Sunday, January 15, 2012

Death and ...

Many areas of medical ethics are Difficult, with a capital D. So many interests of different parties: the patient, the family (not all of whom are thinking the same way), the community, the physician or surgeon, the nurses, the institution, the insurance companies (for health insurance, life insurance, etc.). Everybody wants a say, and some have either louder or more influential voices. Every party will use every manipulation and leverage point available to them as well.

In this gator infested swamp of emotional and financial motivations, it seems clear, though, that there is one primary interest that has to be served above all others; that is the interest and clear minded decision of the individual patient.

So in our striving to support the interest of the patient, the single most important determination we have to make is this: “is it ethical?”. That simple question belies its complexity: is the action or inaction ethical? is the outcome ethical? is the impact on the patient, family, community, or other, ethical or unethical ?

I’d like to think that if we arrived at a conclusion that some action or outcome were ethical, that the conclusion also Feels right. In the real world we easily see on TV many scenarios in shows about lawyers and the legal system, that just because something is legal doesn’t make it right, nor does doing what is obviously the “right thing” is not always legal.

This way of thinking is partly due to a legacy of our friend Aristotle, who was the master of “true” or “false” but nothing in between. Something either exists or it does not; it cannot both exist and not exist. (See “On Interpretation” -- “Everything must either be or not be, whether in the present or in the future.” ) Modern developments in mathematics offer some flexibility in allowing for the probability of something to exist, but it is not really satisfying in a gut feeling sort of way -- exactly what is “50 percent probability of an apple” ? Can you touch a 50% probable apple? Can you eat it? Someone has either broken a law or not, something is right or wrong, ethical or not ethical, they are either pregnant or not, we do not leave room for “halfway”s.

So it feels more than a coincidence that I’m reading this book on “fuzzy logic”, which is a terrible name for an interesting and radical way of looking at the world. It is fundamentally Buddhist (as opposed to Aristotelian) in its outlook: “The fundamental idea of Buddhism is to pass beyond the world of opposites, a world built up by intellectual distinctions and emotional defilements.” [D.T. Suzuki, The Essence of Buddhism] The book is Bart Kosko’s “Fuzzy Thinking” (it’s in your library). I won’t be able to explain the math here, but taking the non-Aristotle view, I think one example of the “fuzzy” approach is not to have to make the decision whether there is an apple, or not an apple, nor do we have to settle for a 50 percent probability of an apple, but the simple existence of half an apple. Now THAT I can touch, and I can eat it too.

What does this have to do with ethics and ethical decisions and the DwD legislation? I think that such proposed legislation is a perfect fit for the intentional audience of fully aware, thinking people who are facing a debilitating or painful disease which will inevitably rob them of self determination or dignity, or the specter of a conscious patient kept going by a multitude of machines that we call “life sustaining treatment” (ventilators to breathe and oxygenate, pacemakers to keep the heart beating, constant adjustment of drugs to maintain a non-lethal blood pressure, on and on). With no prospect of recovering to a living situation “at home” because the removal of any of the equipment would mean death, the patient may face an extended bodily survival in pain, yet might receive no help in ending his suffering. It is for these individuals who have made up their minds to make the decisions regarding how they wish to die, that the proposed legislation is a good match.

Yet, for vulnerable populations, systems created by humans have flaws and undesirable outcomes (side effects, unintended victims, innocent bystanders), any one individual who is victimized by abuse of the system, is subject to the ultimate loss: life itself. There’s no coming back or correcting the error.

So while I feel mostly that the proposed legislation is needed and desirable, and it seems ethically correct for the intended audience, say 80 percent. But I don’t feel completely right about it, and the remaining 20 percent of me is holding back out of concern for the potential unintended casualties and innocent bystanders, particularly the vulnerable populations such as elderly who do not have strong family support or friends who advocate for them, and any cultural group who distrust people outside their family, church, synagogue, temple, or other community group -- they will either not benefit from the available choices, or could be manipulated by others to choose something not in their individual interest.

In sorting out differences between accelerating your own death and killing in general, Buddhists generally abhor any killing, although even the Dalai Lama has noted there are extreme situations that could be considered exceptions. Capital punishment that causes the death by execution of convicted criminals is legal in some states. Interestingly Oregon abolished capital punishment in 1964 only to reinstate it in 1984. How about abortion? I have no ready answer. Is it ethical to kill someone in war ? Even if you believe that killing enemy soldiers could be allowed because you would be killed yourself otherwise, there is the unavoidable civilian casualty which makes such a decision Difficult.

More narrowly: How do I feel about helping someone commit suicide? If it is his or her choice to end his or her individual suffering (not someone else’s, that’s the other person’s choice), and that person is fully aware of the impact on self and family, and others, I believe I would. There are a number of ways to commit suicide, and they all have significant consequences, both in society and financially (e.g. some insurance would cover accidental death, but not suicide)(the Massachusetts voter initiative address and would prohibit the insurance exclusions - please read the details for yourself). It is often combined in discussions on euthanasia (not your decision), sometimes deliberately to confuse the issue. Neither euthanasia, physician assisted suicide, or attempted suicide are legal in many jurisdictions, although there are exceptions such as the states of Oregon, Washington, and Montana, Switzerland, and other places. For someone who has had the appropriate mental health screening, has been confirmed to be terminally ill, has consulted with pain control specialists, is of sound mind, is facing an unbearable end, and wishes to control the time and manner of their impending death, it seems regrettable that well meaning people helping such a person die in the way they wish, at the time of their choosing, would be prosecuted as criminals. Such decisions must not be taken lightly, and we must continually be vigilant in safeguards against abuse and manipulation.

For additional information see the discussion at:  as well as the associated facebook and twitter resources.

Please understand I have no formal training in ethics, bioethics, nor philosophy, but the above topic seems to deserve an open conversation to understand how we feel.  The ballot proposition will upon us this year, in the 2012 election season.

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