRED to feed anybody who comes to them for help, regardless of their resources? I mean if a priest actually gets a salary, why doesn’t he pay the bills of folks who need help anyway? Must be GREED, right?
Right now, the deal appears to be that those in power will, WITH THE TACIT APPROVAL OF THE CLERGY, continue to enslave the young in order to buy votes from the old, and will continue to pretend that everybody who wants to be saved, CAN be saved, and if they cannot it is not because resources are limited, or that we all die anyway, but because physicians (excuse me – providers) are “greedy” and “unethical” and because the millenials and GenX are “lazy” and because “conservatives” spent all the money on wars.
Six years ago there were 20 neurosurgeons in my 300 mile radius. Now there are 4. None of them operate on brain cases, they all just do back surgery. That isn’t because folks don’t “want to be saved”. It is because first, no compensation was given (most folks with trauma don’t have insurance). Second, no protection was offered to the surgeon (excuse me “provider”) who tried to save the patient’s life, (i.e. if the outcome was bad, it wasn’t the drunk driver who caused the accident who was sued, it was the neurosurgeon). And finally, as people slowly gave up aspects of their life saving skills, those skills were lost. If you haven’t done any brain cases in a year, you will not wish to do any. Neurosurgery is NOT like riding a bicycle. Operator skills are lost. Hospital/Operating team (nurses/anesthetist/hospital/ICU back up) are lost. Then, it is no longer becomes possible for those “who provide medical care to try to save lives which can be saved, and want to be saved. ” let alone those who don’t want to be saved.
I think the clergy would do better to return to basics instead of focusing on politics.
EG. Don’t steal (even from succeding generatons).
Don’t slander (not even in a “good cause”)
Don’t encourage usury.
And finally, realize that it is Jesus who saves, not physicians, and that death is by no means the worst thing that can happen to a person.
“In any advanced economy it is incumbent on those who provide medical care to try to save lives which can be saved, and want to be saved.”
Lets try a few more variations.
“In any advanced economy it is incumbent on those who provide legal assistance to try to ensure justice for individuals who wish justice and might be able to have justice.”
“In any advanced economy it is incumbent on those who teach to try to ensure education for individuals who wish to learn and can be taught.”
“In any advanced economy it is incumbent on those who provide spiritual assistance to try to ensure salvation for individuals who wish to be saved and might be able to be saved.” (I.e. don’t whine to me about how little you are paid, why weren’t you in the prison seeing people for free, I know that you had Monday off?).
Not to mention:
“In any advanced economy it is incumbent on those who manage finance to try to ensure wealth for individuals who want to be rich, and might be able to be rich” (with a little transfusion).
Right now, in this “advanced economy” it is not even possible for those who wish to live their lives in peace to be born without being saddled with the excesses of the current generation. Possibly, we are not quite as advanced as we think we are.
As I’ve also said, elsewhere… for America to survive 1. the Federal govt should have a budget (which it has not had since BHO took office), 2. the Fed govt’s expenditures must be cut by 30%, and 3. total revenues must rise by 20%.
America’s share of the true debt (including Medicare and SSI) is over 70 trillion. The interest on the national debt (not principal) was 1/2 trillion and rapidly rising. Interest payments ALONE are anticipated to consume more than 1/2 of all income taxes by 2020. The GNP is 14 trillion and falling. This is not sustainable.
The federal government’s expenditures will need to be cut by some 60%, revenuses will need to rise by 30% AND there will need to be serious cuts in Medicare and SSI including delay of pensions to meet life expectancy (somewhere over 70 years would do it) together with overt rationing of medical care.
There is no “easy” way of doing this. However it will come, and is already coming. Right now, it is simply coming by allowing hospitals to go out of business. Some 20% have closed in the past 10 years, another 20% are expected to close in the next 5 years. When hospitals close, (or specialists simply stop seeing certain types of patients) those patients get to drive several hundred miles and to wait several months to get to the next hospital. Patients need to make that drive regardless of the merits of their individual case. The 20 year old patient who has renal failure due to a temporary problem (trauma to the ureters for example) is in the same boat with the 60 year old with multiorgan failure, and the 5 year old with an immune attack from a viral illness that he is likely to recover from. However it is “unethical” to not pay for 20 years of dialysis for the person with multiorgan failure, while paying for the 3-6 months of dialysis for the two who are expected to recover. Thus, the dialysis center closes for lack of funds, and people are told to drive 300 miles round trip to the next nearest dialysis center. If you need to drive 300 miles round trip 3 days a week to get a dialysis treatment, will you go? Some people will, however the person with multi organ failure probably wont be one of them. The system saves money, and the end result is the same, except for the expense/time off of work required for the parents of the 5 year old, and for the 20 year old. That is rationing. Rationing already happens. Rationing is inevitable when resources are scarce. Rationing does not, however, need to happen irrationally. We just insist on doing it that way.
