A Confusing Variety of Hybrids
What about “choice” in health care?
Americans have not wanted to pay for assisted suicide or euthanasia any more than they have wanted to pay for abortions. When it became clear that physician-assisted suicide might be legalized in some states, Congress passed the Assisted Suicide Funding Restriction Act of 1997.
This act specifically distinguished between assisted suicide or euthanasia — which could not be funded — and withholding or withdrawing food and fluids — which could be funded.
There is reason to believe that the food and fluids loophole has undermined the purpose of the Assisted Suicide Funding Restriction Act, which was to protect Americans from having to pay for medical practices of which they disapprove. Since the passage of this act, it has become increasingly difficult to distinguish between assisted suicide or euthanasia, on the one hand, and withholding or withdrawal of food and fluids, on the other.
It is not unusual when one version of something is legal and the other illegal, that a confusing variety of hybrids begin to spring up.
For example, it used to be that even a child could tell the difference between a car and a truck. That was before the government gave manufacturers of trucks exemptions on certain requirements. After that, manufacturers began producing more and more sports utility vehicles (SUVs), an in-between vehicle that can be used like a car but classified as a light truck.
Similarly, we have recently seen the deliberate promotion of a procedure that can be used like assisted suicide, but classified as refusal of food and fluids.
They Are Ready and Willing to Help You Die
In 1993, Bernat and his co-authors, writing in the Archives of Internal Medicine, described a procedure called Patient Refusal of Hydration and Nutrition (PRHN), the deliberate cessation of drinking and eating by a conscious patient for the purpose of hastening death.
Patients undergoing PRHN receive medical assistance, for example, having their mouths moistened or being given small amounts of liquid, dosed exactly to alleviate symptoms of thirst without meeting requirements for continued survival. Moreover, they are sedated.
In the past, there was some controversy in the medical literature about whether it was ethical for a physician to inform the patient about the legal option to starve with medical assistance.
This past summer, all hesitation with regard to publicizing this option came to an end. Dr. Linda Ganzini, an Oregon psychiatrist, and her co-authors, writing in the prestigious New England Journal of Medicine, reported a survey of the opinions of hospice nurses regarding the quality of death of patients who deliberately starved with medical assistance. These nurses, who were responsible for keeping their patients comfortable, reported that they were indeed comfortable. This conclusion, although not terribly surprising given hospice-style sedation, was featured in newspaper articles across the country.
The legality of this procedure rests upon the argument that the medical profession cannot force food and fluids upon a patient who has refused them.
However, that doesn't mean that Americans, who are protected from having their federal funds used for abortions, should have to pay for this deliberate elaborate multidisciplinary set of procedures that results in a patient's death.
At this moment, anyone over 65 with a doctor's statement that he has a six-month prognosis could enroll in hospice and ask for medical help with self-starvation. Far from having to endure the discomforts of an illegal rendezvous with Kevorkian in a van, leaving an outraged family, he could get medical help with self-starvation in his own home, paid for by Medicare, with government-sponsored counselors to coach his family into “letting go.” According to Ganzini's survey, at least 102 patients met their death in this manner in Oregon hospices between 1997 and 2001.
Americans learned from the unforgettable smiles of Terri Schiavo — the brain-damaged woman whose husband is still trying to remove her food and fluids — that it is not just comatose patients who are candidates for starvation and dehydration. They are reading newspaper accounts of patients whose doctors had given up on them, but who nevertheless recovered. They are beginning to realize that every day in intensive care units and hospices, there are death-hastening decisions that they may not approve of and may not wish to pay for. If the government pays for a particular practice, that very payment gives it an unmerited government stamp of approval. This stamp of approval may influence family decisions by legitimizing this option in their minds.
Can new legal distinctions be introduced? Can facilities that practice starvation and dehydration be subjected to scrutiny? So far, we have allowed the details of who refuses food and fluids and under what conditions to remain in our “blind spot,” so to speak. To begin oversight of these activities at this time would, admittedly, be like making a right turn from the left lane. We would need to have a national discussion regarding which kinds of starvation and dehydration the public is willing or unwilling to support.
It Is Time to Be Alarmed
What I am about to say may sound shocking, but, after some thought, you may agree with me. I believe that ultimately, after we perhaps try to figure out and achieve consensus on which is the “good” starvation and dehydration and which is the “bad,” that we will realize that the most feasible strategy is not to support any kind of starvation or dehydration. Consider:
• Can government regulators get into hospice and really distinguish, for each patient, whether he is dying of his illness or dying of starvation?
• Can they listen to every moment of counseling and find out which counselors are inadvertently encouraging death?
By stopping the federal funding of the care of any patient once his nutrition is terminated, we introduce at least a speed bump on the road to hastened death. It is not too much to ask families of those who opt for self-starvation to pay for the last two weeks of their care.
After all, families who choose curative care sometimes have to pay for years or even decades of care for their loved ones if they need more than a hundred days of nursing home treatment.
How will we know when our experiment of allowing starvation and dehydration to have the status of just another government-sponsored health care choice has gone too far? When will it be time to make a U-turn and change gears so we can climb back up the slippery slope? When cases come along that cause outrage? That has already happened. When the pope says our practices are euthanasia? That, too, has already happened.
It is too soon to evaluate the total impact upon American public opinion and health care institutions of the pope's statement on March 20, 2004 that “administration of water and food” is “a natural means of preserving life, not a medical act” and that it is “ordinary and proportionate, and as such morally obligatory” and that death “by starvation or dehydration” is “true and proper euthanasia by omission.”
However, no matter how great the success of those who will seek to minimize the application of the pope's words, it is very clear that starvation and dehydration are, like abortion, in the category of procedures that many, perhaps even most, Americans disapprove of and would not wish to pay for.
Closing the food and fluids loophole will at least fulfill the intention of the Assisted Suicide Funding Restriction Act of 1997 — to protect Americans from having to contribute, against their conscience, to procedures that cause death.
© Copyright 2004 Catholic Exchange
Dr. Olevitch is a clinical psychologist and author of Protecting Psychiatric Patients and Others from the Assisted-Suicide Movement: Insights and Strategies (Praeger, 2002).
