Monday, December 08, 2003

The Duty to Die

Nat Hentoff wrote another great column last week exploring the implications of the Terri Schiavo case. He has noted that when they first began their efforts, so-called "death with dignity" advocates championed the rights of patients and families to make decisions about providing or withholding treatment.

But now, what was once dubiously called the "right to die" has been transformed by some clinicians and bio-ethicists into what amounts to a "duty to die". He quotes Nancy Valko, a nurse and expert on medical ethics:
This theory [that some lives are no longer worth living] has now evolved into 'futile care' policies at hospitals in Houston, Des Moines, California and many other areas. Even Catholic hospitals are now becoming involved. . . . Thus, the 'right to die' becomes the 'duty to die,' with futile care policies offering death as the only 'choice.' . . . A poor prognosis, which can be erroneous and is seldom precise, will become a death sentence.

Not too long ago, standard medical ethics coincided with Catholic teaching in granting a "presumption in favor" of medically assisted nutrition and hydration. But, as I have researched the Terri Schiavo case, I have discovered that a revolution has been going on for the last 10-15 years. The "presumption in favor of medically assisted nutrition and hydration" found in Catholic teaching is being undermined by an alternative presumption, which is based on redefining the boundaries of what constitutes medical "treatment". Dr. Ronald Cranford was the principal medical witness for Michael Schiavo. He testified that Terri is in a PVS and will never recover. He also tesitified to that effect in the Nancy Cruzan case. But in the Cruzan case, the patient did not require a feeding tube. She could be fed by mouth. Nevertheless, he was willing to redefine even spoon-feeding a patient as "treatment". By this principle, practically anything a health-care provider does for a patient becomes "treatment".

Another attempted redefinition lies in the meaning of the term "futile". It is a commonplace of medical ethics, as well as Catholic teaching, that one is under no obligation to continue, and may indeed be obliged to withdraw, treatment that is "futile." Cindy Province, RN, MSN, Associate Director of the Bioethics Center of St. Louis, has written that a treatment has typically been considered "futile" if it has no benefit or desired effect whatsoever. Food has not been considered treatment because no one expects food to have any "direct curative effect". Furthermore, Province explains, in a patient like Terri tube feeding can be considered effective because it "clearly achieves the objective of maintaining a good nutritional state." But this kind of common-sense thinking has been rejected by much of the medical community:
...This view has been largely replaced by a more general view of the nature of nutrition as treatment... in that it has not enabled the patient to recover from his underlying condition.

Now, since food and water, redefined as treatment, do not help the patient to recover from his underlying condition, it can be labeled as "futile." Having deemed feeding the patient, by this sleight-of-hand, as "futile", it is a short step to justifying its withdrawal. By means of these redefinitions, those who want to help the sub-functional to depart this life a little more quickly have obtained an infinitely fungible, increasingly meaningless and arbitrary set of boundaries within which to do so.