I don't think it's just for the government to abandon its citizens in a disaster and then turn around and prosecute them for the decisions they felt were the best they could make under those unimaginable circumstances.

Surely you don't mean this, at least not as broadly as it's stated.

How about stating it this way?

I don't think it's just for the government to abandon its citizens in a disaster.

I haven't been following closely. Does the decision not to indict reflect doubt over whether it actually happened, or whether it is a prosecutable crime?

Also, you know, if we're talking about non-hotttness related stuff -- has anyone else been following the Libyan "Tripoli Six" thing, which actually ended happily two days ago? Five Bulgarian nurses and a Palestinian doctor were accused of deliberately infecting children with HIV in Libyan hospital, on some ridiculous evidence. It was pretty clear they were innocent, but they were held for years, tortured and abused, sentenced to death multiple times, and then earlier this week... the final steps were finally taken, and they were freed. This is actually a pretty great thing.

I loved this bit from the article:
"I regret their decision," Mr. Foti [the Attorney General who'd ordered the prosecution]said of the grand jurors, while criticizing the district attorney's office for not calling on certain witnesses to testify.
But the district attorney in New Orleans, Eddie Jordan, told reporters, "I agreed with the grand jury."

Not hot, Becks. Not hot.

4: Yeah, I was floored when I saw that. All those years, and then it ends just like that? Amazing.

1 - Yeah, even as I was writing it, I realized my thoughts weren't 100% consistent on it. I'm just too busy to think it entirely through right now.

Like, do I think this woman should be prosecuted? No. Should people who looted shoes and supplies? No. Should people who broke into stores and stole valuables? Sure.

But then I started thinking about, say, Abu Ghraib. Those soldiers were, in a way, also abandoned by our government and made decisions that they thought made sense under the circumstances. Do I think they should be prosecuted? Yes.

I agree with Becks. The standards of normal medicine can't be applied to disaster medicine. As I remember, the hospitals were often without power, lacked clean water and other essentials, and seemingly the doctor just decided that under the circumstances medical care was impossible for some very sick pateients.

I'd change my mind if I found out that the doctor was a Social Darwinist or a racist, ot that the patients really weren't that sick.

Five Bulgarian nurses
Libya insisted on being paid to free them. It's wonderful that they're home again, but this wasn't a humanitarian gesture or spasm of compassion from Libya.

She still has three civil suits pending against her.

And then you've got the case of the seven New Orleans police officers charged with murder in the shooting deaths of Ronald Madison and James Brissette on the Danziger Bridge on September 4, 2005. The case against the officers is a legal mess right now, but it falls into the same category.

Of course, with my track record on this topic, I'd probably be best advised not to weigh in, but here I go anyway...

12 was mostly a response to 8.3, and I come to the same conclusion as Becks.

This seems like a good outcome, and better than not prosecuting the doctor at all. Let me explain. I am pretty sure I can never know the hell that the doctor had to go through and am not inclined to question her decision.

On the other hand, I can't imagine being the families of the victims, knowing that when we left grandma in the facility she was okay, hearing that the doctor might have killed her, and having the state look the other way because we weren't rich enough or white enough or important enough to have an official inquiry done.

It's wonderful that they're home again, but this wasn't a humanitarian gesture or spasm of compassion from Libya.

Sure, but Libya's an insanely oppressive autocracy even by Arab standards; you take what you can get. The important thing is that they're free.

They had a segment on 60 Minutes about this a few months back and I just sobbed all the way through it. The conditions at the hospital were horrifying -- they'd been without water and food for days, the heat was stifling, there was no power, there was sewage floating in the hallways, the patients appeared to be in a lot of pain, and they had no idea if or when they were going to be rescued. I can't imagine how hopeless that situation must have felt.

Is it actually even clear that the doses were fatal, or even potentially fatal?

15 is exactly right. They were imprisoned and tortured over a period of years. It looked like they might have been executed at times. Part of the payment to the families comes out of debts forgiven by Bulgaria and a few other Eastern European countries, and some of the other 'aid' is supposed to go to better hospital facilities in the region.

Who gives a fuck if the Libyans think they were paid off? The important thing is, the doctor and nurses were freed. Even the U.S. was speaking up on behalf of the Palestinian doctor, which should indicate what a completely crazy thing this was.

If you read The Private Life of Islam, it will make sense that North Africans might not like Bulgarian doctors so much.

I think there's a very difficult issue about intent in cases like this -- the dose of opiates necessary to keep a terminal patient comfortable is going to be very close, possibly overlapping with, a dose that has potential to fatally depress respiration. If I recall what I read about this before (which I might not), the doctor's position was that she was keeping the patients out of pain, and under the circumstances the doses necessary to do that were fatal.

In the 60 Minutes interview, she didn't say she administered a lethal dose (likely so it couldn't be used against her) but it was pretty understood that she did and she didn't deny it.

Those soldiers were, in a way, also abandoned by our government and made decisions

I didn't see this. The soldiers were anykid from anywhere and they chose to make crude degrading pornography with the men they had power over. It would have taken willful disregard not to know that the prisoners were at least sometimes there without good reason. The choices they made were not agonized wrong decisions by misguided moral actors dealing with known enemies, but the same bored thuggish crap found the world over. The conclusion that American halfwit jailers are no better than anyone else's halfwit jailers, and that this reflects poorly on the US, is not popular.
Worse, we only know because of cheap digital imaging; we only know by accident. Had this happened in 1991, would anything be known?
Are even cellphones permitted in our jails in Romania? Also, the guy that disseminated the photos is still living in hiding. Not like Katrina.

20:

the doctor's position was that she was keeping the patients out of pain, and under the circumstances the doses necessary to do that were fatal.

This part creeps me out.

Does it creep you out less if you put it like (facts invented for thought experiment, I don't know what the truth was): "Patient X is too sick to take anything by mouth; she has to be hydrated intravenously. We're out of IV fluids. She might last 18 hours, suffering, if we don't do anything. If we give her enough morphine to keep her comfortable, there's a risk it will kill her before the dehydration would have. I'm going to give her the morphine."

I think that's the sort of thing that may have happened.

24: Short answer: yes.

Long answer: The part that creeped me out was that in order to keep her patients out of pain, she allegedly killed them. "[T]he doses necessary to do that [i.e., to keep her patients out of pain] were fatal." That creeps me out.

If we give her enough morphine to keep her comfortable, there's a risk it will kill her before the dehydration would have. I'm going to give her the morphine.

That is qualitatively different, and creeps me out much less.

On a completely different subject, this is funny AND true.

I think that I disagree with 22. I do not think that Abu Ghraib is really analogous to the situation in New Orleans, but I can't entirely blame those soldiers either. Who knows what any of us would be capable of under those conditions. Personally, I think that I'd probably collapse in a corner. I think that the real blame ought to be assigned to those who allowed those conditiosn to exist. Those kids weren't trained adequately, and they were under an excessive amount of stress. War is stressful, but the level fo strain they were under was not necessary. I guess what I'm saying is that I think that Donald Rumsfeld who made terrible decisions from the comfort of his office probably deserves to be prosecuted too, and maybe his punishment should be harsher.

There's a distinction (in American law, if not in English) between Murder I and Murder II. The chief distinction seems to be the level of premeditation involved. I'm willing to call the top brass's behavior the equivalent of Murder I. I'd knock those individual soldiers down to Murder II or, if I'm feeling really merciful, manslaughter.

I realize that I have just violated the analogy ban, but I don't know how to describe what I'm thinking/feeling.

Yeah, if the facts were "We can't take care of these patients, better put them out of their misery" that would disturb me, to the point of being really on the fence about prosecution, too.

28: Comity!!!

And to continue my OT ramblings today, here is definitive proof that Fred Thompson once knew how to tell the truth.

Who knows what any of us would be capable of under those conditions.

For what it's worth, bg, I have a hard time picturing you behaving like Lyndie England under any circumstances..

And in fact these low-ranking soldiers were not "abandoned" until the photographs were made public. They were rather encouraged by their superiors to torture their prisoners in order to soften them up for interrogation. So yes, those "who allowed those conditiosn to exist", in other words, those who gave the orders, should certainly be prosecuted.

Don't the Standford Prison experiments point to the fact that the setup of Abu Ghraib was likely to result in the outcome that it did?

The Standford Prison Experiments are interesting. I haven't looked at them in any detail, but I seem to remember hearing that there were people who behaved differently.

33: I should probably say it is a likely outcome instead of the likely outcome. While I think the actions at AG where atrocious it isn't like it was something nobody could have foreseen being a problem. I also think people tend to think that neither they nor anyone they know could act that way. Between the Milgram experiments and the Standford prison experiment I am not really comfortable saying that.

This part creeps me out.

It probably creeps me out less because it's pretty much how my own father died -- he had terminal cancer and requested that when it got to the point that the amount of morphine he needed to be out of excruciating pain, that was the amount he should be given. And then it did get to that point, and it was.

35: The situation you describe does not creep me out in the slightest. That sounds like a merciful end which was chosen by your father in advance. No one has suggested that any such advance directives from the patients were in existence in the New Orleans case.

"... I can't imagine what the situation must have been like for a doctor to believe that was in the best interest of her patients. ..."

What's so hard to imagine? It is my understanding that this often occurs with terminal patients, that the only way to relieve their pain is to kill them, and that it is fairly common for lethal doses of opiates to be administered under such circumstances.

