Tuesday, May 18, 2010

Guns, Death with Dignity, and Moral Equivalency.

Tell me this: What's the difference between giving an elderly or disabled person a gun specifically designed for their use or giving them a lethal prescription for drugs? Either way, the licensed (and Medicaid-reimbursed) "object" can cause death of the prescribed person or others.

I would say no difference whatsoever, except for how we view personal autonomy with regards to the two lethal "objects." And the horrors of physical violence perpetrated by gun deaths. If I read one more website comment that says, "why legalize aid in dying when the determined ill patient can just end their life without approval?" I'm going to puke.

Where's Wesley J. Smith and his arguments for moral equivalency when you need him?!

The intended target market for the Palm Pistol is the elderly, the disabled, and individuals with limited strength or manual dexterity. [10] Carmel’s hope was for individuals in the target market to be able to request a prescription for the product from their physicians and be partially reimbursed by Medicare or private insurance. [11]

Matt Carmel is an NRA certified firearms instructor in New Jersey and learned that many of his clients had little experience shooting a gun. He observed that they were unable to keep the muzzle of their pistols steady, causing their shots to be inaccurate. He also found that beginning shooters have a tendency to shake because of a fear of recoil, fear of noise, and general apprehension in handling firearms. [12]

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The Case for Suffering.

Here are two interesting clips: one a heartbreaking story from a New Haven, Connecticut newspaper about the experience of a dying friend; the other a article on a talk given by Margaret Somerville on why aid in dying should remain illegal in Canada. What I'm contrasting in these two clips is the way suffering is discussed, the value placed on it, and the religious ideas that inform our justifications of suffering.

The so-called murder-suicide of a North Haven couple suffering from Alzheimer’s and cancer touches me, not only sympathetically, but personally. I have a longtime friend who, as I write, is facing a prolonged dying in "the American way."

She is a virtual prisoner of what, echoing President Dwight D. Eisenhower, one might call "the medical-religious complex."

Certainly, there are reasons to hold life sacred and to beware the institutionalization of death-dealing. Counterweighing these is the respect due to an individual’s autonomy in matters of ultimate value, especially the quality of one’s own life and death.

My friend has led an active, meaningful life, but now finds herself unable even to read, or to take pleasure in personal company, or to get out of her hospice bed, because of both the pain of her illness and the grogginess induced by the drugs used to combat her pain. While everyone caring for her is well-intentioned, the fact is, as she just put it to me, "I want this to be over yesterday."

AND #2:

Arguments against euthanasia are complex and far more difficult to make, she said.

"Today, the argument for euthanasia is the easiest to make," she said, noting the concern for the autonomous individual. "It's my right, my body. The individual has the right to choose death."

The arguments against euthanasia concern its effects on institutions, such as the health care system, hospitals, doctors and society as a whole, she said.

People often argue that we are merciful to dogs by euthanizing them, so why shouldn't we do the same for human beings, she said. "We're not dogs!"

Somerville said one of the biggest challenges is to argue there is something special about human beings without using religious reasons.

Traditional religion used to serve as a way of putting talk of death into a context of eternity, she said. "It is very difficult to justify suffering without some form of religious argument."

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The Opposite of Love is Fear?

Don't miss this fantastic post at GeriPal that makes us think about why we are so unprepared for end of life decisions. Here's a clip but please go read the whole thing:

Talking with patients about their impending death is never simple. However, it’s easier if it’s done with a certain kind of love. This love is related to compassion, the willingness to suffer along with another human being in pain. A quiet joy can emerge when people suffer together like this. Medical training seems to have little to say about death, and even less to say about this kind of love.

Common wisdom tells us that the opposite of love is hate. But that’s only true on the surface. Love and hate are two sides of the same coin, the coin of attachment. Humans are just as attached to the people they hate as to the people they love. Either way, they just can’t stop thinking and talking about each other. Look at the world of politics.

In reality, the opposite of love is fear. Whereas love connects us, fear cuts us off from each other. Fear fosters abandonment, which can take many forms. Some are more obvious than others, but all are damaging.

At times we abandon our patients by ignoring or rejecting them. More often, paradoxically, we abandon them to further treatment, treatment that may or may not extend their lives, never thinking to ask them how they feel about it. High costs can accrue from this thoughtlessness. These costs are not just economic, but emotional and spiritual as well.

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None For Me, Thanks.

Thaddeus Pope observes at his site, Medical Futility Blog:

On Sunday in New Orleans, Robert Fine and I did a pro-con debate on the Texas Advance Directives Act during an ethics session of the American Thoracic Society. There were around 150 people in attendance. One particularly telling moment was the following.

Bob asked who thought that a PVS patient should be dialyzed. Almost nobody raised a hand. He then asked who thought a severely demented patient should be dialyzed. Again, almost nobody raised a hand. Bob finally asked (perhaps wondering if the audience was participating) who has done it or seen it done. A majority of physicians in the room raised their hands. There is your standard of care.

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PVS Patients and Gender.

The curious case of Gary Harvey was covered in a long report at World News Daily yesterday. The title, "Another Terri Schiavo," seems to focus not on Gary but his sad and desperate wife, Sara, who has taken on the Catholic Hospital where Gary was being cared for. Her guardianship of her husband has been revoked and her visiting hours are limited. As the story notes, all of these actions are difficult to understand but it seems that Sara is fighting to take Gary home to care for him. The Schindler family, Terri Schiavo's family, are assisting Sara in her fight to retain Gary's feeding tube indefinitely.

The story has all the trappings of a difficult end of life scenario: a sudden collapse, resuscitation that recovered breathing and heard beat but not brain function, adult estranged children from prior marriages, conflict between the hospital and family members regarding proper care of a PVS patient, the Catholic church, do not resuscitate orders, money, absence of end of life planning, and contested definitions of death. The variables are that the Catholic church has been challenged with not honoring the sanctity of life and the sex of the PVS patient.

The cases of three persistent vegetative state (PVS) patients brought the diagnosis -- and the need for better laws and definitions of futile care -- to the public's attention: Karen Ann Quinlan, Nancy Cruzan, and Terri Schiavo. Though there are roughly 30,000 PVS patients in the country at any given time, the stories of these three young women -- struck down in their youth, their high school photos plastered on the nightly news, their choice of medical care in such a situation undetermined -- have been stories that stoked enormous public controversies over the past 30 years. It's curious that the emphasis of the recent case in upstate New York focuses on the wife.

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Hospice Does End of Life Planning.

It's a simple but obvious point that surely needs repeating: Hospice can help with end of life planning. If doctor's don't get reimbursed for those long conversations and families don't know where to start, perhaps we should think of hospice as the best resources for preparing for end of life care, as Sean Morrison, president of the American Academy of Hospice and Palliative Care, reminds us in a letter to the NYT editor, below. Don't know how to get that defibrillator turned off? Don't know what planning resources are available? Your local hospice does.

Re “Lifesaving Devices Can Cause Havoc at Life’s End” (Business Day, May 14):

As a doctor who specializes in hospice and palliative medicine, I see more patients and families facing critical decisions about advanced technologies near the end of life each day. People should consider hospice not only to assist with pain and symptoms, but also to facilitate decision-making around goals of care and advanced technology devices like defibrillators.

Hospice teams have the knowledge, skills and resources to guide patients and families through these difficult decisions.

R. Sean Morrison
President, American Academy
of Hospice and Palliative Medicine
New York, May 15, 2010

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