Georgia Case: When is assisted suicide murder?

A case in Georgia involves a group called “The Final Exit,” which on its website purports to:

**Serve people who are suffering intolerably from an irreversible condition which has become more than they can bear.

**Foster research to find new peaceful and reliable ways to self-deliver.

**Promote the use of advance directives.

**Advocate for individuals when their advance directives are not being honored.

Law enforcement in Georgia has arrested four individuals associated with the group in connection with the death of a 58 year old man.

Lots of points of view in a case like this, including that of the Center’s Bill Colby in the blurb below. What do you think?

Assisted suicide case in Georgia revives right-to-die debate
Greg Bluestein
Associated Press
February 27, 2009

Some legal experts said they hope details of the network's work would help stoke a deeper discussion over assisted suicide. William Colby, an attorney who is a fellow with the Center for Practical Bioethics, said prosecuting the group wouldn't support that goal.

"People are trying to understand how we navigate the end of our lives, and we need to keep talking about it," said Colby. "But trying to round up people in groups on either extreme end of our social spectrum is not necessarily the best way to move public dialogue."

Ethical Analysis of Healthcare Reform

Rosemary Flanigan
February 25, 2009

Wheee! This has been a busy week—I’ve been talking to groups about the Center and each time I become inordinately proud (even though it’s Ash Wednesday) of the Center’s accomplishments over these past 25 years.

Somebody gave me the title, “Ethics Working for You”, and I have used it shamelessly. Because ethics can really “work” in the healthcare setting.

HOWEVER, in the President’s talk last night I didn’t hear “immigration” though I did hear over and over “healthcare reform” so I am predicting our ethics committees and centers will be “on the point” for discussions of different plans.

Meanwhile, our care for the poor will go on, unabated and unreimbursed! I always knew I was living in the Golden Age of Medicare and I predicted such goldenness would dim before I die—as it needs to do.

The need for ethical analysis all along the spectrum calls us to a renewal of our education out-thrust. I hope we’re up to the task. Any ideas for such an effort?????

The State of the Palliative Care Consult

Nothing has changed in 50 years

John Carney
February 20, 2009

An article and a letter to the editor in the February issue of Journal of Palliative Medicine both reflect the state of the palliative care consult. The verdict? Not good.

What I find troubling is that for far too many, goals of care rarely get talked about prior to the palliative care consult. Patients are often left to their own devices. Providers only narrowly discuss the disease for which they feel qualified and hardly any patient gets good information about the state of their advanced progressive chronic diseases. And, excuse me, but who among us is going to ask unless quality of life is hovering around zero?

We owe it to those with advanced chronic disease to be more honest and not rely on palliative care consults for the “truth dumping” that Nick Christakis reminds us can be just as deplorable.

What’s so hard about talking with folks - even theoretically - in early stages of chronic disease that it’s likely someday you’ll die from this condition? At the age of 80 or so my grandmother died after almost a half century of complications from diabetes. My father in law, at 91, died a similar death two years ago.

Little has changed with the advanced treatment of that disease in 50 years. His doctors refused to discuss palliative care alternatives with us.

At 55, I already know the chronic disease that will likely someday take my life. I just hope along the way, as it advances, I have the guts to ask where I am. Because everything tells me that neither my specialist nor my primary care doc will ever broach the subject.

Links:

The Clinical Quagmire of Palliative Consultation, Paul Russo, MD, Journal of Palliative Medicine, February 2009

Ensuring Informed End-of-Life Decisions, Kathryn Tucker, JD, Journal of Palliative Medicine, February 2009

A Bioethicist in the White House

What will that mean?

Dr. Ezekiel Emanuel is advising the Obama administration on healthcare reform. Dr. Emanuel is the Chair of the Department of Bioethics at the National Institutes of Health and was keynote speaker for the Flanigan Lecture in 2007. (Dr. Emanuel spoke on Allocating Scarce Vaccines in an Influenza Pandemic, evaluating principles that should guide decision-making around the allocation of scarce medical resources during a flu pandemic.)

So ... what will it mean to have a bioethicist in the White House? How will that influence the direction, scope and nature of healthcare reform?

Medical Students and TV Shows: Medicine Imitating Art?

John Lantos, MD

February 13, 2009

"This is America; haven't they ever heard of the Bill of Rights? We have a Bill of Rights in this country. It's right over there, on the wall. Tell them to go over there and read it."

Salvatore Locascio shouted those words at the trial of his father, a real world mob boss for the Gambino crime family. Did Salvatore learn them from the 1959 Hollywood movie, Al Capone, in which Rod Steiger, playing the title character, shouted at a judge, "We have a Constitution in this country. The Constitution -- ever heard of it? I suggest that when you go to your office you read it?"

It shouldn’t surprise us that life imitates art. It is as true for mobsters as for medical students.
But are we learning the right lessons?

Some fear that if we watch House, we will become House. This fear underestimates both our sophistication and House’s.

It underestimates ours by imagining that we are passive an uncritical emulators of whatever behaviors we see, rather than moral agents and interpreters who judge role models as either positive or negative. It underestimates House’s sophistication by imagining that everything we see on the show is bad or not worthy of emulation.

Doctor shows are popular and successful to the extent that mix up the admirable with the abhorrent, and show us the complexity of human character. Watching such shows can be excellent occasions for medical education.

