Lethal Drips

     In the matter of giving fellow citizens their last gentle nudge down the chute, the Supreme Court has suddenly discovered the old principle of federalism, rebuking Attorney General Ashcroft for suggesting that the federal government has any say in whether addictive drugs can be administered for lethal purposes.  Not to worry, all ye statists; the Court will predictably lose that principle again when it is convenient to do so, for instance when a Utah or a Nebraska attempts to define for its citizens what shall and shall not constitute a legal marriage.

     But there's one thing about lethal drugging that most people don't know.  At least, I didn't know it, but someone who is very dear to me, a doggedly pro-life specialist in infectious diseases who works at a hospital in rural Pennsylvania, has opened my eyes.  And that is that euthanasia is going on behind and beneath the law, all the time, everywhere in the country.

     I don't mean pulling the plug on a respirator when somebody is dying of incurable cancer and has lost consciousness.  No, I mean direct, willed killing of people who are not dying of anything that can't be cured but who are for one reason or another inconvenient.

     A typical example goes something like this.  An old woman enters the hospital under her own power.  She can walk and talk and do many things for herself, but she is getting on in years and her mind is beginning to weaken noticeably.  She has double pneumonia, and is, naturally, in some discomfort.

     Immediately the pulmonologist prescribes a morphine drip, to ease the pain.  The problem is that morphine also shuts down the body's defenses; after a certain point it begins to put your own organs to sleep.  Now, the pneumonia is quite curable with massive doses of antibiotics.  But the pulmonologist works on the family and procures an agreement not to resuscitate should the woman slip into a coma.  Do you see the problem?  A little bit of morphine is not a big deal, but a lot of morphine will prevent the body, and the antibiotics, from effecting the cure.  Thus the desire to spare momma some pain, and the hidden desire to be relieved of having to care for momma (because, and I am not being sarcastic, momma is difficult to care for sometimes), work synergistically here.  Momma in fact does not get better.  She dies -- sad to say.  She dies, unless a pro-life doctor, loathed by almost everybody in the hospital, knocks herself out fighting the hospital lawyer and finally obtains authority to order the morphine drip curtailed.  Then she cures the woman with antibiotics and in two weeks sends her -- still ambulatory -- home with a sullen and disgruntled family.  Naturally, Momma is never told that the family had been preparing, with complacency, for a very different outcome.

     Or another example: euthanasia used to conceal medical incompetence.  An old man enters the hospital with colon cancer.  He has a colonectomy; but the surgeon botches the procedure and the intestines become infected.  In two weeks the man develops a dangerously high fever and a huge distended belly.  The family is warned that if anything is done their father will almost certainly die.  A morphine drip, with lots of antibiotics, is recommended.  But a pro-life doctor loathed by almost everybody rushes in to warn the family that if nothing is done he will certainly die, no almosts about it.  The original surgeon refuses to touch the man.  Finally she persuades an outside surgeon to open the man up -- and he discovers the problem area, under many liters of pus.

     According to my source, about 30 people are euthanized every year at this hospital, and it is by no means unusual.  Because of the vagaries of Medicare compensation, it's often a lot quicker and more profitable to let the elderly die when they're very sick and when they aren't in complete possession of their faculties -- that is, when the family would not be over-distraught should something unfortunate happen.

Comments

[A reader]

Under what circumstances is it permissible to let nature take its course? As a person whose four great grandmothers lived to an average age of 95 and who evidenced every willingness to "go on to their reward," I respectfully disagree with this analysis.

[Christopher]

My wife is a resident in a specialty that happens to deal with patients who are often in chronic pain, and indeed who are often dealing with chronic 'incurable' or 'end of life' disease, for want of a better term. Her experience thus far has been tended to the opposite extreme of Mr. Esolen's friend, in that doctors are too reluctant to prescribe the appropriate amounts of morphine (and other strong narcotics). Also, due to legal liability (or the fear of it) doctors often go to heroic efforts to 'keep a body alive', even when the family/patient (often for cynical reasons of their own - usually $$$ or lack of will to further care for their elderly 'loved one') have expressed reservations.

