2000 Voices: Intentional Death in America Beyond the Hype

Voices Online Edition
Winter 2000
Volume XV No. 1

Bioethics Watch
Intentional Death in America Beyond the Hype
by Nancy Valko, R.N.

More than 30 years ago, when I was a new RN, my otherwise sophisticated grandmother confided that she was afraid to go into a hospital. “I hear they have a black bottle there and I know too many people who went in just fine but didn’t come out”, she insisted.

I laughed about the black bottle at the time, but I don’t any more. In 1997, Oregon voters approved the equivalent of a black bottle in the form of euthanasia known as physician-assisted suicide.

Glowing reports of the success of this law have been rampant in the press. But a closer look reveals major cracks in this carefully crafted facade.

A case in point is the most recently reported legal physician-assisted suicide in Oregon last October. Reported, that is, only in Oregon. The rest of the media conveniently missed it.

Kate Cheney, age 85, was diagnosed with terminal cancer and was showing symptoms of a growing dementia when she (allegedly) asked for a lethal overdose. She said she wanted the option of suicide in case she developed intolerable pain or if the loss of control of her bodily functions became unbearable. Mrs. Cheney had had her request for suicide turned down by a doctor concerned about her mental ability to make such a decision, but her daughter Erika was determined that the vaunted safeguards in Oregon’s physician-assisted suicide law would not become roadblocks to her mother’s death. Erica took her mother to other doctors and, in the end, found a physician/ethicist from Mrs. Cheney’s HMO who would approve the suicide. It turns out that such doctor-shopping and family enthusiasm for assisted suicide is not uncommon.

Despite assurances from the right to die folks that physician-assisted suicide would be strictly reserved for competent, terminally ill persons in unbearable pain who, without outside pressure, choose to take a lethal overdose when all other remedies have failed, Mrs. Cheney’s case is a cautionary tale for those who believe that legalized killing can be controlled.

Enter the Pain Relief Promotion Act
Since Oregon voters approved a physician-assisted suicide law in 1997, controlled medications like barbiturates have been used in all the reported cases. This posed a problem since the use of such medications appeared to violate the 1970 Controlled Substances Act which restricted doctors’ use of such medications to legitimate medical practice.

Indeed, initially U.S. Drug Enforcement Administration administrator Thomas Constantine ruled that using such drugs to terminate patients was not a legitimate medical practice. But later, Attorney General Janet Reno overruled this, maintaining that states have the right to determine what constitutes legitimate medical practice. (Ironically, Ms. Reno did support an earlier decision that California did not have the right to legalize medical marijuana when its voters approved it.)

In response to Ms. Reno’s actions, the US House of Representatives overwhelmingly passed The Pain Relief Promotion Act in November, which not only forbade the use of controlled medications to intentionally cause patients’ deaths, but also provided measures to improve the care and symptom relief of patients.

This was met by howls of outrage from most of the media, who seem to consider euthanasia a matter of choice like abortion. Stalwart opponents of increasing states’ rights in areas like abortion and school choice such as the New York Times now found themselves arguing that Oregon should be allowed to pursue its policy of assisted suicide unencumbered by federal regulations. Senator Ron Wyden of Oregon threatened to filibuster the Senate to prevent the Pain Relief Promotion Act from becoming law, and the Senate vote has been delayed to this date.

Right to die proponents respond
The powerful euthanasia movement also mobilized to protect Oregon’s assisted suicide law, especially since 4 other states are now considering similar assisted suicide laws this year. Contrary to press reports that the Pain Relief Promotion Act would outlaw assisted suicide, the Act only forbids the use of controlled medications for assisted suicide. But euthanasia proponents argue that such medications and medical involvement are necessary to ensure a peaceful death.

Thus, proponents of assisted suicide have pressured such groups as the American Medical Association, the American Nurses’ Association and the National Hospice Organization to oppose the Act. The American Nurses’ Association did go on record as opposing the Act; but the other groups, joined by scores of medical, pain, and hospice associations, do support the Act.

The euthanasia movement reaped a publicity windfall at the same time the Act was being considered by holding a convention of international right to die groups in Seattle to discuss methods of self-suicide which would circumvent laws against assisted suicide. According to Death Net, a website promoting the legalization of euthanasia, the convention was also a way to show that the resistance by lawmakers all over the West to legalizing physician-assisted suicide is forcing people to use “underground” tactics and methods. Most of the conference reportedly concerned the use of plastic bags and gases such as helium to induce black-outs and comfortable suffocation. (Personally, I wondered why the convention apparently did not mention such old suicide techniques like running a car in a closed garage.)