Link: TV doctors' flaws become bioethics teaching moments, American Medical News, January 26

Speaking for those with diminished decisional capacity

Public ready to serve as surrogate

Gary Pettett, M.D., F.A.A.P.
Fellow, Center for Practical Bioethics

America’s nearly 70 million post-WWII “baby boomers” are now reaching their 60’s and beyond. Estimates suggest that as many as 30% will develop aged-related dementias of which Alzheimer’s Disease is the most common paradigm.

Efforts to prevent or minimize the health burden of dementia will be critical to sustaining a comprehensive and affordable health care system for an aging population.

Unfortunately, our current understanding of the epidemiology and pathophysiology of many of these disorders is incomplete. Clinical research designed to expand our knowledge of age-related disorders and answer many of these questions is essential.

However, much of that research will require the participation of elderly individuals with diminished decisional capacity. Despite years of debate, the absence of clear public policy on the participation of patients with diminished decisional capacity in clinical research leaves much of this work undone. Who will speak for those who cannot speak for themselves?

Interestingly, the public seems to be reasonably comfortable with the concept of a family surrogate to speak for those who have lost decisional capacity. In the January 13th issue of Neurology, Kim, et al.[1] reported the results from the 2006 Health and Retirement Survey, a biennial survey of a representative sample of Americans aged 51 and older.

Participants were queried specifically as to whether one would want to participate in a research study, whether our society should allow family surrogate consent for participation in clinical research, and whether one would allow surrogates some or complete leeway to override stated personal preferences.

In 2006, the Center for Practical Bioethics published a policy brief, Protecting Research Subjects with Diminished Capacity, providing a series of recommendations that might serve as a template for the development of public policy on clinical research in patients with diminished capacity.

These recommendations addressed the need to ensure that studies involving adult subjects with diminished capacity are conducted on firm ethical ground, that uniform procedures should be established for identifying surrogate decision-makers and defining the extent of their authority when acting on behalf of adults with diminished-capacity, and develop clearly defined criteria for determining the allowable levels and types of research related risks that would be appropriate for adults with diminished capacity.

Never before has research on age-related dementia been more important or more needed. The public seems ready. The ethical issues are not entirely new. Many were debated at length during the formulation of the federal guidelines for protecting human subjects in clinical research in the early 1970’s.

It is time now to focus our efforts on developing meaningful public policies and guidelines that foster clinical research to help us more fully understand and manage age-related dementias. The social and economic cost of ignoring these issues will far exceed the investment required to develop more effective health care for one of the most rapidly growing segments of our population.

Link:

Decide for Me When I Can't, Most People Say
HealthDay News
January 21, 2009

The survey of people age 51 and older found that at least 68 percent believed family surrogates should be able to grant consent for a mentally incapacitated loved one to participate in a research study.

[1] Kim SYH, Kim HM, Langa KM, et al. Surrogate Consent for Dementia Research. Neurology 2009, 72:149-155.

Octuplets -- Crazily Irresponsible

John Lantos
February 4, 2009

People seem to be bending over backwards to make this seem like a semi-reasonable decision by both the mother and the doctor who transferred eight embryos.

Why???

The mother is crazily irresponsible (having 6 small children at home, nobody to help her, and having eight more is insane - it is NOT like someone choosing to have a large family and giving birth to fourteen children, one at a time, over fifteen years.) It is absolutely impossible that she could take care of these children herself. To have them is absurdly, obviously, parental negligence.

A doctor who transfers 8 embryos - regardless of the woman's social situation - is professionally negligent - putting the woman and the embryos at risk. It violates professional standards for IVF, violates the best interests of the babies-to-be, and violates the doctor's fiduciary responsibility to take care of the woman's health.

The woman should have been sent for counseling, not IVF. The doctor should lose his license.

Link:

Octuplets, 6 Siblings, and Many Questions
Randal C. Archibold
Whittier Journal
February 3, 2009

A bioethicist at the University of Pennsylvania, Arthur L. Caplan, said the case posed thorny ethical questions, including whether a doctor should have accepted Ms. Suleman for fertility treatment considering she already had six children and the costs of caring for 14 offspring.

Musings on Organizational Ethics

Rosemary Flanigan
February 1, 2009

At any minute, Hans will be e-mailing me that I’m committing a FALLACY (“composition and division”, we used to call it)—but I have been thinking of the role of the ethics committee and of MEMBERS of the ethics committee (no, Hans, I do not expect of the members what I expect of the whole—but. . . .) regarding organizational ethics.

In the document, “Core Competencies for Health Care Ethics Consultation,” credit is given to Myra for her comments on an early version of the section on Organizational Ethics and she and Robert Potter, MD have written extensively on the subject. (Robert edited a whole edition of HEC Forum on the topic.)

So over the week-end I thought about us in the ethics committee movement and wondered how we were doing in this regard.

The areas are broad (health care business—cost shifting and billing practices; interactions with the marketplace—endorsing products, market promotion; societal and public health obligations; institutional obligations in training future healthcare providers or in performing research; and general business issues) and the ability to handle them requires a new kind of education.

The report concludes, “We encourage additional efforts, including both empirical and conceptual research, to define more clearly the scope of organizational ethics consultation; the most effective and efficient organizational structures for its delivery. . .; the degree to which it should include preemptive, unsolicited interventions; the appropriate approaches for dealing with organizational ethics issue; and the knowledge and experience that it demands.”

Can you give me any examples of such “empirical and conceptual research”??? HELP! Thanks.