#9 logic never seems to be much of an issue for you. You simply revise the facts to support your conclusion or attack the person making the point, or both. There was no discussion of payment by another person, or payment by government in anything I said. The premise of the author was that POLST type legislation enables people to commit suicide by refusing life saving treatment.
In my fact patter there were only two entities. A person who wanted and needed life saving health care, but who could not afford it without leaving his family destitute; and a person or entity capable of providing the life saving health care but who wanted a price that would leave the patient and his family destitute.
I contend you cannot logically argue the decision of the patient to to forgo treatment and die so that his family will not be forced to live in poverty is suicide, and simultaneously argue the decision of the health care provider to refuse to provide the treatment unless payment is forth coming is not murder. Each side has reduced the patent’s life to a monetary value and has concluded the cost of providing life saving health care exceeds that value.
If the free market is to reign in health care the equation must balance. Either it is neither suicide nor murder; or it is suicide and murder.
POLST-type legislation goes hand in hand with a free market health care delivery system. If you believe life saving health care can be morally withheld from someone who cannot pay for it, you surely cannot object to POLST-type legislation. In a free market system a POLST type document would become the primary instrument by which a person with resources would set the amount he is willing to pay to live. Otherwise the government would be able to force him to pay more than his life was worth.
Clueless I do not disagree with you. We should not expect only doctors to give up their wealth for the lives of others. If society will not pay for the health care of those who cannot pay, we must allow doctors to turn them away when they cannot pay.
“Clueless I do not disagree with you. We should not expect only doctors to give up their wealth for the lives of others. If society will not pay for the health care of those who cannot pay, we must allow doctors to turn them away when they cannot pay. ”
Or we could make it easier for physicians to engage in charity. For example if we got rid of all physician payments for both medicaid/medicare/charity, but instituted a law saying that physicians who saw at least 20% of these patients became ipsofacto agents of the state with governmental immunity from malpractice suits (for their entire practice) I think most docs would take up the offer. Gone would be the (subcost) payment, but gone would be the billing expenses, paperwork, malpractice headaches and litigation.
Not that this would save much money, since the physician payment portion is only 10% of medicare/medicaid costs. But it would help (and for free).
A similar offer could be made to hospitals, but this would be insufficient to cover costs since hospital costs would include nurse/tech/administrator salaries together with drugs, ivs, etc. Therefore, rationing would still be necessary. Either by letting the hospitals close, or by “choosing the slain”.
RE: “#9 logic never seems to be much of an issue for you. . . . ”
Heh — by *your* definition of “logic” you’re precisely right.
RE: “I contend you cannot logically argue the decision of the patient to to forgo treatment and die so that his family will not be forced to live in poverty is suicide, and simultaneously argue the decision of the health care provider to refuse to provide the treatment unless payment is forth coming is not murder.”
Yes — you certainly contended that. And I pointed out that your contention that it is “murder” to “withold treatment that will save the life of another” is unconnected to 1) the actual definition of suicide [and indeed the actual standard definition of “murder” but let that pass since Mitchell has made up his own definition of “murder” and trotted it out for all to see] and 2) not able to be consistently held across contexts.
You’ve responded by simply making it “murder” within *one context* — which demonstrates that you do recognize the problem with your original principle and are now attempting to backtrack only without saying so.
Nice.
#19 I have backed off on nothing, and I obviously did not define murder. As usual you seek to win your arguments by attacking your opponent rather than addressing the issues.
The discussion was of the nature of suicide. Suicide can only be defined in relationship to murder (homicide) as both are the same evil, the unjustified taking of human life. Only the perpetrator of the evil changes.