37:

It is my understanding that this often occurs with terminal patients, that the only way to relieve their pain is to kill them, and that it is fairly common for lethal doses of opiates to be administered under such circumstances.

In the absence of an advance directive from the patient? Or an often agonizing decision made by the patient's family?

We don't have any doctors who comment here, do we? I've got the strong impression that it's not as clear as 'this dose of morphine will kill the patient'. Much more like 'the patient is dying, and getting weaker and weaker. If I keep giving them enough opiates to kill the pain, at some point they'll be too weak to live through it.' The doctor is making a choice to risk a somewhat faster death rather than allowing the patient to suffer, but the death comes as a result of the continuous process of pain control, not as a discontinuous decision to euthanize the patient.

I think I blogged this story when it first surfaced, right after the flood. And I agree with Becks--it's a horrible story, and I'm very glad they decided not to prosecute the doctor.

I don't understand the being creeped out. Have you guys forgotten what the floods felt like, emotionally? There *really were* bodies floating in the streets. There *really were* people dying of thirst and heat stroke on roof tops. There *really were* old people who simply *died* in their wheelchairs at the superdome waiting for someone to come evacuate them.

Under those circumstances, I think it seems entirely reasonable for a responsible doctor to administer lethal drugs to people who seem to have been abandoned to die of heat exhaustion, in a sewage-filled rest home, where clean water is running out and there's no contact with the outside world.

38

It would be less common absent such directives but that says more about the doctor's fear of consequences than about their judgement about the best interest of their patient.

NCP, as I understand, the doctor was being forced to improvise everything under disaster conditions during a considerable period when even the most minimal prerequisites of good medical care were not available. I'd be willing to change my attitude in the face of certain facts (a history of racism by the doctor, patients who really weren't that sick), but the doctor was being forced to triage patients under what amounts to battlefield conditions. I think that your attitude is unreasonable.

38: Can you think of an advance directive that could have possibly anticpated the conditions those patients were subjected to? "In case the hospital is flooded in, has no power, water or fresh air, sewage is floating in the halls and the government has so completely abandoned the city that it's not clear if help is coming, ever, then please euthanize my mother?"

39

That's just the politically correct rationalization.

I agree with everything in 40, except the not understanding why this would creep out people. I understand why it would; it just isn't my reaction at all.

So's your old man.

Now that we're got the discourse running at an elevated level, anyone around here work in health care?

42, 43: My comment at 38 was in response to an assertion by MBS that such euthanasia "often occurs." I was seeking clarification that this "often occurs" in the absence of an advance directive from the patient or a decision by the patient's family. At no time did I ever suggest that the doctor in NO would have needed such a directive to act.

Oh, and Emerson?

I think that your attitude is unreasonable.

Please read my comments in their actual context, not the context that causes you the most outrage.

47: "MBS" s/b "JBS"

I distrust prosecutors when they second guess such medical decisions.

Let the civil suits proceed, but beyond a reasonable doubt is supposed to be really high.

The administration of pain medicine is a nightmare for doctors and pharmacists. Prosecutors feel as if their judgment is better than the medical professionals. These are tricky judgments, not hard science.

The DEA waltzes in and acts as if the decisions are simple. ARGAGRGARGGAR

49: Not all prosecutors:

But the district attorney in New Orleans, Eddie Jordan, told reporters, "I agreed with the grand jury."

You mean, Eddie Jordan, the prosecutor who immunized the two nurses to try to testify against the doctor?

You don't think he wasnt swaying in the political wind?

47: As stated in my 39 above, I think you're mistaken about the extent to which this sort of thing either really is, or is perceived by the doctors and families involved as, active euthanasia. I'm talking out of stuff I kind of remember, and conversations with my big sister, and google is not being helpful because this is such a contentious issue, so my facts here are not authoritative.

But that all said, my strong impression is that it's not easy to kill someone with opiates unless they're already dying -- the line between a pain-management dose and a fatal overdose is pretty far apart for someone who isn't very close to the end of life anyway. So this isn't the sort of decision that is innately terribly fraught -- the decision to medicate a terminal patient for pain isn't a decision between life or death, it's a decision between painful death and painless death, both on their own schedules, but the painful death might be a little slower.

The New Orleans case is complicated because the reason for the painful death was the unavailability of medical care -- these were patients who mightn't have been immediately terminal if the hospital were still functioning -- but I think it's essentially the same pattern.

Here's a link to the 60 Minutes segment and the transcript. It does appear from that (and from another article I'd read) that she injected a muscle relaxant along with the morphine, which pretty much guaranteed death.

46: Only indirectly, but I could ask around.

Note that Foti is up for re-election and is behind his opponents in fundraising.

Speaking of Katrina, I'm behind on my charitable donations this year. Where's the best place to send money for Katrina relief these days?

The administration of pain medicine is a nightmare for doctors and pharmacists. Prosecutors feel as if their judgment is better than the medical professionals. These are tricky judgments, not hard science.

The DEA waltzes in and acts as if the decisions are simple. ARGAGRGARGGAR

Boy, do I concur. Pain medication is such a legal minefield for care providers, I can't possibly imagine the tenacity it takes to become a pain management specialist.

Although on the topic of "what if the level of morphine required to ease someone's pain kills them", we discussed this a lot in my Death and Dying class in Catholic school. Even the pro-life, anti-euthanasia Catholic church says this is OK and gets all doctrine of double-effect about it.

I think you're mistaken about the extent to which this sort of thing either really is, or is perceived by the doctors and families involved as, active euthanasia.

If all that's required is perception, then, per Shearer, all that's needed is a sufficiently convincing if inaccurate explanation. I think it's crazy not to think that there isn't some euthanasia going on, and my recollection of the reporting of the issue is that a significant portion of doctors acknowledge that this happens.

I find some of the reactions here a bit odd, partly because my parents, who were of a generation now almost gone, lived in mortal terror of being forcibly kept alive by medical technology beyond the point at which they "ought to die". Luckily for both of them, the issue never arose. But I know that if my parents had been Dr Pou's patients under those conditions, and she had let them die, unmedicated, by slow dehydration when she might have administered the morphine, I would be screaming foam-flecked abuse in her face, calling her a cynical torturer and meaning every word of it.

It seems utterly inhuman and inhumane to respond otherwise. Ensuring that a dying person goes easy seems to me to be a much more sensible interpretation of "Primum non nocere" that forcing them to suffer until every last organ in their body shuts down.

Pain specialists and Obgines both. Also anestheseologists. Socialized medicine now!

I distrust prosecutors when they second guess such medical decisions.

I don't work in healthcare, but I did have the opportunity to work on a case in which a doctor was convicted of dealing drugs for prescribing pain medication to a patient in chronic pain. While the New Orleans case has some unique facts, it is one of a growing list of cases where doctors are being criminally charged for deviating from the standard of care in the administration and prescription of pain medication. These physicians don't profit from the sale of the drugs and are not providing the drugs for recreational use, they just have a more agressive perspective with regards to the treatment of pain.

a significant portion of doctors acknowledge that this happens

Obviously, my father hasn't practiced medicine since he died in 1987, but he claimed at the time that it was not uncommon.

I agree with everything in 40, except . . . .

Not good enough, my friend. You're almost there.

NotATurtle is absolutely correct. The arrogance of some people is galling. Judgment calls about the treatment of pain become criminal decisions.

I believe in a healthy distrust of all actions of the powerful, governments in particular.

I had a very long and impassioned response worked up on this issue, but then I decided that we're all people of good will struggling over this very difficult and emotional issue. We'll never understand the horrible choices that faced Dr. Pou and her staff during the worst days of the Katrina disaster, and any attempt to second guess her would be foolish indeed.

Speaking more generally, end-of-life issues spark such intense responses because many of us have had relatives go through them, or because we can each imagine how we would want those issues dealt with in our own cases. Regardless, prosecutors and law enforcement officers should tread very lightly (and certainly more lightly than they have in a number of notable cases pointed out here) in reviewing the way that medical professionals work through these difficult decisions. Health care personnel have hard enough jobs without the threat of criminal prosecution hanging over their heads.

58, 62: I perceive, and I think many other people do as well, a pretty bright line between 'euthanasia' meaning 'taking affirmative action to end the life of someone who might live for an indeterminate amount of time, so that they can avoid suffering during that indeterminate period' and meaning 'taking affirmative action to palliate the suffering of someone currently in the process of dying, even when you're certain that it will speed that process'.

The distinction relies on being able to distinguish between 'terminally ill but might live for an indeterminate amount of time' and 'currently in the process of dying', but while there may be borderline cases, I think that's a distinction that can be made.

Just to be clear, your claim is that the critical distinction is between "might live for an indeterminate amount of time" and "currently in the process of dying," is that right?

I guess I didn't quite finish that last. To continue:

I'm sure both kinds of 'euthanasia' happen. The first strikes me as a real moral question, the kind that's a difficult decision requiring advance directives and maybe sometimes shouldn't be allowed at all. The second, on the other hand, I am certain happens dozens of times a day in every hospital there is, and doesn't seem to me to prevent any significant moral problem at all.

67: Yeah, pretty much, although 'currently in the process of dying' is a circumstantial as well as a medical determination. Someone who can't take fluids by mouth, and there are no IV fluids or prospect of getting any, is 'currently in the process of dying' even if they wouldn't be in a properly equipped hospital.

