Thursday, November 19, 2009

Catholic Health Australia and Palliative Care.

A number of converging issues bring the below article about Catholic Health Australia's revision of palliative care materials to my attention: 1. Australia is in the midst of a fierce struggle over the legalization of assisted suicide (or rather aid in dying) and 2. The United States Conference of Catholic Bishops have recently revised the Ethical and Religious Directives that govern all care, including end of life care and the honoring of individuals' advance directives in the US. I wonder what role the Catholic church has in medicine in Australia. And I will have to do more digging to find out what this brochure says about individuals' advance directives.

In part, the article reads:

According to Professor Richard Chye, a palliative care specialist at Sydney’s St Vincent’s Hospital who worked on the guide, this is partly due to a range of misconceptions about palliative care that are still common among health professionals.

“We know that we not only have a death-denying society but we also have a large number of death-denying health professionals,” said Professor Chye.

“Many of my colleagues, both doctors and nurses have a number of misconceptions about palliative care.

“For instance, a lot of them think palliative care is just about administering morphine and that palliative care patients only have days left to live. But giving morphine is only about 15 per cent of what I do as a clinician and as many as five per cent of my patients are still alive after 12 months.”

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Happy Birthday, Jesus!

My sister and I, when growing up, would spend an evening every holiday seasons singing carols with the neighbors. We would traipse around the sparsely populated neighborhood, harassing any inhabitants of houses with lights on with out songs. Then we would return, chilled to the bone, to the brightly decorated house of the Petersen family where hot punch was on the stove and snacks were arranged on plates emblazoned with Santa Clause faces and Christmas trees.

The evening would conclude with a loud belt of, "Happy birthday to you, happy birthday to you, happy birthday dear Jesus, happy birthday to you." Applause, cheers, a group blow-out of as many candles as the little cake could hold.

My sister and I would go home and report the events to our father who repeated that the Petersens just were not right. Of course, Mr. Petersen's clog-wearing and sweater-knitting didn't lend my father to favorable feelings either. My father, a former Mennonite, still stoic and reserved, had little patience with the slightly hippy Jesus worshippers up the road.

Looks like the entire world can join the Petersens this year! ReallyWooly offers you and your family a chance to join the world's largest digital celebration of Jesus' birthday ever!


Kier Starmer Asks for Other Faiths to Weigh In.

As the Director of Public Prosecutions winds his way through the debate on revision of assisted suicide guidelines in England, he has asked for those of other faiths to weigh in. reports:

The Director of Public Prosecutions is calling on Jewish communities across England and Wales to give their views on his interim policy on assisted suicide.

Keir Starmer, who leads the Crown Prosecution Service (CPS), has published the factors he takes into account when deciding whether or not to allow prosecutions for assisted suicide.

Mr Starmer said: “I am keen for as many people as possible to take part in this debate, including Jewish communities throughout England and Wales.

“I recognise how sensitive this area of law is and I respect the fact that there are many people who hold strong views on assisted suicide.

“I want to hear those views and that is why I have launched a public consultation. By considering as many opinions as possible, I can produce a final policy which is true to both the law and public feeling.”

Assisting suicide has been a criminal offence in the UK for nearly 50 years, and Mr Starmer said his policy did nothing to change that.

He said: “I also want to make it perfectly clear that this policy does not, in any way, permit euthanasia. The taking of life by another person is murder or manslaughter — which are among the most serious criminal offences.”

Anyone who wishes to view the policy and complete the consultation document can or write to the Assisted Suicide Policy Team, Crown Prosecution Service Headquarters, Sixth Floor, 50 Ludgate Hill, London, EC4M 7EX.

The closing date for responses is December 16 and the finalised policy will be issued in Spring 2010.

Rabbi Barry Marcus of the Central Synagogue said: “Were we to be asked, our attitude would be that we are mindful of and not totally insensitive to a situation that could bring a person to take their own life — or help someone else to do so. But the overall Jewish view is of the importance of the sanctity of life and its preservation.”

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Mennonite Mutual Aid: Is it Possible to Invest with Ethically?