The other thing that comes to mind is the older gentleman with colon cancer; surgery is still a serious matter. Particularly with older patients, even if they do survive the initial procedure, they often die shortly after because their body simply will not heal and return to strength. Unfortunately, medicine is more art than science. Doctors of otherwise good will often disagree on patients such as these (particularly older patients with multiple primary and secondary diagnoses). We will have to trust Mr. Esolen's friend that the original doctor made his decision out of an ill will. Perhaps it is certain hospitals that somehow create a cultural of acceptance around "euthanasia", and my wife simply has not experienced this (Thanks be to God). One thing is for certain, we in fact do have socialized medicine in this country, and it's name is Medicare. Most folks do not have the vaguest idea how the system works, or how doctors/hospitals/pharmaceutical companies really get paid...

[little gidding]

My mother had an experience very similar to that of the botched colon operation case described here. In her case, an operation on her back took longer than the doctors expected and they had her positioned in such a way that the blood supply to part of her intestines was cut off for the entire time of the operation, killing a section of her colon, and the surgeons did not know it had happened. Afterwards the symptoms described here manifested themselves. The problem was diagnosed, and it was to be a simple operation to open her back up, take out the now-dead part of her colon and make a colostomy--except that she was already in her seventies, and she had already had two bouts of breast cancer within the previous ten years. One of the doctors was very diffident about the advisibilty of performing the operation, and some of the family also thought it might be best to refuse. My mother, too, was inclined to think that having a colostomy should, in her case, tilt the scales toward "just" letting her go. However, she was in quite a bit of pain at the time, so I didn't know how much she was really speaking "as herself," and she had some reasonable fear, not only of living with a colostomy, but also with being a burden on her children who would have to take care of her. But I reasoned that she had no evidence at the time that her cancer was back again, and so she was not terminally ill. Also, another one of the surgeons explained that the operation for the ostomy was rather simple, relatively speaking, and normally a decision to perform it was quite straightforward, so I decided it should go ahead and convinced the rest of the family to go along. My mother also accepted my judgment and so had the operation. It was a long recovery, but in fact she had almost another decade of life, with her mind clear, out of pain, living in her home, tending her garden and enjoying her grandchildren.

[Janet]

Neither do I find this scenario common. I've been in an acute care hospital setting for many years and I find a generally high respect for life among the professional staff. There certainly are botched operations (!), and families who would rather put Mom in a nursing home, but the general emphasis of the staff is to make Mom better at the least. Also, morphine (or another narcotic) is not always a bad thing when there is pain. The most likely people to be negatively affected by an appropriate dose would be those with very compromised respiratory symptoms.

[Ken Peirce, M.D.]

I do not understand the comment of "A Reader."

Christopher's comments make sense and I am glad his wife works in a hospital atmosphere that attempts to use all regular and accepted medical care to restore and prolong life with patients of any age.

I am a retired neurosurgeon in a state which has tried to pass a "death with dignity" law but fortunately failed.

I agree that there are end of life circumstances, each one to be determined by such a physician of good-will who values life and a patient who can understand the situation and voice an opinion and who has family support close by with the same good-will, where a decision is made to no longer do all heroic treatments available, and medical care should be changed to comfort care alone.

A modern problem is that many times when a patient is admitted to a hospital for acute care, the long-time family physician is no longer part of the decision-making process. The new physician is most often a specialist who may be of good-will but who in fact does not even know this individual's life situation nor has the time to learn even if they had the inclination. They depend then on a social worker and the surrounding nurses to "help" make these difficult situations. The specialist just throws his/her specialty opinion into the mix with "medi-speak" explanations and possibly scientific details and statistics attached, but really doesn't even make the final decision. If the first dramatic treatment failed, he/she loses interest quickly. If the family decides to "go all out" with what information they have been given, the doctor may do it half-heartedly or turn the patient over to another for them to give a similar "old college try."

If the situation gets as far as a "committee" or "team medicine"...we all know how well they work.

About hospice. They have provided a great and caring nursing service much of the time. However, I have had many a patient with a malignant brain tumor, who either has had all standard treatment and is now terminal or the standard treatment clearly would cause the patient great harm, who decided in the best decision-making situation described above to do no treatment and be transferred to hospice care. They went there perfectly alert and conversant, able to interact with family and friends, have no pain whatsoever, and even be out of bed, with my estimate of 3-6 weeks before they would become comatose and die. They were given morphine for their non-existent pain on the advice of hospice nurses and were dead in two or three days. Many people would call this humane care and death with dignity- euthanasia, Greek meaning good death. I call it a missed opportunity to come together as a family and say the things that really matter in life and watch a person face the death part of life with courage and hope as no other creature is able to do - this is death with dignity.