59: dear god, yes.

the conditions were what were fatal for many of the hospital patients already, I'm sure. I'm not a health care professional, but I've seen a little more of these things because my mother right now is in the hospital in what she insists on calling an "isolation room," because she's neutropenic and hasn't got an immune system for the moment. There are plenty of other patients like her on her floor. The flora occuring naturally on her body are enough to kill her right now, were the doctors not taking all sorts of low and high tech measures; surviving no electricity or water and sewage in the corridors, let me just laugh.

I was with my father when he died, and I believe that he may have been euthanized. He had been breathing very heavily all night, and calmed down after an injection, and then died. He was and MD himself and we talked about these issues, and I am absolutely sure that this was what he would have wanted, and what my mother would have wanted. He had known he was terminally ill for a period of months and had signed the do-not-resuscitate-type forms, but there's no real euthanasia form. So I don't even know if it happened, but if it did, that's a good thing.

A lot of people live in constant pain because of medical paranoia about the use of painkillers, motivated partly by personal conviction and partly by fear of prosecution. It's really a sick situations.

No documention, unfortunately, but this is not a wild allegation.

I know for a fact that my grandmother was euthanised, because the doctor told my father what he'd done. It probably shortened her life by four to six hours. Before the injection, she'd been screaming incoherently with pain; afterwards she fell asleep and died within a couple of hours.

My father and all his siblings were profoundly grateful.

Upthread there was talk of doctors acting in the best interests of the patient. There are at least three standards for decisions when you've got an incompetent patient:

A. Best interest of the patient

B. What the patient wants or would have wanted (needn't be in patient's best interest)

C. What a designated substitute decision maker decides.

C can look a lot like A, but needn't. For example, I've signed a durable power of attorney giving my agent 'the same power I have while competent to make health care decisions for me that are arbitrary, capricicious, and contrary to my best interest.'
I hope this gives her the power to say "I'm tired of the old fart, pull the plug and shoot him full of opiates" refuse medical treatment.

Does anyone believe that best practice should entail (if logistically possible) the doctor talking about euthanasia with the patient and/or the patient's family before administering a lethal dose of painkiller?

[please note that this gentle query is entirely separate from the New Orleans doctor situation]

Yeah, that sort of thing seems completely distinct from Dr. Kevorkian-style euthanasia of someone who isn't dying yet. (About which I'm not sure what my opinion is.) But what happened to Emerson's father and OFE's grandmother happens constantly, and doesn't seem to me morally problematic at all.

(mmf!: My sympathies, that sounds really rough. But from the way you say it, she's expected to recover? I hope?)

75: Yes. In an ideal situation, a patient whose situation was desperate and uncertain would have the option of being fully informed, including frank discussion of the chance it won't work, any crippling side effects possible from a failure to bring about death and all other treatment options available to them.

76 to 73.

To 75, I'd say maybe, not always. If the goal of each individual action is to make the patient more comfortable, the fact that the doctor is fairly sure that the sum of their actions will hasten death doesn't mean that they've decided to kill the patient. I don't know that it's in the patient's best interests to frame a treatment question as "Should I kill your grandmother" rather than "Should I do everything I can to make her comfortable."

Oh, I was assuming we were talking only about the patient's family. Certainly, if the patient themselves is capable of making decisions they should have the opportunity to.

78:

the fact that the doctor is fairly sure that the sum of their actions will hasten death doesn't mean that they've decided to kill the patient.

But shouldn't the physician have a duty to share the "fairly sure their actions will hasten death" part with her patient and/or family before administering the drugs?

75: NCP, over here it's pretty standard for the doctor to have a conversation at some point with the next of (available) kin about whether to strive officiously to keep alive or to go onto a pain relief only regimen, which isn't quite what you suggest, but based on the same logic.

Isn't this also the case in N.Carolina? Because if not, let me write myself a memo not to allow American doctors near me in my last illness

Also, mmf!. My best wishes to your mother and yourself. It's a bugger. There's no way round it.

If I may respectfully disagree with LB, I don't think the question should be 'what is in the patient's best interest?'

The first question is "who is the decision maker?" If it's the patient or family, then they should be given all relevant information and presented with all available choices. If you've got a substitute decision maker, they get all the rights and privileges of the patient.

If it's not the patient or family, there's a problem. Personally, I don't think doctors should ever be the substitute decision makers for their patients because of the inherent conflict of interest.

75: Does anyone believe that best practice should entail (if logistically possible) the doctor talking about euthanasia with the patient and/or the patient's family before administering a lethal dose of painkiller?

I'd say it would be best practice for the broad spectrum of people whose beliefs on this line up with mine; but I don't necessarily think that it follows that it would be best practice for a family with different religious beliefs, or who had experiences of medical mistreatment that would color their reaction (Holocaust survivors and their families, for instance). Even just bringing the subject up for discussion as standard operating procedure seems like it would have the potential to really damage the Doctor/Patient relationship in a lot of cases, for really legitimate reasons, at exactly the wrong time.

80: I'm hedging because of your handle. I don't think there should be a legal duty as you describe (to the family -- duty to allow the patient to make their own decisions I'm much more comfortable with) failure to abide by which would be prosecutable. I think it would almost always, but not only, be the best ethical decision to talk to the family about the potential that treatment intended to alleviate suffering would be fatal, but that that duty should be subsidiary to the duty not to allow a dying patient to suffer.

81: Yes, I'm pretty sure that the prevailing standard of care requires such a conversation, although IANAD (or a lawyer specializing in the prevailing standard of care). Please feel safe in visiting the Tarheel State!

83: Yeah, while this is a reasonable position, I can't agree with it. I don't see the inherent conflict of interest between the doctor and the patient here.

72: The non-terminal end of pain management and legal risk around it was the subject of a last month. Lots of documentation there about the paranoia, and the pain people are living in because of it.

85: My response would be along the lines of 83, my handle be damned.

Frankly - and I'm not saying this just to disagree with NCP! - I think it will still involve judgement calls on the part of the medical professional on-hand. Is the family too distraught to handle making a decision? Is the patient is going to die that night anyway one way or the other and the family is too distraught? I realize that the What If game isn't a fair or honest tool for argument, but I'm not trying to nail down any particular scenario with it; I merely think that regardless of clear and agreed ethical guidelines for various scenarios there will always be exceptions that leave doctors and nurses with some part of the decision to be made on their own.

85: Wait. I just re-read your comment. Are you really saying that a doctor's "duty not to allow a dying patient to suffer" should trump the right of a patient and/or their family to be told that "the potential that treatment intended to alleviate suffering would be fatal?" Really?

With my dad, doctors kept us informed about chances for recovery and easing of pain. His pain didn't increase, so his medication didn't need to be ramped up; we took shifts and waited it out. My sister was the one there at the end.

We had a "Revocable Power of Attorney for Health Care" and would have been called on to make these decisions, but they were all straightforward. He was doped, but I couldn't say it hastened his death.

The conflict of interest can arise because some doctors have a lot of ego wrapped up in saving people. They may well want to pull off the miracle cure, the astounding medical miracle, when the patient might rather be allowed to die in peace. Doctors tend to think they know best what patients ought to do, and can tend to impose their will on patients.

85: ...that duty should be subsidiary to the duty not to allow a dying patient to suffer.

I guess I don't agree that there's a duty not to allow patients to suffer. I'd say that the duty is to do what the patient (or his designee) instructs, so long as it's within the bounds of law and ethics. I'd give all the power to the patient rather than the doctor. I don't care how distraught they may appear. I guess I put a very, very high value on autonomy

Agreed with RMMP. The fact of the matter is that dying--like gestation--usuallly something you can draw clear lines around. "Oh, at *this* point it becomes a baby" "Oh, at *this* point death is inevitable." And people are individuals, and are going to have mixed feelings and confusion and so on.

I think that the one thing (good) doctors get that a lot of us don't is that death and illness happen, and sure, you can fight them, but sometimes the cure is worse than the disease. When my grandfather (a g.p. of many many years) got prostate cancer in his early 70s, he had it removed, and when it came back he didn't even consider chemotherapy. He figured he was 70, something else might kill him first, and if not then it was his time, and the chemo would be worse than accepting it gracefully. I don't think too many non-doctors would make that call; I probably wouldn't. But it was, I think, from seeing how it played out, the right call to make.

When the cancer spread, they called in hospice. He probably died of a morphine overdose; certainly at the end he was morphined up most of the time.

I guess I put a very, very high value on autonomy.

But the thing is that when you're under a lot of stress your autonomy breaks down. Even people like me, who get more and more rigid about their autonomy when they're stressed out, really need help making decisions (or refraining from making them prematurely) in the middle of it.

The thing is, I think even outside the end-of-life arena, the idea that patients or their representatives are in a meaningful sense their own medical decision makers is kind of a myth -- the 'decisions' they make are between tightly circumscribed options that doctors present to them as medically reasonable. A competent patient always has the option to walk away completely, but while under medical care they aren't really making their own decisions.

For a personal example, when Sally was born she was discovered to be breech while I was in the middle of labor. Normal US standard of care is that all breech births are C-sections. Because I was already in transition, and everything was going smoothly, the OB asked whether I wanted a C-sec or to go forward with the natural childbirth. Now, I was given the chance to make my own decision there, but only because the OB considered either decision medically reasonable under the circumstances -- if in his opinion progressing naturally was prohibitively dangerous, he wouldn't have, and shouldn't have, asked me which I wanted to do, he would have told me I needed a C-section.

