Considering that approximately 25% of older Americans die in Intensive Care Units (ICUs), (Angus D et al, Crit Care Med 2004;32:638-43) it is imperative that physicians consider End-of-Life practices from divergent secular and faith-based approaches. While not intended as a full paper on the subject, I would like to offer some brief thoughts on modern medicine’s approach to end-of-life and palliative care that were prompted by a heated discussion in medical circles about the “appropriateness” of physicians’ active participation in hastening the death of a dying patient (i.e., physician assisted death). As a practicing intensivist (ICU physician) and a Catholic, my opinions are based on the teachings of the church (Evangelium Vitae, JP II) and my anecdotal experience in caring for thousands of dying patients. I would preface this by saying that I consider myself a student (not a teacher) of this masterful moment in life, the transition from Earthly life into death and the hereafter. That is to say, my comments are opinion and subject to your edification.
In a recent publication of the U.S. Society of Critical Care Medicine’s journal, a leader in critical care wrote the following: “Our collective repudiation of physician-assisted death, in all its forms, has complex origins that are not necessarily rational. If great care is taken to ensure that a request for physician-assisted death is persistent despite exhaustion of all available therapeutic modalities, then an argument can be made that our rejection constrains unnecessarily the liberty of a small number of patients.” (Manthous C, Crit Care Med 2009; 37:1206 –1209). In this article, the author presented a very carefully posited argument asking ICU physicians to consider physician-assisted death openly and to raise concern about the American College of Physicians’ and the American Medical Association’s position statements that oppose physician-assisted death (and physician-assisted suicide).
By way of background, the reader should know that a recent European Intensive Care Units Study (ETHICUS) on End-of-Life practices reported that physicians intended to therapeutically expedite death in almost 1 in 5 patients whose life support therapies (e.g., mechanical ventilation) were being withdrawn. This process was referred to by ETHICUS as SDP for “shortening the death process.” Many physicians, and also theologians such as John Paul II, not only accept but endorse the principle of ‘double effect,’ which states that there is no harm or sinfulness when well-intended medications are used to achieve comfort but happen also as a ‘double effect’ to accelerate death. The clinician’s challenge, then, is striking the balance called the ‘bright line” that separates permissible palliative care from SDP, which is prohibited in most of the world. Despite prohibitions, some ETHICUS respondents secretly ignored the bright line with intent not just to reduce suffering but also to hasten death. Physician-assisted death, physician-assisted suicide, or euthanasia are legal at this time in Switzerland, Beligum, the Netherlands, and in 3 states including Oregon, Washington, and Montana
Considering the conflicting stances of major religious, medical, and societal organizations, it is not surprising how much confusion arises on a daily basis when these situations play out in hospital rooms and family discussions. Thus, I took interest in this recent article by Manthous and thought it prudent to address four points:
(1) Critical care has made great progress in our attempts to care for patients compassionately and attentively when their stated preferences, aligned with a futile prognosis, dictate withdrawal of life support in accord with our respect for their inherent dignity. [Along those lines, it is worthwhile pointing out that the process of ‘withdrawal of support” (i.e., removing technology such as life-support devices for lungs or kidneys that are felt in a particular patient’s situation to be prolonging death rather than saving life) should not be referred to as “withdrawal of care,” a common but unfortunate phrase used by medical and non-medical parties during End-of-Life conversations.] The Catholic Church condones the appropriateness of switching from “cure to comfort” in such situations. Those circumstances are very different, however, from the entire premise of and arguments for physician-assisted death. The article by Manthous, in its discussion of religious prohibitions, glances by the actual prohibitions of the Ten Commandments and the Koran, which say, for example, that we “shall not kill.” Instead, a focus is placed on the fact that these religious documents do not say anything explicit about assisted suicide. This reminds me of a day that I specifically told my children not to eat any cookies before dinner. I pointed to a cookie jar and commanded, “Do not even take the top off of that jar.” Thirty minutes later, I found them munching on cookies, at which time they explained to me that they had taken these cookies from another cookie jar that I had not designated off-limits. Rather than looking for a loophole, perhaps we all should focus back on the Hippocratic Oath, which all physicians take at the time they are gifted the privilege of practicing medicine: “…I will neither give a deadly drug to anybody who asks for it, nor will I make a suggestion to this effect.”