Many medical decisions are straight forward and have to be accepted, but many are increasingly complex.

My advice is always to get a physician who understands all of this, hopefully is a Christian, and is well-known by the patient or family and find the person in the family who is most knowledgeable and strong in medical knowledge or can ask intelligent questions until everyone's questions are answered satisfactorily, and then have a conference separate from the healthcare personnel, go back and ask some more questions, and then make the best possible decision, knowing that it may not be perfect, but it is the best decision all can make, in the best interests of the patient and it is what each family member of good-will would want done if they were the patient, and then make sure the medical team does it.

It takes work and unconditional love, but you can't leave such decisions up to the doctor.

[William Luse]

Neither do I understand A Reader's comment. Tony wasn't describing situations in which nature was allowed "to take its course," but rather those in which the interests of indifferent doctors and the self-indulgent concerns of "loved ones" merge into a singular course of action: the easy way out. It seems often enough the price one pays for growing old, though it doesn't need to happen very often to constitute a horror.

[Anne]

It's definitely not just old and disabled people who fall victim. It can happen to anyone when an unethical doctor botches a surgery.

This type of euthenasia was attempted on my sister in a hospital in Idaho after they badly botched up a surgery. My brother-in-law took her out of the hospital against doctors orders to another hospital, who saved her life. It was agreed on by everyone that it was a definite attempt to keep her quiet. We were all scared for her life.

It seems this type of thing happens to "everyone else". It's scary when it's your family.

[Gene Godbold]

I wrote a review of neuropeptides and their receptors recently. Before that I hadn't known that long term use of opioids (like morphine) can suppress the immune system. Even short term use can suppress histamine secretion--which is an important component in coordinating the activity of the cells of the innate immune system. But I hadn't thought of how this might affect real patients receiving treatment until reading this discussion.

[GL]

For an excellent example of calling hypocrisy to task, see Justice Thomas' dissent in Gonzales v. Oregon:

When Angel Raich and Diane Monson challenged the application of the Controlled Substances Act (CSA). . . to their purely intrastate possession of marijuana for medical use as authorized under California law, a majority of this Court (a mere seven months ago) determined that the CSA effectively invalidated California’s law because “the CSA is a comprehensive regulatory regime specifically designed to regulate which controlled substances can be utilized for medicinal purposes, and in what manner.” Gonzales v. Raich, 545 U. S. ___, ___ (2005) (slip op., at 24) (emphasis added).

* * *

Today the majority beats a hasty retreat from these conclusions. Confronted with a regulation that broadly requires all prescriptions to be issued for a “legitimate medical purpose,” . . . a regulation recognized in Raich as part of the Federal Government’s “closed . . . system” for regulating the “manner” in “which controlled substances can be utilized for medicinal purposes,”. . . the majority rejects the Attorney General’s admittedly “at least reasonable,” . . . determination that administering controlled substances to facilitate a patient’s death is not a "‘legitimate medical purpose.’"

* * *

The majority’s newfound understanding of the CSA as a statute of limited reach is all the more puzzling because it rests upon constitutional principles that the majority of the Court rejected in Raich.

* * *

I agree with limiting the applications of the CSA in a manner consistent with the principles of federalism and our constitutional structure. Raich, supra, at ___ (THOMAS, J., dissenting); cf. Whitman, supra, at 486–487 (THOMAS, J., concurring) (noting constitutional concerns with broad delegations of authority to administrative agencies). But that is now water over the dam. The relevance of such considerations was at its zenith in Raich, when we considered whether the CSA could be applied to the intrastate possession of a controlled substance consistent with the limited federal powers enumerated by the Constitution.

* * *

The Court’s reliance upon the constitutional principles that it rejected in Raich—albeit under the guise of statutory interpretation—is perplexing to say the least. Accordingly, I respectfully dissent.

The Democrats seemed awfully concerned that Samuel Alito might ignore precedent established by his predecessors. Perhaps they should be concerned about sitting justices ignoring precedents established by themselves.

[Kathy]

Christopher posted that some family members 'express reservations' about continuing care. From what we've heard, many families are blunter than that. My father-in-law is in a nursing home, and when he was in the sub-acute unit ($$$$), the head nurse told my husband that many families, when Medicare would no longer pay, just tell the nurses to 'let them die', because they don't want the patients estate depleted by costly nursing home bills. Apparently, this is very common.