Similarly, I'm uncomfortable with a duty that lets someone other than the patient or their doctor decide that a death of slow torture is preferable to a quicker, painfree death. There seem to me circumstances where withholding painkillers, even if the painkillers would hasten death, would be medically unethical regardless of what the family might say.

96:

I'm uncomfortable with a duty that lets someone other than the patient or their doctor decide that a death of slow torture is preferable to a quicker, painfree death.

Who is saying this? I've always said patient and/or family. Maybe our disagreement here is based on my unstated assumption that the family would only be involved in the medical decision-making if the patient were unable to (for whatever reason).

93: I put a high value on the patient's own autonomy. Once we're talking about a substitute decision maker, there are circumstances in which I'd let medical ethics trump family decisionmaking.

97: Sure, but if the patient can't decide, it's the family or the doctor. I'm comfortable with a patient being able to tell the doctor: "I'd rather die in agony than shorten my life by an hour." I am uncomfortable with a patient's representative being able to tell the doctor: "I'd rather he die in agony than that you shorten his life by an hour."

I am in NCP and MHS's camp on this. I can't really make sense of the notion that you owe a duty to disclose to a competent patient but not the person to whom the patient has turned over decisions if not competent.

I agree that there's a practical problem with letting patients participate in their own medical decision making. Just this morning I was speaking forcefully to a medical lab that apparently feels it's merely a courtesy to send patients their results, and that it's okay to promise to send them and then repeatedly fail to do so.

You're apparently creating a non-delegable power. I don't see any reason for that. If I, while ostensibly in my right mind, want to delegate my medical decision making powers to a non-family member (as I have tried to do, in writing, notarized) I don't see why I shouldn't. Part of my definition of autonomy includes being able to say who should make decisions for me if I can't, and it damn well isn't going to be a doctor.

I gotta learn to think (and type) faster.

This is why Powers for Healthcare exist, so that the individual may designate particular persons to make those decisions when and only when the individual is incapacitated. And presumably with an understanding about what decisions should be made.

96, 99: Isn't it a bit of both, though? You can respect the patient's wishes, or their wishes as guessed by their family, and the doctor's decision about what medical option is best or most likely to succeed. "Death by slow torture" doesn't sound like something anyone would wish on their family, but maybe 'Dr. Pou, I know she's in pain, but could you skip the muscle relaxant so she might be in a little more pain but isn't a definite goner' seems like the sort of thing a patient's family is in a better position to assess than the doctor who's known them all of a few minutes.

101: Kind of, with the non-delegable power. The power to withhold pain relief is a very particular class of medical decision, and I just can't see delegating that power to someone who might be less than fully informed about the implications. (That is, someone who might be distraught, and hung up on "Killing Grandma" rather than "Letting Grandma die peacefully rather than after 18 additional hours of intense pain.")

If they were holding a medical proxy that spelled out the right to refuse pain relief specifically, then maybe.

If they were holding a medical proxy that spelled out the right to refuse pain relief specifically, then maybe.

If that, then maybe?? Jeebus.

104: IM limited E, the doctors are usually pretty upfront about it: Grandma's definitely going to die, it's just a question of when and how. (And in some cases, 'enough morphine to stop pain' isn't necessarily fatal. It just means they drift out.)

103: The thing is, I think the doctor is in an infinitely better situation to judge 'definitely a goner' than the family. While the family knows the patient better, the risk that I see is that they'll make decisions that aren't in the patient's best interests out of a misunderstanding of the medical situation.

Building on 105: do you think family proxies generally ought to have any say in medical decisions at all? Or are they just a bad idea altogether? Given what you've said, I'd think you'd lean towards the latter. And quite frankly I'm not sure--again, given what you've said--why you support the patient's right to make any decisions, either. After all, they too are likely distraught and underinformed.

Has anyone here ever *been* the family in a decision like that? It's not as though everyone agrees, you know.

You can respect the patient's wishes, or their wishes as guessed by their family, ..

Once you've called them "wishes" rather than "orders" or "instructions" or "decisions" you've begged the question.

If they were holding a medical proxy that spelled out the right to refuse pain relief specifically, then maybe.

I'd forgotten tht NY call's em 'medical proxies'. My aunt designated her cousin as her proxy.

But now you're asking for special magic words to give a proxy designation full effect. Considering how confusing proxy and power of attorney forms can be anyway, I'd rather not have the added language.

109, see 102. It doesn't have to (and probably shouldn't) come down to a democratic decision.

109: Twice. Additionally, there's a one in three chance I'll be the spouse-equivalent for that choice within the next five years.

107: And it's the doctor's job to explain that to them so they can understand it. And I'm not seeing why, if the patient is qualified to make decisions for himself when he doesn't have a medical degree, his designated representative isn't at least as qualified. It's not as though they're being permitted to diagnose.

When my grandma died, she had a stroke, and the doctor explained they could insert a feeding tube, and then she'd die when the money ran out to keep it in, or they could just turn up the morphine and she'd die in about a week. I think the only thing that could have made such a decision more painful is the doctor, not my dad, making the call.

If they were holding a medical proxy that spelled out the right to refuse pain relief specifically, then maybe.

LB really is the party of death.

110: How so? Not everyone has a living will. Not everyone has written out a formal request. Sometimes it isn't an order. My grandfather had only ever mentioned 'I don't want to be a vegetable like my mother was at the end.' That was enough for my uncle to instruct the doctor. It's not begging the question to fail to pretend it was an instruction.

109:See my 92. We were the responsible parties, due to the Power, my brother for the third time in a dozen years. Our choice went against heroic measures, which is what everybody, certainly the doctor wanted when the signs started to go down.

Jeez, people. People are different, families are different, situations are different. While I expect doctors to involve patients and families in decision-making to the extent that they're able and willing to participate, I can't see anything even vaguely outrageous about a doctor's looking at the dynamics of a family situation and deciding that it wouldn't be in the patient's interest or the family's to ask them to decide what to do with some sorts of end-of-life issues. I'm sure doctors make those decisions all the time and that they get some of them wrong, but that doesn't mean the alternative isn't worse.

115: Good point.

There are different situations that may need to be treated differently: Written substitute designation, or not. Clear recent oral instructions, or not. Some cases there are decisions and instructions, in other case there may only be vague wishes.

I had mistakenly taken you to be talking about situations in which there were clear instructions, at least about who should make the decision. My apologies.

102: I don't think I'm communicating myself clearly. Let me try it from the ground up.

Regardless of what you think of health care proxies, a doctor isn't going to take medically unreasonable orders from a patient's representative. If you've got a patient who can't make decisions for themself, and their representative says "Amputate the left leg" when there's no reason for it, a doctor isn't going to do that.

Similarly, a doctor isn't generally going to withhold lifesaving care on a representative's orders, and I don't think they should. If an unconscious patient's representative says "Turn off the respirator", I think a doctor is ethically required to say "Fuck you turn off the respirator, he's going to be fine in another day or two if we keep him on it, it stays on," if in their medical judgment those are the facts -- the doctor might eventually have to allow the representative to remove the patient from the hospital, but I think they'd be ethically justified in stalling and resisting that decision. The delegated right to make health care decisions isn't a right to make absurd or injurious health care decisions.

I would say that what I called type 2 euthanasia -- providing palliative care to a patient in the process of dying -- is in some circumstances going to be a decision where withholding it would be not something a doctor should be ethically required to do. While I agree that generally proxies and family representatives should be (and I think they generally are) fully informed, I can't picture a circumstance where a doctor should be required by a third-party's orders to allow a patient to writhe in agony until she dies, where palliative treatment is possible.

"lifesaving care" above should be understood as "care with the real potential of actually bringing the patient to genuine recovery, rather than prolonging death" if that wasn't clear.

LB has managed to push me to the right on euthanasia.

I don't think I'm communicating myself clearly.

Noted only for its irony.

I never thought of it as anything more than a transfer of the right of informed consent. We consented, as he would have.

The doctor did canvas our views about death, and might have taken extreme pro-life views, common there if anywhere, into consideration. Didn't come up.

122: Did that come off snide somehow? It wasn't meant to. I just got the impression that people thought I was talking a harder line, or at least a different line, than I thought I was.

119: But none of are saying 'the family gets to decide to cut off limbs' or any kind of trump card generally to make bad decisions on a whim. But ethically tricky ones -- and I've been assuming we're not talking mere palliative care but actual stop-the-heart euthanasia or whether to take heroic measures-- really seem to be not just the sort of thing where the family should be expected to say 'Whatever you think is best, doctor.'

(I'm not sure where these families are that run around denying palliative care are, but they're out in the straw with the rogue euthanasia-wielding doctors.)

(I'm not sure where these families are that run around denying palliative care are, but they're out in the straw with the rogue euthanasia-wielding doctors.)

Made me laugh.

Honest question: how realistic a problem is a "doctor ... required by a third-party's orders to allow a patient to writhe in agony until she dies, where palliative treatment is possible"? I sure it could happen sometimes, but it strikes me as a mostly a straw. But I'm not that well-versed in this topic.

125: Not to put too fine a point on it, but some families are going to handle "ethically tricky" questions better than others, and the potential harms aren't limited to making the dying person suffer more.

a doctor isn't going to take medically unreasonable orders from a patient's representative.

This is the problem of the blood transfusions and the religious group - Jehovah's Witnesses? - and I'm on their side.

