Genuine compassion in dying

As I've noted in an earlier post, I strongly oppose active euthanasia and physician-assisted suicide. The medical profession should never participate in killing. Killing is the antithesis of medical care. Physicians should never participate in capital punishment, active euthanasia, or abortion, or in any act which intentionally ends a person's life.

There is a long ugly history of medical homicide, and it was (and is) invariably justified as necessary for the relief of suffering. The German T4 program comes to mind, and even Joseph Mengele's sadistic experiments at Auschwitz were justified at the time as being necessary to advance medical science.

But there is no excuse, then or now. Medical killing is killing, not medical.

What then is the ethical role of a physician in the care of people who are dying? Do people have to suffer? There is in fact much that physicians appropriately do to alleviate suffering.

First, patients have autonomy over a broad range of options for medical care. Patients may decline medical treatments in most situations, and there are many situations, such as treatment of a severe infection in the terminal states of cancer or connection to a ventilator at the end of life, when refusal of heroic medical intervention is ethically appropriate by universal agreement. There is no ethical requirement to continue heroic medical care which is merely prolonging the process of dying.

For patients who are experiencing pain or anxiety, there is an enormous armamentarium of narcotics and tranquilizers and even procedures that doctors can use to alleviate suffering. All pain of dying persons can be controlled, with competent and conscientious medical care. Hospices do this especially well, but pain can be relieved in intensive care units, on hospital wards, and at home. The euthanasia proponents' argument that physician-assisted suicide killing is necessary to alleviate pain is a lie.

Some unnecessary confusion arises when large doses of narcotics are necessary, because the narcotics may hasten death. It is agreed by all ethicists, including those who are most strongly pro-life, that administration to terminally ill people of large doses of medications necessary to alleviate pain is entirely ethical, even if the medication (unintentionally) accelerates the process of death. The intention is to alleviate pain, not to kill, and that is entirely ethical.

There are many more things that can be done to ease suffering. Most people want loved ones to be with them, and modification of visiting rules can allow the person dying in a hospital to be with their family. Spiritual support is also very helpful for many dying people.

The issue of feeding tubes is perhaps the most contentious issue we routinely face. Is it ethical to withdraw (or never place) feeding tubes for people who are terminally ill? I believe that it is not ethical to remove feeding tubes. Here's why.

There are two kinds of care provided in medicine. One kind of care is extraordinary care, which includes surgery, the administration of drugs such as antibiotics and medications to support blood pressure, and ventilatory support on a respirator.

The other kind of care is ordinary care, which is the provision of nourishment, hygiene, clothing, and shelter.

There is no obligation to provide extraordinary care if it is against the patient's wishes, or if the care is merely prolonging the dying process. Under the appropriate circumstances, it is perfectly ethical to withdraw support of a ventilator if the respiratory support is serving merely to prolong death. I have done it hundreds of times.

There is, however, an obligation to provide people with nourishment, shelter and clothing. These are basic necessities we all need. Starving someone to death is very different from discontinuing a drug or disconnecting a ventilator. Starving someone to death is morally equivalent to leaving them without clothing and shelter to freeze to death or letting them lay in their waste. It is never ethical. There are rare exceptions to this, such as when, in the last hours or days of a terminal illness, the ingestion of food and water causes pain, and it is ethical to withhold it under that circumstance.

What about the patient's autonomy? Doesn't he (or his proxy) have the right to refuse even ordinary care?

No. Patient autonomy is not unlimited. If a person comes into my office and asks me to perform an operation that they do not need, I am under no obligation to do so. In fact, performing an unnecessary operation or providing any sort of unnecessary care is unethical regardless of whether the patient requests it. Doctors are not under any obligation to do unethical things just because a patient requests it. Autonomy has limits.

Intentional death by starvation when done at the request of a patient is suicide, and no physician is under any obligation to facilitate suicide. In fact, physicians are under an obligation to prevent suicide if possible. If an 18 year-old comes into an emergency room declaring that he wants to kill himself because his girlfriend left him, doctors are under an obligation to stop him. He will be admitted to a locked psychiatric ward involuntarily to protect him, if necessary.

So what happens in real life when I am asked by a patient (or a family) to remove a feeding tube and allow a person to starve to death? I meet with the patient/family, tell them that I ethically cannot do that, and I explain why. Actually, most patients/family end up agreeing with me; it's very common that they feel pressure from the others on the medical staff to withdraw feedings, and many are relieved to hear that they don't have to.

For those patients/families who do wish to discontinue feedings, the hospital assigns another physician to write the order.

The bottom line is that there is no reason for anyone who is dying to suffer. In my professional life I have seen thousands of people die, and the vast majority have passed with dignity and in comfort. A very important part of my job is to alleviate their suffering, and provision of ordinary human needs-- nourishment, hygiene, clothing and shelter-- is part of the alleviation of suffering.

There is never any role for killing.