(2) Perhaps the most under-appreciated component that is rarely considered in medical writings, which I have come to believe as the cardinal danger to both patients and families from physician-assisted death, is the elimination of the ‘refiners fire’ that is spoken of in Malachi and by nearly all Saints in their mystical writings. Who are we to know the purpose of and the benefits gained by an individual person’s dying process? I am commonly told over the course of my patients’ deaths that beautiful events unfold within both patients and families regarding relationships, resolution of long-standing conflicts, understanding of life and one’s purpose. I have been taught on many occasions by both patients and families as they describe how thankful they are for having lived through and fully experienced the death process. While we must definitely relieve suffering such as pain and dyspnea, intentionally causing death may deprive or cheat the patient out of the unexpected blessings that often occur during the last stages of disease. While I would not self-impose my beliefs regarding this point on patients and families, it is something that needs to be considered as an unquantifiable but very real potential downside of a process whereby physicians are adjudicating these decisions individually.
(3) Untreated or inadequately treated depression, while already a focus of current laws allowing for physician-assisted death, is clearly a source of potential error in complying with a patient’s request for administration of fatal drugs or assisted death via any means. The following poignant message written to me recently speaks volumes on this topic: “When I am mentally healthy, the thought of suicide is horrifying to me. It is beyond my understanding that my brain could lie so effectively to me during times of mental and physical illness. It is apparent, however, that given enough untreated physical pain and suffering, my brain becomes diseased and thinks that self-destruction is the only viable option. I know you would stop me from shooting myself or jumping off a bridge if I had the idea that my life was of no worth.” All means of “assisting” a patient’s choice of death—whether by lethal injection, carbon monoxide, or jumping off a bridge—end in precisely the same result, which is the killing of the person. Would any of us help a person to the guard rail of a bridge to end his/her life via that means? If not, why not?
(4) Lastly, secular arguments for hastening death often hinge on the premise that physician-assisted death may be tolerated because there is evidence that society is already moving towards acceptance of addressing decisions regarding physician-assisted death on an individual level. The dangers and errors of such thinking are evident when one considers the crucial fact that the cornerstone of public trust in the medical profession is that physicians have 100% incentive to benefit patients and 0% incentive to harm them. Allowing individual decisions about intentionally causing death moves us not-so-subtly from our historic course and directly into a culture of death, as it was referred so often by Pope JP II. This path is in stark opposition to our role as leaders in building a culture of life. The culture of life, which must be our aim in medicine, certainly includes facilitation of a comfortable dying process for dying patients as part of the continuum of life, but it should never include participation in intentional physician-assisted death.
In conclusion, those practicing critical care medicine may soon find themselves increasingly on the front lines of the culture wars between a traditional viewpoint that values the preservation of life and societal policies that do not. Difficult decisions will be required of many medical professionals, sometimes with personal as well as moral costs. Let us pray for the strength and perseverance to run the race faithfully and to give witness to the virtues of faith, hope, and charity in administering final care for our patients. As JP II wrote in the Church’s Declaration on Euthanasia (ref: Sacred Congregation for the Doctrine of the Faith – Declaration on Euthanasia, Vatican, May 5, 1980, URL http://www.euthanasia.com/vatican.html), those in healthcare should strive “to neglect no means of making all their skill available to the sick and the dying; but they should also remember how much more necessary it is to provide them with the comfort of boundless kindness and heartfelt charity. Such service to people is also service to Christ the Lord, who said: ‘As you did it to one of the least of these my brethren, you did it to me’ (Mt. 25:40).
Wesley Ely, MD, MPH
Nashville Guild of the Catholic Medical Association