I have a friend who is refusing to get a colonoscopy, despite being in the age group when it's strongly recommended. Obviously this is an absurd and injurious - possibly fatal - decision. However, he may be going in for a different procedure involving general anaesthesia. While he is incompetent, should the doctor - or his family - just go ahead and have the colonoscopy done?

The usual answer is "no" and then we get into various weighing factors such as the likelihood of bad outcome and the probability of better outcome if we impose the treatment. Personally, I hate those weighing games. I like autonomy. Patient's (or patient's designee's) decision. Even if it kills him in agony, as colon cancer would.

oh, calapwned, the worst kind.

125: No, that's exactly what I'm disagreeing about. I'm not talking about affirmative stop-the-heart-euthanasia -- I'm very uncomfortable about that as anything other than an active decision of the patient's. I'm talking about "If we control the patient's pain, they'll probably die somewhat faster than if we don't." And I do think that if that statement is framed as "Do you want to kill Grandma now, or keep her alive as long as possible?" that there's a real, non-straw risk that a distraught family may not understand that 'as long as possible' is hours or days of unremitting pain, leading inevitably to death, and may ask the doctor to withhold reasonable pain relief because they don't want to kill Grandma.

If those families are straw, and it never comes up, then we don't disagree about anything. But if it does come up, I think the doctor's ethical responsibility not to torture her patients overrides the family/proxy's right (always limited by medical reasonableness) to decide on care.

131: maybe the "doctor's ethical responsibility" is instead to frame the question better than "Do you want to kill Grandma now, or keep her alive as long as possible?"

Also, even though I think we're talking about an unrealistic straw case, "torture her patients" is a laughably strong way to frame a doctor's decision (duty?) to obey a family's presumably well-informed wishes with respect to the medical treatment of a loved-one.

131: I worry that the doctor may find that the palliative euthanasia may be the most responsible choice when the insurance money runs out.

Sure, but I think that at any level of disclosure that remains honest ("Controlling Grandma's pain will almost certainly shorten her life somewhat; she might live a little longer if we didn't but she'd be in agony.") the potential for the family getting it wrong remains, and I do think this is a situation where prolonging a painful death other than at the specific and express wishes of a competent patient is the wrong answer.

If you like, you can say that the family gets to make all the decisions, and trust the doctor to force the cards they see skillfully enough that the family won't get anything important wrong, but that seems more patronizing than my position.

But if it does come up, I think the doctor's ethical responsibility not to torture her patients overrides the family/proxy's right (always limited by medical reasonableness) to decide on care.

But the doctor is not torturing her patients. The doctor is honoring her patient's decision (expressed through a proxy or by a substitute decision maker) to refuse medical care even though it might increase the patient's pain, and even though other people might make a different decision in those circumstances.

Not everything that happens is attributable to the doctor's agency. That's the playing god delusion.

Or you can say that allowing others to get things wrong, to make mistakes, is to honor their agency and their autonomy.

Gotta think faster. type better.

135 to 132.

131: I think this is better addressed by training the doctor to express the reality of the situation better. The doctor in my grandmother's case said something (I paraphrase) like: "The likelihood that your grandmother will ever regain the ability to swallow, at her age, is very small. I can put in a feeding tube, but that won't keep her alive forever, and it's very very likely that by the time the money for the tube ran out, she still won't have relearned to swallow, and all we would have done is prolong her suffering by a few months and we'll be back here making this decision again. Or, we can make her very comfortable and allow her to sleep out this last week."

Not really, "You wanna kill her now or let her starve to death in three months?, you know? And I think the doctor should offer guidance if asked. But concealing information seems the wrong way to go about it.

139: Again, what was right for the doctor to do with your family doesn't necessarily generalize to all families with whom the doctor has to work through similar decisions.

Sure, it doesn't generalize, but I'd rather the patient's family make the hard call than the doctor with sixteen other patients running on 4 hours sleep.

Has anyone here ever *been* the family in a decision like that? It's not as though everyone agrees, you know.

My grandmother died earlier this year, and the decision making among the family was relatively easy. We ended up not having to increase pain medication to hazardous levels.

The staff were relatively clear about the fact that they were willing to increase the dosage of pain medication if we wanted them to, and we felt like we would be comfortable making that decision if necessary.

It made it much easier that it was obvious to everyone that she was very close to death. I can only imagine that it would have been a much more difficult conversation if anyone thought there was a chance she could improve/recover.

It's not as though the decisions are ethically easier just because someone went to medical school, in other words. The degree doesn't come with a nice personality, let alone the wisdom of Solomon.

LB, I honestly can't read your comments in any way other than that at the end of the day you just flat-out believe that prolonging the life of anyone "in the process of dying" by withholding palliative care is an unreasonable decision. Which, okay fine, but it's somewhat illiberal of you not to at least grant that some people might feel differently. You're honestly saying that if Buck were terminally ill and told you that under no cicumstances did he want any steps taken that could shorten his life, regardless of pain (for whatever reason, say, he wanted to be able to spend as many final living moments with Sally and Newt as possible, even if completely unconscious and unresponsive) and he signed a statement to this effect and you agreed to this, that's you'd just prefer the doctor ignore it? I mean, again, it's clear from your comments that you'd think his decision was irrational and unreasonable, and hell you'd probably try to talk him out of it, but if that's really what he wanted?

Maybe you just believe no one could really want this?

I've got to run, but I just wanted to say that this is one of the best threads I've seen here. Thanks to everyone for caring so much and thinking so hard about a difficult issue that, at some point, all of us will likely face.

You've all given me a lot to think about.

the potential for the family getting it wrong remains

No offense, cause I don't think you mean to be, but it sounds kind of hubristic to say that you know what the right decision is in all of these situations. Which is pretty much what you would have to think if you worry that the family is going to get it "wrong". If the patient refuses or gives someone a medical proxy who are any of us to tell them they are wrong.

pwnd by Brock.

You're honestly saying that if Buck were terminally ill and told you that under no cicumstances did he want any steps taken that could shorten his life, regardless of pain (for whatever reason, say, he wanted to be able to spend as many final living moments with Sally and Newt as possible, even if completely unconscious and unresponsive) and he signed a statement to this effect and you agreed to this, that's you'd just prefer the doctor ignore it?

Meet

I put a high value on the patient's own autonomy. Once we're talking about a substitute decision maker, there are circumstances in which I'd let medical ethics trump family decisionmaking.

and

I'm comfortable with a patient being able to tell the doctor: "I'd rather die in agony than shorten my life by an hour."

and

If they were holding a medical proxy that spelled out the right to refuse pain relief specifically, then maybe.

I think refusing palliative care is something any competent patient has the right to do for themselves. I also think that it's not something I'm comfortable delegating to someone who may not have a full understanding of what they're refusing and what the implications are.

So, no, I don't think that where there are specific, clearly expressed, wishes of the patient's that they should be ignored.

66

"The distinction relies on being able to distinguish between 'terminally ill but might live for an indeterminate amount of time' and 'currently in the process of dying', but while there may be borderline cases, I think that's a distinction that can be made."

This makes no sense to me. It's ok to kill someone to spare them a few hours of pain (because they are about to die anyway) but not ok to kill them to spare them years of pain?

Maybe there are practical arguments (involving the liklihood of abuse) to allow the first but prohibit the second but given perfect information I see no logic to this.

148: I was envisioning him expressing those things to you, not the doctor. In the hospital he's unresponsive.

And the next hypothetical of course is that he hasn't expressely said those things, exactly, but he's said plenty of similar things and based on your many years of marriage to him you know with certainty that's exactly what he'd want. Because that's probably something close to the typical proxy situation that you seem to want to throw out the window.

I also think that it's not something I'm comfortable delegating to someone who may not have a full understanding of what they're refusing and what the implications are.

That's definitely a worry. But the flipside is that the doctor doesn't know the patient, the family, and what the implications of making such a decision for them (because they might get it wrong) are. I guess I see this as primarily an ethical decision, and I'm deeply uncomfortable with the idea that the doctor is in a better ethical position simply because of his greater medical knowledge. He's in a better position to evaluate the possible outcomes, but in these tricky situations it's part of his responsibility to communicate that.

LB, 146 seems clearly to get it right. I presume you would not ever be okay with a doctor refusing painkillers to a dying and near-death patient over the objections of a family proxy because the doctor believed the medicine might shorten the patient's life. So I don't think you're deferring to medical authority nearly as much as you're trying to imply.

149: Doctrine of double effect. Relieving pain, even when the pain relief may kill or hasten death, seems like an entirely different thing to me than deliberately causing death to avert suffering. I'm not sure how I feel about the latter, but the two situations are entirely different.

150, 151: I'd consider that providing pain relief to a dying patient without consideration of whether it might bring death somewhat faster is ethically uncontroversial, to the point that only the patient's own judgment expressed to the health care provider should be allowed to override it.

152: But the thing is, the doctor's having the power to withhold pain relief under those circumstances is the current, and only possible, status quo. I'd think that such a doctor was making an ethically mistaken decision, but there's no way to give the power to determine how much pain control is appropriate to the patient or their proxy without making all drugs available without a prescription.

It's not as though the decisions are ethically easier just because someone went to medical school, in other words. The degree doesn't come with a nice personality, let alone the wisdom of Solomon.