From The Kalona News in Iowa, an article on Mennonite Mutual Aid's efforts to create ethical investing practices, tools and opportunities:

"For what profit is it to a man if he gains the whole world, and lose his own soul? Or what will a man give in exchange for his soul?"
Matthew 16:26

"The man who has won millions at the cost of his conscience is a failure."
BC Forbes

The American public has been bombarded for the past several years with news accounts of massive Ponzi schemes, predatory lending, unfair labor practices, industrial poisoning of water and air, excessive bonuses, corporate greed, Wall Street manipulations and toxic loans.
All these, along with the cost of the Iraqi War, have been blamed for the meltdown of the American economy. And all of these, says Jeff Swartzentruber, vice president of the MMA Trust Company in Kalona, are inconsistent with Christian principles. What is consistent with these standards, he added, is "stewardship investment."
The concept of stewardship investment is not new. The Religious Society of Friends (Quakers) founded an insurance fund in 1832 to provide life assurance to its members - and excluded investments in "sin" stocks. That insurance fund, now the FTSE 100 company, Friends Provident, celebrated its 175th anniversary.
Through the years, its exclusion of unethical companies expanded to include issues such as climate change, biodiversity and labor.
Swartzentruber says MMA's origins began in the 1930s when the Mennonite Church leaders identified some financial needs of its members, such as assistance with housing loans and sharing resources among Mennonite churches. It eventually morphed into Mennonite Mutual Aid (MMA) - incorporated in 1945. Its services expanded, along with the members its represents. These now include a number of churches that have Anabaptist ("rebaptize") roots and historic ties to the 16th Century religious reformers, among this list are the Religious Society of Friends, Old Order Amish and Church of the Brethren.
MMA's stewardship investing examines both the financial and social records of hundreds of companies, Swartzentruber says, and uses these six guidelines for investments:
* Respect the dignity and value of all
* Build a world at peace and free from violence
* Demonstrate a concern for justice in a global economy
* Exhibit responsible management
* Support and involve communities
* Practice environmental stewardship
There are obvious types of companies that MMA does not invest in because of Mennonite beliefs, said Swartzentruber - manufacturers of alcohol and tobacco products, as well as companies where incomes are significantly generated through military contracts.
MMA does invest in some companies that at first glance might not appear to be live up to these standards, acknowledged Swartzentruber. Since no company is perfect, he said, their stewardship investment strategy also includes shareholder advocacy, which can help steer a company in a more ethical direction through the use of dialogue and other means.
MMA literature states, "Socially concerned, active shareholders in publicly-traded companies are becoming increasingly important. The voice they provide in the development of responsible business practices that provide both social and financial benefits cannot be underestimated."
"As part-owners, we believe it is also within our rights and responsibilities to communicate with corporate management about the practices and activities we believe have a negative impact on communities, individuals, and the environment."
An example is Wal-Mart, said Swartzentruber. Some of the practices of the giant retailer might exclude it from some stewardship investment lists. But through proxy voting and interaction with its board of directors, MMA hopes to have a positive impact on its future practices.
Just recently, Wal-Mart announced plans to develop a "sustainable product index" that will establish a single source of data for evaluating the sustainability of products. The company is beginning with a survey of its more than 100,000 suppliers. The survey's 15 questions will allow the suppliers to evaluate their own sustainability efforts, focusing on four areas: energy and climate; material efficiency; natural resources; and people and community. Wal-Mart will take this information and create a rating label on each product.
MMA is a member of Interfaith Center of Corporate Responsibility (ICCR), which includes nearly 300 faith-based institutional investors. When ICCR asked Pepsi if it was not concerned about the AIDS pandemic in Africa, said Swartzentruber, company officials replied that they didn't think it was within the company's responsibility.
MMA representatives brought it to the floor during a stockholder's meeting, noting that AIDS has a direct impact on Pepsi's African employees, as well as its customers. Pepsi now has a number of HIV/AIDs programs in Africa, Swartzentruber said.
"We don't have all the answers," Swartzentruber admitted when it comes to deciding who should be on their investment list and who shouldn't.
Some are pretty clear, though he said. Exxon is excluded because of its historical environmental record. General Electric is on the no-go list because of its defense contracts--the same goes for Caterpillar. Jack Daniels doesn't make the grade for obvious reasons. It should be noted that the mention of these company names is not meant to disparage, only to recognize a difference in values understanding--each investor must make their own decisions and choices when buying individual equities.
Microsoft does have products purchased by the military, but since they were not developed specifically for military purposes, MMA does invest in the computer software company.
Swartzentruber says there are now a number of firms and funds that follow the stewardship investment philosophy. He pointed to Pax World, billed as the nation's first socially responsible mutual fund that was launched in 1971.
Pax World's website states, "Pax World is at the forefront of a new investment approach: Sustainable Investing - the full integration of environmental, social and governance factors (ESG) into investment analysis and decision making. Pax World is a leading advocate for Sustainable Investing, an emerging discipline based on the financial materiality of ESG factors."
Calvert Investments is another investment management company he says involves stewardship investment. The company describes itself as a leader in sustainable and responsible investing (SRI).
The three SRI approaches Calvert lists are:
* Two distinct research frameworks: a rigorous review of financial performance, and a thorough assessment of environmental, social and governance performance.
á* A thematic approach to solving some of today's most pressing environmental and sustainability challenges.
* An "enhanced engagement" approach emphasizing strategic engagement to advance environmental, social and governance performance in companies that may not meet certain standards today, but have the potential to improve.
In the end what is of importance, Swartzentruber said, stewardship investment is a way to bring ethical considerations, faith-based values, to otherwise soulless corporate entities.