Other news life and death
In a case termed a Christmas miracle, Patricia White Bull, 42, awakened after 16 years in a vegetative state which occurred after she experienced a lack of oxygen during the birth of her youngest child. She spent the last several years in a nursing home receiving total care. She was tube-fed and reportedly did not respond until she suddenly started talking on Christmas Eve.

Unlike most patients who recover slowly from such a condition, Mrs. White Bull’s progress has been amazing. She is now eating, walking with support and even writing letters. Her doctors now say that her prognosis is excellent. Mrs. White Bull’s husband, who had divorced her when he was told that there was no hope, now says he is willing to re-establish a relationship with her if she wants.

Ironically, Mrs. White Bull’s recovery comes at a time when there is new pressure to remove feeding tubes from patients with dementia as well as from those in a so-called vegetative state like Mrs. White Bull.

In October 1999, the Journal of the American Medical Association published an article stating that tube-feeding elderly persons with dementia caused these patients more difficulties than benefits. A similar article appeared in the New England Journal of Medicine in January 2000. Both articles were not based on any new research but on reviewing studies as old as 30 years about the use of feeding tubes in a variety of patients. Both articles argued for changes in nursing home policies and Medicare guidelines so that tube feedings could be routinely withdrawn or withheld from the estimated 10% of nursing home patients diagnosed with dementia if they could not be fed by mouth. The New England Journal of Medicine article even bemoaned the “pervasive failure by both physicians and the public to view advanced dementia as a terminal illness” which would facilitate this change in policy.

Both articles state that there are virtually no benefits from tube feeding patients with dementia, even making the amazing assertion that tube-feeding has not been proven to prolong life.

Instead, the articles depict feeding tubes as fraught with dangerous complications, including even death itself. The mere presence of the tube itself is depicted as so onerous that many patients’ arms have to be tied down to keep them from removing the tube. This reminds me of the case of Mary Heier several years ago. Mary had dementia and the delusion that she was the Queen of England. Relatives brought suit to remove her feeding tube not because of problems with the tube feedings but rather so that she could be allowed to die. Mary Heier’s case was duly reported in a Boston newspaper one day along with a short item about Rose Kennedy having a minor procedure performed: the insertion of a feeding tube.

Ethicists have long been concerned about the number of doctors, nurses and families who are uncomfortable with death by starvation and dehydration. Articles which maintain that there are dire consequences to feeding patients by tube while simultaneously minimizing the effects of starvation and dehydration can go a long way to convince reluctant care givers that withdrawing food and water is the kindest way of dealing with a patient who has dementia.

In a largely unreported yet powerful October 1998 statement on this subject, Pope John Paul II addressed the issue of tube feeding by stating,
As ecumenical witness in defense of life develops, a great teaching effort is needed to clarify the substantive moral difference between discontinuing medical procedures that may be burdensome, dangerous, or disproportionate to the expected outcome what the Catechism of the Catholic Church calls ‘the refusal of “over-zealous” treatment’ (2278); (cf Evangelium Vitae, 65) and taking away the ordinary means of preserving life, such as feeding, hydration, and normal medical care. The statement of the United States bishops’ pro-life committee, Nutrition and Hydration: Moral and Pastoral Considerations, rightly emphasizes that the omission of nutrition and hydration intended to cause a patient’s death must be rejected and that, while giving careful consideration to all the factors involved, the presumption should be in favor of providing medically assisted nutrition and hydration to all patients who need them. To blur this distinction is to introduce a source of countless injustices and much additional anguish, affecting both those already suffering from ill health or the deterioration which comes with age, and their loved ones.

May we all join the pope in this great teaching effort to combat all forms of euthanasia and to restore a renewed respect for the life and the dignity of every human being.

References:
1.”Rethinking the Role of Tube Feeding in Patients with Advanced Dementia”, The New England Journal of Medicine January 20, 2000 Vol. 342, No. 3 , by Muriel R. Gillick, MD.

2. “Does Tube Feeding Prevent the Consequences of Malnutrition? A Review of the Evidence”, Journal of the American Medical Association, Vol. 282 No. 14, October 13, 1999 by Thomas E. Finucane, MD; Colleen Christmas, MD; Kathy Travis, MD.

3. “Is Mom capable of choosing to die?”, by Erin Hoover Barnett, The Oregonian, Saturday, October 16, 1999.

4. “Miracle Awakening After 16 Years Woman Out of Vegetative State After 16 Years”, By Shawna Vogel of ABC NEWS.com, 12/29/99.

5. Oct. 2, 1998 EWTN Feature Story “Pope Tells American Bishops: Fight Death Culture”, full text of an address delivered by Pope John Paul II to the bishops of California, Nevada, and Hawaii. The American bishops were in Rome for their ad limina visit.

6. Information on groups supporting and opposing the Pain Relief Promotion Act from private correspondence with Richard Doerflinger, NCCB.

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