151 has partly addressed my response to this, but I still think you're underestimating the ethical value of experience, Cala. Even a doc who does his best to communicate to the family what the process of dying is likely to be like, or what the progress of a disease is, isn't going to be able to communicate that sort of thing. A lot of what goes on in these situations is stuff that, I think, you really cannot grasp intellectually. Factor in things like stress, grief, and hope that one's loved one might be an exception to the rule, and I think it could be *very* hard to figure out what the "patient's best interests" are. I mean, think of the Schaivos--I have no doubt whatsoever that they fought to keep their daughter on the feeding tube because they really thought that was the right thing to do.

I think what I'm saying is that I agree with your premises, but not your conclusions.

there's no way to give the power to determine how much pain control is appropriate to the patient or their proxy without making all drugs available without a prescription

I don't see how this is true. I am assuming the choice the doctor is going to give is, the patient is in pain. I can up the pain killer to relieve the pain, but that might hasten death, or I can not up the pain meds. They aren't saying how many CC's of morphine are you comfortable with me giving grandma.

I have no doubt whatsoever that they fought to keep their daughter on the feeding tube because they really thought that was the right thing to do

If there wasn't another legally interested party would you have been OK with the doctor overruling them?

but I still think you're underestimating the ethical value of experience, Cala.

Oh, gawd, I don't. I think you overestimate the extent to which doctors weep when a patient dies. It's not that they don't care about their patients,but...I dunno, as one doctor friend told me, you're not really a doctor until you kill someone by mistake. There are, in fact, horror stories about people with insurance who are in hospital. People who trust doctors more than families to do the "ethical" thing for an individual patient worry me.

153

"149: Doctrine of double effect. Relieving pain, even when the pain relief may kill or hasten death, seems like an entirely different thing to me than deliberately causing death to avert suffering. I'm not sure how I feel about the latter, but the two situations are entirely different."

So you are ok with giving a nondying patient in terrible pain enough pain killer to alleviate the pain when that is also enough to kill them? I am not seeing a clear distinction here.

156: Sure, but if the doctor says "No, I'm not prescribing more morphine, in my medical judgment it's inappropriate" there's no way for the family's expressed wishes to compel the provision of more pain relief.

156, 157: I'm not saying all doctors are saints, and that they're never going to make careless or unethical decisions. I'm saying that in these limited circumstances, where they know the patient to be in the process of dying, they should not be ethically obliged to withhold pain relief in the hopes of extending life where the patient has not themselves expressed their wishes. I don't think that's far down a slippery slope to condoning euthanasia for lack of insurance.

If there wasn't another legally interested party would you have been OK with the doctor overruling them?

The main reason I would be okay with the doctors saying, sure, we'll keep her on the tube, is because she was essentially a veggetable--i.e., she was not herself suffering. This is quite apart from questions like the cost, the amount of time her care took away from other patients, etc.

I mean, sure: in a perfect world, keep your vegetable daughter around forever, if it gives you comfort. OTOH, in terms of *the effect on the patient*, no; I wouldn't have had a problem with the doctors deciding to pull the tube, if her husband hadn't been around.

I think you overestimate the extent to which doctors weep when a patient dies.

Quite the opposite; I'm saying that it's in part because they see the end of life as a fairly common thing that they're less likely to be panicked by a single approaching death.

I realize that there are awful extensions of this argument that I wouldn't agree with at all. I'm explicitly disavowing the slippery slope argument here and saying that *in the specific situation* where an experienced physician has to make a decision like that, I'm more inclined to trust her judgment than not.

155

I agree with this. Laymen are apt to have unrealistic fantasies about miraculous recoveries while doctors are likely to have a more realistic view of the results of insisting on all heroic measures.

where the patient has not themselves expressed their wishes

But the patient can't always express their wishes to the doctor by the time they get to the hospital, post-stroke or whatever. THAT'S WHY WE HAVE PROXIES.

you're not really a doctor until you kill someone by mistake

I know doctors make mistakes. Making honest mistakes doesn't mean their judgment is unreliable.

162 to 159.

162: But we don't expect doctors to listen to them in all circumstances. We wouldn't let a proxy refuse genuinely lifesaving care on behalf of an unconscious patient; we wouldn't let a proxy demand medically inappropriate care. This seems to me like the sort of situation where a doctor should be allowed to determine the patient's best interests; much closer to "No, I don't care if you're holding a health care proxy, he stays on the respirator because he'll be fine in a couple of days if he does."

Exclude bad actors from the scenario. No doctors consciously thinking, "I'm killing this loser." No proxies thinking, "I always hated him." Then the obvious subconscious negative incentives, it seems to me, are unrealistic hope on proxies, as balanced by love of the patient, and financial incentives on doctors, as balanced by a desire to first do no harm. I know which one I think is likely to be more pervasive, more persistent, and over any significant length of time, more likely to influence care.

financial incentives on doctors

Huh? How does a doctor's financial interest drive her to kill a patient?

166: Generally I'm all about unconscious venality, but the way our medical system is set up now, these sorts of decisions are going to generally be made by salaried house staff with no direct financial interest in the decision.

Sure, it doesn't generalize, but I'd rather the patient's family make the hard call than the doctor with sixteen other patients running on 4 hours sleep.

It's not as though the decisions are ethically easier just because someone went to medical school, in other words. The degree doesn't come with a nice personality, let alone the wisdom of Solomon.

I'm comfortable asserting that the doctor is better situated than a lot of families, not because a medical degree conveys wisdom but because it's a pretty good sign that the individual is reasonably intelligent, has thought about and dealt with end-of-life issues before, and isn't personally invested in whatever else may be going on in the family. That doesn't mean being totally elitist and doctor-knows-best. But lots of people and lots of families don't deal with death or stress particularly well. I think it's OK, even admirable, for a doctor to look at a family and decide to take something pretty general and maybe contradictory--"we want you to do everything you can for Grandma, but we don't want her to suffer unnecessarily"--as a license to do what the doctor thinks is right if it appears that seeking more specific direction is likely to (a) result in a poor decision on how much treatment to provide, or (b) start a family feud over who killed Grandma. And if pushed, I might even say that (b) is more important than (a).

But we don't expect doctors to listen to them in all circumstances

I would expect the doctor to listen to them in any situation they would listen to the patient directly. So they could actually refuse life saving treatment.

Don't we have any actual doctors here?

On second thought, maybe their work schedules aren't as conducive to blog commenting as, say, lawyers'.

Many HMOs use financial incentives for doctors -- "If you can treat patient type X for less than $2000 a year, you get the difference." Talk to your free-marketer friends about this one.

I would expect the doctor to listen to them in any situation they would listen to the patient directly.

No way. E.g., a woman with cancer who refuses an abortion, knowing that means she can't treat the cancer. Just off the top of my head.

these sorts of decisions are going to generally be made by salaried house staff with no direct financial interest in the decision.

Now who's being naive, Kaye?

we want you to do everything you can for Grandma, but we don't want her to suffer unnecessarily

Given the statement above I, and I would guess most others, wouldn't have a problem letting the doctor decide.

172: Ah. Okay, then the problem is insurance companies, not doctor's judgment in and of itself. It isn't doctor v. patient: it's doctor & patient v. insurance.

175: See, I think that what I'm arguing is that that's the default position, the one I assume everyone has. And that therefore, I have no problem letting doctors make decisions.

I do think that MDs should avoid metaphors like "circling the drain" and "take her out behind the barn" when talking to family.

170: Now that's weird. A patient is unconscious and will die if left untreated, but will be fine if treated, and you'd say a doctor is obliged to walk away on orders from someone holding a health care proxy? What about a spouse who doesn't have a formal proxy?

179: That does sound like standard-issue refusal for religious reasons.
As was mentioned above with transfusions.

No way. E.g., a woman with cancer who refuses an abortion, knowing that means she can't treat the cancer. Just off the top of my head.

What does this mean?

we want you to do everything you can for Grandma, but we don't want her to suffer unnecessarily

This to me is an explicit grant of do what you think is best. I assume that is what most people want. The other case is when the medical proxy or patient specifically wants something that the doctor doesn't think is best. In that case my opinion is patient or proxy wins given what they want is legal.

you'd say a doctor is obliged to walk away on orders from someone holding a health care proxy? What about a spouse who doesn't have a formal proxy?

Yes, and walk away.

180: Right, and while I'm okay with an individual refusing such treatment, I am not okay with a proxy doing so.

I cannot believe I got no love for the Godfather quotation. You people are barbarians. No wonder Gans hates you.

What does this mean?

It means what 182 says. If I choose to refuse chemo in order to gestate a pregnancy, great. If someone else chooses that for me, no. Not even if that person is my nearest and dearest.

You know what would be funny? A market innext-of-kin proxies.

If I choose to refuse chemo in order to gestate a pregnancy, great. If someone else chooses that for me, no. Not even if that person is my nearest and dearest

That decision seems like it is ethically ambiguous depending on the person involved. Why would you want the doctor deciding that rather then a person who would actually could know what you wanted?

186: Remove the would from that sentence.

This to me is an explicit grant of do what you think is best. I assume that is what most people want. The other case is when the medical proxy or patient specifically wants something that the doctor doesn't think is best. In that case my opinion is patient or proxy wins given what they want is legal.

If you're taking it that way I haven't phrased the hypothetical well enough. What I'm driving at is a situation where the family--and it's important to remember that there's usually a whole family involved even if one or two of them have explicit proxies--is able to say something that sounds vaguely like a preference but is at such a high level of generality that it doesn't actually convey any information, but would have a hard time making a reasoned decision if pushed.

