Category: Philosophy of Medicine

Death, Dying, Euthanasia and Physicians

shawnwhatley.comDying people show up each day in my emergency department.  Young and old take their lives, or have life taken from them.

Death is everywhere, if we look.

Recently, death and dying holds media attention:  legislation in Quebec, Dr. Low’s passing, and even Sue Rodriguez.

Aside from places like the Netherlands, physicians have almost no experience with euthanasia or assisted suicide.

Doctors know end of life care, not euthanasia; palliative care, not physician assisted suicide.

Dr. Wooder, president of the OMA, was wise to focus on what physicians know best, when he decided to focus on end of life care this year.

Emotional stories and tragic personal experiences fill most discussions about death.  We wade over our heads into content and debate unfamiliar beyond anecdotes.

When we don’t know, we tell stories.

We need to start with definitions.  As President Clinton said, “It depends on what the meaning of the word ‘is’ is…”

Six terms you need to know:

Euthanasia:  few agree on a definition, but most say that “euthanasia involves doctors making decisions which have the effect of shortening a patient’s life and that these decisions are based on the belief that the patient would be better off dead” (Keown, 2005).

Active, physician-assisted suicide (PAS):  you end your life.  You push the button, take the drug, or start the infusion.  Your doctor gets you started with supplies and instructions, but you end it.  If PAS doesn’t go far enough, your doctor might have to perform voluntary, active euthanasia.

Voluntary, active euthanasia (VAE): you let your doctor end your life.  You give consent; your doctor pushes the button…

Non-voluntary, active euthanasia (NVAE): your doctor ends your life when you are not competent to give consent due to severe disease, dementia, etc.

Involuntary, active euthanasia (IVAE):  your doctor ends your life against your wishes.

Passive euthanasia (PE):  PE involves withholding or withdrawing of medical treatment by a doctor with intent to kill.  Defining what includes “medical treatment” is tough and needs its own blog post.  Are tube feeds medical?

Finally, we need to grapple with: Intent – aiming to have something occur, and Foresight – being aware that something might occur.

Most of this post came from two great books:

Euthanasia, Ethics and Public Policy: An Argument Against Legislation by John Keown

Rethinking Life and Death: The Collapse of Our Traditional Ethics by Peter Singer

These books look from opposite ends of life.  Keown writes clear, careful prose and offers an in-depth review of the Danish experience of euthanasia.  Singers writes engaging, thoughtful philosophy about difficult cases in support of unpopular ideas like involuntary euthanasia.  On the back of Singer’s book, the Washington Post blurb says:

Far from pointing a way out of today’s moral dilemmas, Singer’s book is a road map for driving down the darkest of moral blind alleys…Read it to remind yourself of the enormities of which putatively civilized being are capable.

Keown reminds us that, “Hard cases make bad law“.  So far, most of the news serves up ‘hard cases’.  We need to move past these and start discussing how most people die and what we are doing to improve that process.  

What do you think?  Can we have an adult discussion about death?  Should we let everyone do whatever they want with their lives and how they end?

Physician Autonomy: an Historic Relic?

Physician autonomy was sacrosanct; even enshrined in the Warsaw declaration.  

Lately, it’s negotiable.

Ballooning costs of care and medico-legal risk make more doctors call for clinical practice guidelines (CPGs) to protect them, simplify complex decision making, and justify not ordering unnecessary tests and treatment when patients demand them.

Looking for something solid on which to make clinical decisions, physicians elevate evidence based medicine as a weapon against bureaucrats’ cost cutting and so-called expert opinions.  But, the weapon also slices off physician autonomy.

Battle-lines form, with cost on one side, autonomy on the other, and evidence held hostage by whoever can show it best supports them.  Patient centeredness, another hostage, usually hangs from physician banners.  National associations weigh in; things get nasty.

When physicians call for CPGs, are they calling for limits to their autonomy? 

Doctors usually say, “No.  We can ignore the CPGs when indicated.”

If so, it seems CPGs afford little protection from lawsuit.  If standard care is to ignore CPGs when indicated, how can doctors rely on CPGs to decrease medico-legal risk?

Having CPGs, but ignoring them at will, seems to be the worst of both worlds: loss of autonomy without decreased risk.

While the aroma of clinical autonomy lingers, any trace of operational autonomy in hospitals or large groups disappeared long ago.  Even so, some physicians discussing system decisions still say:

Every physician should be involved in every decision

Every change idea should be shared at the earliest possible moment with every MD

Consensus with all physicians should be reached before any change

Are we in a post-physician-autonomy age?  How does this impact professionalism?  Is autonomy something that’s earned or protected?  Is autonomy the wrong question?

Responsibility, accountability, and autonomy are inseparable.  Some want to remove physician responsibility  as a way to decrease physician influence; others want to remove responsibility as a way to decrease risk.  Some insist on keeping accountability, but work to remove responsibility and autonomy.

Should we forget about physician autonomy and only ask what’s best for patients?

Medicine Beyond Technical Wonder: Intentionality

DSC_0469[Note: this post tackles a complex corner of medicine.  I left out bold and italics skimming tools since I couldn’t figure out a way to summarize it more than it is.  Cheers.]

Some say ‘medicine has lost its way’ and become a technical discipline focused on fixing broken physiology. The doctor-patient relationship requires human compassion and care in so far as they further a physician’s ability to perform real clinical work: diagnosis and treatment.

Intentionality fills nearly every aspect of the doctor-patient relationship. Intentionality, the collection of abilities by which our minds form concepts about other things, includes our capacity to comprehend, understand, believe, hope, and perceive. These operate toward something else: patients understand treatment; physicians believe what their patient tells them. Understanding and believing are always directed toward something; they never stand by themselves. We understand something; we believe something.

Intentionality forms a core element of the doctor-patient relationship which itself is the heart of clinical care. Intentionality cannot be reduced to physiology or material explanation. It belongs to a different category than matter and energy. Still, intentionality plays a critical and ubiquitous role in medical care.

Medical science impresses with technological success won by reducing everything to physiology (matter and energy). Over the last 100 years, the powerful tools of reductionism and materialism have come to enjoy an elevated cognitive status. Things that exist materially and can be explained with a reductionist heuristic exist more certainly than those that cannot.

With the growth of medical science and material explanation, physicians have become experts at diagnosing and fixing disordered physiology. Expertise and success foster increased trust in the reductionist, mechanistic heuristic such that it becomes more than a tool. It becomes an all encompassing philosophy of medicine; a meta-narrative of clinical care. Physicians are most certain when managing physiology. In fact, we now define quality by technical expertise and outcomes, and negligence by technical failure. Lack of skill on the human elements of clinical care gets viewed as negligent only in so far as it negatively impacts physiologic outcomes: the important work of medicine.

Medicine (quite possibly society as a whole) has allowed one way of knowing and explaining, one epistemology, to attain a status far above all other ways of knowing. Law, business, psychology, art – all of the humanities – hold maximum sway only in proportion to their ability to explain themselves materialistically.

Medicine needs to build its own heuristic – its own philosophy of clinical care – that encompasses all the data self evident in the doctor patient relationship. Medicine cannot let basic science define what is most true or most important about the doctor patient relationship. Medicine cannot allow only data that fits into materialist explanations to hold an elevated cognitive status without patients feeling a loss of the human elements of clinical care.

We need to retain materialist explanation as a tool in clinical care, but build our own philosophy based on the core of medicine: the doctor-patient relationship. Highlighting intentionality will take us on a first step toward a fuller philosophy of care.