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No Longer Relevant? Medical Ethics and Philosophy

The Yale Daily News has a little post on a visit paid by University of Chicago Professor William Meadow. The article is brief and I'll post it in whole at the bottom, but note these zinger quotes from Meadow:

“Everything you might have ever learned in a philosophy class about medical ethics,” William Meadow whispered to a crowd of about 20 students, “[is] useless.”

“The problem with bringing philosophical implications into these discussions [is that] they get the easy questions right, and they don’t help with the hard ones,” Meadow said. “I’ve been accused of not having a moral compass before, and I’m OK with that.”

“Medical ethics changed drastically the minute you could keep people alive mechanically,” Meadow said. “Aquinas and Aristotle just didn’t know jack about medical ethics.”

** Entire Article

“Everything you might have ever learned in a philosophy class about medical ethics,” William Meadow whispered to a crowd of about 20 students, “[is] useless.”

At a Master’s Tea Tuesday in Saybrook College, Meadow, a professor of neonatology at the University of Chicago, led a discussion about the ethics surrounding euthanasia. Because philosophy often presents abstract, universal solutions, Meadow said, it often fails to resolve such difficult decisions.

“The problem with bringing philosophical implications into these discussions [is that] they get the easy questions right, and they don’t help with the hard ones,” Meadow said. “I’ve been accused of not having a moral compass before, and I’m OK with that.”

Meadow presented six case studies that deal with the questions of when it is morally acceptable to take a patient off life support, who is responsible for making the decision and what the decision says about society as a whole.

For the first half of the interactive talk, Meadow presented a case in which an elderly man had been diagnosed with a cancer that had spread throughout his body, causing multiple-organ failure and leaving the man unable to breathe by himself. Meadow argued that as the details of the case changed, the decision to place the man on a ventilator became more complicated, to the point where audience members were unable to say what they would do.

When the conversation turned to a situation where the elderly man had no one to speak on his behalf, Stephen Paquin ’11 asked whether the writings of 13th-century philosopher Thomas Aquinas could provide an answer to whether to keep the man alive. But Meadow said the writings of many philosophers cannot apply to modern medicine.

“Medical ethics changed drastically the minute you could keep people alive mechanically,” Meadow said. “Aquinas and Aristotle just didn’t know jack about medical ethics.”

New Haven resident and attendee Joshua Safran asked whether utilitarianism, which calls for the greatest amount of happiness for the greatest number of people, could answer whether the $2,000 per day it costs to keep a patient on a ventilator would be better spent if used elsewhere.

Meadow said this would be impossible in the United States because the money could not be reallocated under Medicaid, which helps to cover some health care costs for low-income individuals.