188: If there are explicit proxies then I would have to say well tough. You are the proxy it is your decision to make. That decision could be do what you think is best and that is fine. I don't know how the hypothetical I now think you are trying to make would even come up unless the doctor is acting without consulting the family or proxies at all. This I also think would be wrong.

Why would you want the doctor deciding that rather then a person who would actually could know what you wanted?

Because I am assuming that most doctors would see their responsibility as providing care to the patient.

In other words, I'm not okay with just a blanket "doctors should decide what treatments patients get"--obviously docs who refuse to give, say, emergency contraception are, imo, behaving unethically. What I think is that

1. Doctors should be expected to provide treatment unless the patient himself refuses it.
2. If a patient is unable to state or make a decision (e.g., the patient is in the middle of a schizophrenic episode), the doctor should provide care, and should be immune from legal prosecution after the fact (if, say, the patient turns out to be a Christian Scientist schizophrenic);
3. If a patient is terminally ill and/or treatment is likely to prolong pain and suffering, we ought generally to assume that the doctor's judgment in providing or withholding treatment is sound, absent actual evidence otherwise;
4. If a patient is in mortal danger and is likely to suffer greatly and die in an extreme situation (war, natural disaster, genocide), then I'm inclined to trust a doctor's judgment in administering a painless death, again absent actual evidence of the doc's (say) being in collusion with a genocidal government.

189: I think we're just operating from very different premises about how end-of-life decisions get addressed.

190: OK take this hypothetical. Husband and wife at near term pregnancy get into a car accident. Wife is unconscious when they get to the hospital husband is conscious. Doctor determines that he can save either wife or baby. Who make the decision on who to save?

I think my argument is predicated on a lot of assumptions.

First, I'm pretty bourgie; I'm inclined to trust the judgment of certain professionals more than the judgment of joe average, when there's a difference of opinion. Doctors and teachers are who I'm thinking about here.

That trust depends in an assumption of mine that certain professions are not, and should not, function like a completely free market--i.e., that neither doctors nor teachers should simply "give people what they ask for."

It's a tough issue, to be certain--surely there are professionals who are arrogant assholes, and certainly people, collectively and individually, should be assumed in most situations to know their own interests. But I can't get on board with a blanket rule that professionals are legally obligated to act against their judgment *as* professionals (as opposed to their judgment as, say, Catholics or as racists who think black kids can't learn). All your doing there is substituting the power of the state for professional judgment.

All your doing there is substituting the power of the state for professional judgment.

You're begging the question. There are things we believe are legitimately technical questions, and we would leave those to doctors. The questions regard other, non-technical, matters, usually dependent on following the patient's wishes.

192: Assuming that the doctor understands his professional obligation, which is to treat the patient, I say the doctor.

194: No, I'm not. We're specifically talking about situations where judgment has to be used, not about what's possible, but about what's desirable. I'm saying that my instinct is to trust doctors on that one when it comes to life or death situations.

That is going with the assumption that the baby is the lesser patient which is an ethical decision. What if the people involved thought that saving the baby was equally or more important?

I am assuming in 197 that the husband is acting in good faith with respect to the wife's wishes.

The baby isn't the patient. The woman is. I'm pretty sure that this is the established medical opinion, and it is the correct one. It's the explicit idea that the baby's status relative to the mother is an ethical tossup that I have a problem with, and a doctor who acted on that rather than on professional standards would imo be behaving both unprofessionaly and unethically.

I'm saying that my instinct is to trust doctors on that one when it comes to life or death situations.

Poor pregnant woman comes in unconscious. Abortion will marginally improve her chances, but not a ton. Can I imagine a doc saying, "She's probably got eight at home that she can't feed, anyway; this one's gone"? Yes, yes I can.

So, to continue, if the wife is unconscious and the husband says "my wife is a committed Catholic, save the baby," I think the doctor should ignore those wishes. The wife is not herself able to express them, she is dying, and the doc has an obligation to save her life if he can.

What if the doc decides that he's sure, as a mother, she'd want the kid to live, whatever the husband claims? (There was a pretty tragic story somewhate like this in the blogosphere, as I recall.) Still trust the doc?

200: So what? Nobody's arguing that doctors don't fuck up. The question is whether there are times when patients' family members are enough more likely to fuck up than doctors are that the doctor ought to go ahead and make the decision.

Abortion will marginally improve her chances

If this is the case, and the probable outcome of an abortion more than outweighs the possible complications of same, then he ought to do the abortion. Because it is in the patient's best interest, whether or not she's poor.

Poor pregnant woman comes in unconscious. Abortion will marginally improve her chances, but not a ton. Can I imagine a doc saying, "She's probably got eight at home that she can't feed, anyway; this one's gone"? Yes, yes I can.

Can I imagine the attorney salivating to take that case if the doc does make such a dubious call? Yes, yes I can.

202: No, because in that case the doc is deciding to withhold care.

205: Of *course* in a lot of these cases, someone's going to fucking file a lawsuit after the fact. Hence 190.2.

200, 202: These don't seem like even related hypotheticals to me.

205: Seriously? You really think there aren't poor women this doesn't happen to? You think that's the language he's going to put into the chart?

It used to be said that you could count on pro-choice Republican women because they thought of it as ghetto population control. It's all too easy for me to imagine this happening.

190: 2. If a patient is unable to state or make a decision (e.g., the patient is in the middle of a schizophrenic episode), the doctor should provide care, and should be immune from legal prosecution after the fact (if, say, the patient turns out to be a Christian Scientist schizophrenic);

Hypothetical: I'm by the bedside of my partner. I hold a signed, notarized durable medical power of attorney for her. She has, while competent, affirmed the validity of this document to everyone. I have issued a DNR directive for her. I also have a concealed carry permit valid in this jurisdiction. She has lapsed into a coma and stopped breathing.

I see a doctor approaching with a breathing tube and ventilator. I throw my body into his path, crying "No! Patient Autonomy, right to bodily integrity!". Doctor tries to push me aside, crying "medical ethics! I can save her!"

Question: Do I have the right to use deadly force to prevent the battery on my loved one?

I don't think the question should be "who is more likely to make the correct decision?" because people can differ in their opinions of correctness based on their own experience, beliefs and values. Given that, it's much better to say "who should make the decision" and let that person decide, right or wrong, mistaken or correct than to be trying to rig the game to produce the correct result

208: The thing is, though, if the doc is lying in the chart about the medical facts to justify his desire to do eugenic abortions, that's squarely unethical, and not on the same slope, slippery or not, as the other stuff we've been talking about.

And (to answer a possible hypothetical in advance) say a mom and a kid are in a car accident. A doc happens to be on the scene, and he has to decide who to treat first. Both will die without immediate attention; therefore, whoever is the second person treated is going to die.

Now, I personally, am going to say treat my kid every damn time. I don't know if the doc is going to treat me first (perhaps he hates children), my kid first (perhaps he hates women), or just go with whoever he trips over first. I don't think that any of those decisions should be second-guessed, because *in that situation* the kid and the mom are both patients, and it's the luck of the draw. It's not the same situation as an accident with a mom and a baby in utero; in that case, the baby is medically, scientifically, and physically speaking a part of its mom's body.

209: If it turns out that you were under a misapprehension of fact, and she would have been fine if treated, wouldn't you want the doctor to have disregarded your wishes?

He won't lie: it does improve the patient's chances. It's a judgment call, and it's his to make.

Since Schneider is apparently asking whether it's appropriate to shoot a doctor to keep a loved one from being kept alive, I'd just like to remind everyone that he lives in New Mexico.

213: You're changing the hypo. If it puts the patient at risk to continue the pregnancy, yes, the doctor should do the abortion. If it doesn't, not. If the doctor is putting his thumb on the scale for ideological reasons, he's acting unethically.

208: Yes, seriously. If the abortion will improve the woman's chances of a positive outcome, then I think he ought to do it. I think that the "poor" thing is a red herring.

Now, if what you meant is, the doc decides that an abortion is a good idea even though performing one is likely (for the sake of argument) to have *no* effect on the outcome (really, I suspect it would be detrimental, but for the sake of argument let's say it's neutral), then no. He should not perform an abortion. There is no reason for him to do so.

There is no reason for him to do so

Medical reason, obvs.

215: Risk is a sliding scale. If the doctor says "there's an increased risk if we don't terminate," he could mean that the patient is slightly more likely to die (say 1%) or much more likely to die (say 99%). You can't push him on which, because he never has to say that sentence to anyone except the chart.

Or, 215, see 216.

he never has to say that sentence to anyone except the chart.

So you're presuming that he will either lie, or that his *medical* judgment is compromised by his racism/classism. In either case, he is not behaving professionally.

206.2 If I showed up unconscious in the ER and a doctor decided to abort my baby even though it was only marginally more likely to improve my chances, I'd be pissed. I may be -- no, surely am -- minimizing the significance of the fact that I am facing death in the hypo. But I'd want that abortion to have a much greater chance of being useful before the doc went and took such a step.

I don't think immunizing doctors is generally a good policy choice -- and not just because it would deprive me of opportunities to defend them. I want the doc to think long and hard before making that decision (well, maybe not long) and knowing that s/he's immune from suit removes some of the motivation. Let a jury decide, based on the testimony of doctors, whether that was a reasonable medical decision. As far as criminal prosecution, I agree with you.