In the example both sides did exactly the same thing. They refused to save a human life. Both sides used the same criteria to make that decision. Monetary cost. We as Christians and Americans (perhaps a divergence of conclusions between the set and the subset) must decide for ourselves whether we define what the patient did as suicide and what the health care provider did as murder. I stand by my belief that logically they are either suicide and murder or not suicide and not murder. I think the answer turns on whether you believe taking life and allowing someone to die when you could prevent it is the same thing. In this case no one did anything to cause someone to die. They simply elected not to prevent it.
Can this very limited debate be expanded to a macro level involving entire nations. Yes, but in that case we must add into the debate the issue of ability. In the debate at hand ability was not in issue. The patient could save himself by sacrificing his family and the health care provider could save the patient by sacrificing his money.
“In the debate at hand ability was not in issue. The patient could save himself by sacrificing his family and the health care provider could save the patient by sacrificing his money. ”
Actually the “provider” could save the patient by sacrificing money, time, health and family. Part of the reason our numbers of neurosurgeons have dropped is that in the past six months, one has committed suicide, one dropped dead of a massive heart attack right before entering the OR (he was 44), one had his hospital priviledges revoked because he was busted driving on amphetamines (which he was taking because he couldn’t stay awake without them, and work the hours he was forced to work). A fourth’s son just committed suicide and his dad is planning to retire early (in his late fifties) in order to provide more time to his surviving children. If he does, we will have only 3 neurosurgeons where previously there were 20.
All of these individuals worked more than 100 hours a week.
But of course, Mitchell, it’s just about money. THey are all just greedy, to not put their patient’s above their own needs. What right have they to have any needs. It is murder to consider your own needs and those of your family
As I recall, Mitchell is a lawyer. He must be aware that there are numerous miscarriages of justice because so many individuals facing criminal and civil charges are unable to have access to legal assistance. Or at least they can only do so by “sacrificing their family” (eg selling their homes, taking their kids out of school etc).
So how is it that Mitchell is not working a minimum of 80 hours a week performing Legal Aid for free? Must be greed, right? A price has been placed on a man’s freedom. Since the individual could not afford the price, and Mitchell did not see fit to pay the price for that individual, then Mitchell must be guity of slavery.
Mitchell, presumably must believe that enslaving somebody, and allowing somebody to be enslaved (have his freedom unjustly taken away) when you could prevent it is the same thing. In this case no one did anything to cause someone to be enslaved. They simply elected not to prevent it.
We could also discuss the numerous kids who grow up ignorant and unable to complete high school due to the lack of tutors. Where are the hordes of good Christians, working 80 hours a week or more to instruct these kids for free? More greed, I suppose…
Clueless
I appreciate your frustration. I think I said earlier, that I believe we cannot leave the care of those who cannot afford care to doctors alone. I believe doctors should be fairly compensated for their services. I do not think it is an issue of greed, and you are correct, reduced money equates to reduced lifestyle. Doctors alone do not have the ability to provide the care needed by all those who cannot pay for care. Especially if you expand beyond the borders of the first world.
In my defense the nature of my business results in a lot of free legal work. Last year I provided about 400 hours of free services to people who could not pay, and when asked I provide legal services to my church and a couple of other charities at my cost.
You are a off base however on the issue of legal services for indigent criminal defendants. In 1963 the US Supreme Court ruled that indigent criminal defendants must be provided with legal counsel in any case were deprivation of liberty is a possibility. While I cannot speak for all states, my state provides about half of that representation through the public defender system. i.e socialized legal services. The balance is provided by the private bar. If the public defender system is overwhelmed or conflicted out in a case, the government requires lawyers in private practice to undertake the indigent’s defense. If it is death penalty case the court appoints a lawyer with death penalty experience and another lawyer to help him. This is done largely for no compensation. I believe lawyers are the only profession the government compels to provide services to indigents.
I am called upon to represent indigents in criminal and family court. Since I am wholly incapable of preparing a proper legal defense in a criminal matter, I pay from my pocket for another attorney to do that for me.
“I believe lawyers are the only profession the government compels to provide services to indigents.”
I wasn’t aware that lawyers are required to take on an indigent’s defense. However, it should be noted, that with EMTALA all specialist who see outpatients for a hospital, are required to provide the same services to indigent inpatients admitted through the ER. When I was in private practice (as a neurologist, not a neurosurgeon), indigent inpatients represented about 20% of my caseload, with (subcost) medicaid/medicare representing another 60 percent. I paid for practice expenses and my salary with the remaining 20 percent of my practice (and worked over 100 hours/week).