Discussion then turned to an infant born 13 weeks prematurely, who needed a ventilator to breathe. In this case, Meadow said, the parents did not want to keep the baby on a ventilator because they were not sure what health complications the infant would face later.

Meadow said that the question of whether the baby would face physical or mental disabilities was important to consider. For example, if the baby only needed braces in order to walk, Meadow said that most people would disagree with the parents’ decision to not put the baby on a ventilator. But if the baby were mentally challenged to the point where the parents would need to care for it indefinitely, Meadow said many would probably agree with the parents’ choice.

Meadow also serves as a professor of community health sciences within the Institute for Molecular Pediatric Sciences at the University of Chicago and assistant director of the MacLean Center for Clinical Medical Ethics at the University of Chicago.

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Compassion & Choices Press Release on USCCB's Denial of Patients' Advance Directive Rights.

Catholic Health Care Facilities to Ignore Advance Directives,
Patients will be Force-Fed Against their Will

The United States Council of Catholic Bishops has ordered Catholic healthcare institutions to veto the Advance Directive wishes of millions of Americans on the refusal of tube feeding if they were to become permanently unconscious. Compassion & Choices, the nation’s oldest and largest nonprofit working for end-of-life care and choice, sharply criticized the action as an imposition of dogma over the desires and dignity of patients and families. Polls show that at least three-quarters of Americans report they would not want to be kept alive artificially if they were in a persistent vegetative state. Most people who fill out advance directives indicate they do not want artificial feeding if they become permanently unconscious.

But the revised “Ethical and Religious Directives for Catholic Health Care Services” (ERD) decrees those wishes will not be honored at the 565 Catholic hospitals across the nation, by Catholic HMO’s and health care plans and by millions of nurses, doctors and hospital workers who must follow the bishops’ lead.

“The impact is enormous, for Catholics and non-Catholics alike,” said Barbara Coombs Lee, president of Compassion & Choices. “The USCCB order runs counter to written instructions in hundreds of thousands of Advance Directives and the clear wishes of many individuals with no written document. The primary consideration in healthcare decisions should always be the individual’s values, beliefs and desires, not fixed doctrine of any one religion. We respect the beliefs of all Catholics, but we do not respect an attempt by Catholic Bishops to override the health care decisions of a majority of Americans. This Directive could bring an equivalent of Terri Schiavo’s tragedy to 300,000 families each year.”

Catholic healthcare institutions must abide by a set of rules called “Ethical and Religious Directives, written by the US Bishops. Meeting in Baltimore, the bishops yesterday overwhelmingly approved a revision to the directives with a specific reference to the “persistent vegetative state” that afflicted Terri Schiavo. Removing all flexibility to respect the wishes of a patient or family, the revised directive creates “an obligation to provide patients . . . medically assisted nutrition and hydration” in all instances except when a patient is actively dying. Thus, Catholic hospitals and nursing homes are now obliged to insert and maintain feeding tubes in all patients with severe advanced dementia, permanent unconsciousness and persistent vegetative state.

An estimated 10,000 to 25,000 adults currently live in a persistent vegetative state (PVS), according to Ronald Cranford, neurologist and clinical ethicist at theUniversity of Minnesota. Every year, 300,000 feeding tubes are inserted, usually in patients with PVS, advanced Alzheimer’s disease, and permanent unconsciousness from other causes, such as strokes. Decisions must be made to withhold them, withdraw them, or retain them indefinitely. The prior version of the ERD suggested a “presumption in favor” of feeding tubes, balanced against the burdens to the patient. That balancing allowed doctors to give weight to a patient’s previously stated wishes and reports from family of what the patient would want. The new guidelines allow no consideration of the burden to the patient or the testimony of the family.

“When a healthcare institution adopts a conscience provision that effectively invalidates the advance directives of millions of Americans, it calls into question whether federal dollars are funding religious discrimination against Americans who do not share the Catholic view of end-of-life decisions,” said Barbara Coombs Lee, President of Compassion & Choices.