Whoops, I misread. Ignore #219.

Question: Do I have the right to use deadly force to prevent the battery on my loved one?

Nope, and it has nothing to do with the medical particulars. Deadly force can properly be used only in response to an immediate threat of death or great bodily harm, at least in civilized states.

In either case, he is not behaving professionally.

Right, but I don't actually believe in magical angel doctors. See #157.

221.1: So might I, but I don't think that the doc should be *legally liable* for guessing how I would feel afterwards, y'know?

225: Even if your husband was there, saying you'd prefer to take the risk?

224: I don't think it's believing in magical angels to say that we ought to concede that most professionals do their jobs to the best of their professional ability. Or that we ought to extend them the benefit of the doubt absent evidence of their failing to do so--which yes, there *is* evidence of that when it comes to poor women and reproduction.

The baby isn't the patient. The woman is. I'm pretty sure that this is the established medical opinion, and it is the correct one.

What if that changed? This to me seems like an ethical toss up. Provided the likelihood of saving the mother and child are the same I would see no reason to save one over the other. If the rules changed would you still want the doctor to decide?

208: Seriously? You really think there aren't poor women this doesn't happen to? You think that's the language he's going to put into the chart?

I see your point, I think. I'm not sure this doesn't happen. And I, sadly, can also picture the salivating attorney grow uninterested when he learns the potential client is just so poor woman who might be less sympathetic to the jury and thus less likely to bring in the big bucks.

Nonetheless, I think the prospective benefit of the hypothetical abortion needs to be better than the 1% chance of helping before it should be done. Truthfully, I don't know quite where I'd draw the line.

228: If that changed, I would argue that the change was unethical and unscientific, and therefore a poor decision on the part of the profession. Just as I argue that current "professional" standards--like being neutral about whether or not pharmacists should supply birth control--are mistaken, *as professionalism*, not simply because I disagree with them.

And yes, of course those things aren't completely in separate boxes, but I'm at least going to base my argument on what I think "professionalism" means.

I think the prospective benefit of the hypothetical abortion needs to be better than the 1% chance of helping before it should be done. Truthfully, I don't know quite where I'd draw the line.

Me too, and me either. Which is why I'd say, leave it up to the doctor, *assuming he isn't an asshole.*

My MD father worked in Catholic hospitals during the 50s, and even then and there the rule was "If you have to choose between the mother and the baby, assume that the baby is already dead".

231: I think you have much, much better information about whether your husband (or other proxy) is an asshole than about whether the doctor is one. At the end of the day, that's really the point.

233: But the doctor does not have that information, at least in re. the husband. He does have that information about himself.

But the doctor does not have that information, at least in re. the husband. He does have that information about himself.

If he is an asshole he either doesn't know or doesn't care. He also knows he doesn't know what the patient wants, but the husband might.

aaaaaaah This topic pisses me off.

Isn't it ironic that the same party begging to stop lawsuits pushed to ban the sometimes safest procedure available when a woman's health depends on an abortion?!???!??!??!?!

If he is an asshole he either doesn't know or doesn't care.

Right, in which case he can do what he likes and then lie about it. And if he willfully violates professional standards, then he should have his license yanked.

212: If it turns out that you were under a misapprehension of fact, and she would have been fine if treated, wouldn't you want the doctor to have disregarded your wishes?

Absolutely. I have a standing rule that my most important and formal decisions should always be disobeyed in cases where it will turn out that I would have made a different decision if I had known how things were going to turn out. This is especially true if I'm operating under a mistake of fact. I do love the subjunctive. Seriously, I'm usually operating under some sort of mitake of fact, and I'm often wrong. So are most people, in my experience.

But that's what it means to be an autonomous agent: it means that I get to be wrong, and suffer the results of my wrongness, instead of having the State say that since I'd probably be better off letting someone else decide, they get to decide. Sometimes it means that other people suffer from my mistakes, especially when they've entrusted matters to me. That's life, too.

223: Deadly force can properly be used only in response to an immediate threat of death or great bodily harm, at least in civilized states.

And you're presuming that having something shoved down your throat against your will, and running the risk of being kept alive in agony for an indefinite period, doesn't constitute great bodily harm?

Me too, and me either. Which is why I'd say, leave it up to the doctor, *assuming he isn't an asshole.*

A powerful assumption, which is probably pretty reasonably to make in most cases. *But* once you immunize all docs, then the guy who goes with the 1% chance when really your condition wasn't that critical is immunized right alongside the good guy who is trying to weigh the right choice on the fly in an emergent situation. I'm pretty comfortable letting a jury make the call after listening to the doc explain the circumstances, and a couple more docs explain medically how likely the abortion was going to help. But I'll admit I'm probably more optimistic than most about juries' ability to get these thigns right.

Immunizing docs is a bad idea.

Been away for a bit, but catching up on the thread, I'm glad it moved to a life-of-the-mother-or-the-baby discussion since I was having a hard time finding the example of a family that refused non-lethal palliative care very hard to imagine. (Since I think the real problem is that doctors are loathe to give out dangerous levels of pain medication, not chomping at the bit and being held back by families who like watching their loved ones scream.) And I, at least, would give the doctor the benefit of the doubt and the sole decision in any sort of emergency case.

But I think respecting the autonomy of the patients if doing so doesn't immediately kill them is very important, because the *professional judgment* doesn't give you an answer on 'who is more important to this family? the life of the woman or the life of her child?' 'Does this person value life at any cost or would they rather die than be a vegetable?' 'Should she take the morning after pill?' The doctor has not had a conversation with my dad about what he'd want.

The professional judgment makes you qualified to assess the risks and the likely outcomes, but not whether the woman (say) wants an abortion or wants to keep the pregnancy even though it means delaying her cancer treatment. It's not doc-on-demand, because these situations are the ones where there is a choice and not a clear *medical* answer.

240: I think it's pretty evident that holding them accountable to all kinds of second-guessing is a bad idea as well.

241.2: Well, I honestly believe that most docs do this sort of thing where they can.

Doesn't it open them up to less second-guessing if the family gets to make the call (whenever it's blah blah feasible)?

I was having a hard time finding the example of a family that refused non-lethal palliative care very hard to imagine

When my grandmother was dying, it came down to a point where she needed diuretics (IIRC) pretty frequently to reduce the fluid buildup that was making it difficult for her heart to beat, but the diuretics screwed something else up (blood pressure?) such that it was a matter of treat the fluid buildup, then allow time for the blood pressure to come back up (again, IIRC) as the fluid also built up, and repeat. The cycles kept getting shorter, and eventually it got to the point where another dose would only buy a few more hours, most of which she'd spend unconscious. At that point, the doctor asked my dad and his siblings whether they wanted to continue and they decided not to. That's the kind of decision that I wouldn't hold a doctor to be ethically bound to refer to the family in all cases. She was receiving pain medication so it wasn't squarely a question of relieving suffering, and there were no heroic measures involved, but additional care would have been pretty pointless.

244: Legally, it does. I'm just not convinced that that's in the best interests of the patient a lot of the time, y'know?

I can imagine refusing additional care, but not saying no pain meds.

Again, probably being willfully naive. But where it's a genuinely close call, I think it's pretty hard to make a lawsuit stick. At least in my state, you have to essentially get a doctor on board from the get-go willing to say "no reasonable doctor would have made that call."

I think it's pretty evident that holding them accountable to all kinds of second-guessing is a bad idea as well.

That is why there is a standard of care. And you have to have a point at which someone cannot fall below. We can disagree about how high you want that level.

I'll leave it to someone else to demonstrate that point.

Just saying that stuff relating to pain control isn't the only sort of end-of-life decisionmaking that affects survival time.

250 to 247.

I note, for the record, that the only ones here insisting on the right to sue the docs are lawyers. Make of that what you will...

That is why there is a standard of care. And you have to have a point at which someone cannot fall below.

But it's not a question of standard of care, except (maybe) in the emergency where there's no prior knowledge of this patient and no possible available substitute decision makers (family, proxies, agents, etc.)

It's a battery question, a question of informed consent, perhaps of implied consent. Where there's no consent - even if the patient (or fully empowered substitute) is withholding consent for reasons every doctor on earth thinks is a mistake - treatment is wrongful.

229

"Nonetheless, I think the prospective benefit of the hypothetical abortion needs to be better than the 1% chance of helping before it should be done. Truthfully, I don't know quite where I'd draw the line."

Nothing unique about abortion here. Most people would accept a slightly increased risk of death to save an arm or a leg but it is unclear where to draw the line.

HEY! Keep that cat the hell away from grandma!

Most people would accept a slightly increased risk of death to save an arm or a leg but it is unclear where to draw the line.

That's why we need a competent organization to set the standard for medical care. Not governmental, but private, along the lines of UL or ASTM or ANSI. Perhaps we could have an Organization for Research Grounded Application of Standard Medicine. Every medical condition would have its ORGASM treatment, and those treatments (and only those treatments) would be available.

This would eliminate
- the possibility of patients making bad decisions
- second guessing of individual docs' decisions
- frivolous medical malpractice lawsuits
- questions about the treat incompetent patients
- anguish and conflict within the family about what to do with Grandma. The answer would always be "give her the ORGASM treatment"

255: Best line:

Furry harbinger of death.

256: This would eliminate
...
- anguish and conflict within the family about what to do with Grandma. The answer would always be "give her the ORGASM treatment"

Maybe in your family.