The proposed revision to the ERD reads, “As a general rule, there is an obligation to provide patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic conditions (e.g., the ‘persistent vegetative state’) who can reasonably be expected to live indefinitely if given such care.”

Compassion & Choices is a nonprofit organization working to improve care and expand choice at the end of life. We support, educate and advocate.

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Getting Lost in the Hypocrisy.

The American Catholic writes that the Republicans are guilty of hypocrisy by now, in the debate to reform health care, standing against cuts to Medicare.

Despite the collective amnesia of the American people, to the obvious joy of Republican political strategists, historical record on the other hand points out a glaring contradiction that makes their arguments seem wholly and entirely politically pragmatic. For example, during a vote in the House on April 2, 2009 the majority of House Republicans sought to end Medicare as it currently exists in the vote on the Republican budget alternativesubmitted by Budget Committee Ranking Member Paul Ryan (R-WI). The amendment won support from nearly four-fifths of House Republicans and effectively would have converted Medicare into a voucher system providing future retirees with a fixed amount of money to buy private insurance plans.

Valid point, sort of. But what the writer gets wrong is 1.) the nature of the cuts to Medicare as proposed by Democrats; and 2.) the "inevitable" rationing that faces the country under health care reform and such budgetary cuts.

I can't blame the writer, really. Democrats have avoided the rationing conversation since the beginning when they should have embraced the discussion to reveal the ways in which current practices of rationing will be regulated by government intervention. And they haven't clearly defined how they will cut Medicare, allowing the cuts be wrongly characterized as simple rationing instead of cutting the over-treatment, over-medication, and over-testing that is done to seniors - with little benefit - under the current system.

Hypocrisy is one thing that unfortunately both sides of the aisle have engaged in for their ends. Clearer information is needed to debunk the rationing and cuts accusations. I wish the media were working harder to set The American Catholic and other misinformed parties straight.

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Peter Singer, Catholic Directives, and the "Slippery Slope"

I was lucky enough to catch a showing last night of the movie "Examined Life" by Astra Taylor at the Brooklyn Society of Ethical Culture, hosted by (my sometimes other home). It's a beautifully shot series of interviews with a number of philosophers including Cornell West, Martha Nussbaum, Kwame Anthony Appiah, Judith Butler and Peter Singer. They are outside, not in their academic halls or behind desks, talking about ethics, life's meaning, revolution, justice, and cultural relativism, roving around cities in cabs, digging through trash, rowing boats on a lake, or perusing shops on 5th Avenue. While the movie is demanding, the take away is worthwhile.

And in one of life's overlaps, Peter Singer, one of the featured philosophers in the movie, has an article up at the DailyStar today titled, "Voluntary Consent is Neglected in the Euthanasia Debate."

Singer writes that while the Catholic Church and opponents of aid in dying often cite the "slippery slope," the argument that allowing patient-elected aid in dying will result in state or doctor directed assisted suicide, this argument has been disproven in countries and US states where aid in dying is legal. The greater danger, explains Singer, is in what the Catholic Church has decided is theologically acceptable:

In 1957, a group of doctors asked Pope Pius XII whether it is permissible to use narcotics to suppress pain and consciousness “if one foresees that the use of narcotics will shorten life.” The pope said that it was. In its Declaration on Euthanasia, issued in 1980, the Vatican reaffirmed that view.

The Vatican’s position is an application of what is known as “the doctrine of double effect.” An action that has two effects, one good and the other bad, may be permissible if the good effect is the one that is intended and the bad effect is merely an unwanted consequence of achieving the good effect. Significantly, neither the pope’s remarks, nor the Declaration on Euthanasia, place any emphasis on the importance of obtaining the voluntary and informed consent of patients, where possible, before shortening their lives.

According to the doctrine of double effect, two doctors may, to all outward appearances, do exactly the same thing: that is, they may give patients in identical conditions an identical dose of morphine, knowing that this dose will shorten the patient’s life. Yet one doctor, who intends to relieve the patient’s pain, acts in accordance with good medical practice, whereas the other, who intends to shorten the patient’s life, commits murder.

(Incidentally, the Catholic Church supports the use of the "double effect" for pregnant women whose life is in danger: an ectopic pregnancy can be ended by surgery because the objective is to save the woman's life; less invasive medicinal treatment is not allowed because the objective is to kill the fetus.)

Singer uses the example of doctors at Memorial Medical Center in New Orleans who ended the lives of immovable patients during Katrina rather than let them suffer alone and unattended in the hospital after nurses and other patients were evacuated. Of one doctor and what occurred at Memorial, Singer writes:

Cook had little time for such subtleties. Only “a very naive doctor” would think giving a person a lot of morphine was not “prematurely sending them to their grave,” he told Fink, and then bluntly added: “We kill ‘em.” In Cook’s opinion, the line between something ethical and something illegal is “so fine as to be imperceivable.”

At Memorial Medical Center, physicians and nurses found themselves under great pressure. Exhausted after 72 hours with little sleep, and struggling to care for their patients, they were not in the best position to make difficult ethical decisions. The doctrine of double effect, properly understood, does not justify what the doctors did; but, by inuring them to the practice of shortening patients’ lives without obtaining consent, it seems to have paved the way for intentional killing.

And concludes:

Roman Catholic thinkers have been among the most vocal in invoking the “slippery slope” argument against the legalization of voluntary euthanasia and physician-assisted dying. They would do well to examine the consequences of their own doctrines.

By poking a finger at the Catholic Church's directives, Singer means to turn the "slippery slope" argument around on them, insinuating that patients' consent is already undermined by Catholic doctrine. He pits the Church and medical profession against one another (at a time when the Catholic Church is working double duty to "protect" doctors with conscience clauses so long as they do the Church's bidding).

Yet Singer fails to address what ethical decisions the doctors at Memorial should have made: should they have allowed the immobile patients to die in suffering? Should they have risked their own lives and the lives of their staff by remaining with patients?

The Catholic Church has never been a strong defender of patients' rights in any way. They are too invested in their own fight for jurisdiction over suffering, working to impose their own doctrines over end of life situations for both patients and doctors.

The medical profession too has not strongly come out on the side of patient's rights; they have their own claims to suffering that are enforced by the contemporary nature of their profession: aggressive treatment, avoidance of developments and investment in hospice and palliative care, reticence to talk about death, what the doctor views as failure.

The Death with Dignity, aid in dying movement - a movement that has asserted around the world a patient's right to choose how they die - works to prepare patients for those questions and establishes that the patient is the one who controls their death decisions with advanced directives, medical proxies, and access to information. This is done in conjunction with doctors and family members in a way that prepares all parties to accept and enact a patient's decisions.
What occurred at Memorial hospital had nothing to do with patients' rights, as Singer points out. It was a crisis situation that forced doctors to determine the best way to keep patients from needless suffering. It's a practice, mercy killing, as old as time.

The Catholic Church's directives on the "double effect" had little bearing on the doctor's decisions: with or without Catholic approval, the "double effect" is used in hospice and retirement facilities and hospitals across the country every day to prevent suffering and to protect doctors from prosecution. It shocks us because we don't like to talk about it; because we don't often have to face how we die in such a graphic manner as the Memorial event portrays.

If Singer's purpose is to show the complicity the Catholic Church has in the erosion of patient's rights - in essence, that they have created their own slippery slope - I fear he has chosen the wrong example; yet the point is incredibly valid. (Note the USCCB's recent decision to reclassify removal of patients from artificial nutrition and hydration as impermissible, despite the patient's advance directives.)

If the purpose of the article is to assert patient's rights, again, the sad situation in New Orleans would not have been helped if all the patient's choices had been written on their charts. And lastly, if he intends to vilify doctors like Cook who had few if any options of how to keep abandoned patients comfortable, his argument is unconvincing.

In "Examined Life," Slavoj Zizek addresses what he calls, "the temptation of meaning." Once we assert ideas of "meaning" on life, we tend to stop questioning that meaning, we cling to old traditions, beliefs or practices that may no longer apply. I wonder if Singer's ethics have settled on a meaning of patients' rights that advancement in medicine and the stagnation of Catholic doctrine have too long dictated and obfuscated. Perhaps it's time to find a new meaning.

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