Tasmanian Devils.

If you want a rational voice on end of life care and law, I can recommend some others than Wesley J. Smith who makes his money from the ultra-conservative Discovery Institute and books, blogs and articles (for the likes of National Review and First Things) on nebulous, bible-esque stuff like the "sanctity of life" and the "slippery slope" and the "culture of death" that's out to kill, you know, any body it can. The underlying groan of Smith's writing is anti-"socialist" -- whatever that means -- and yet strangely all for government telling us when and where we can die. It's an odd, potent mix of narrative that, thanks to a host of popular (but not truly populist) politicians and media celebrities, has tea party (hence, well-funded think tank) legs at the moment.

Australia has been debating assisted suicide for a while. Never one to lose a chance at the limelight, Smith's decided to weight in. From ABC News Australia:

Wesley Smith has been brought to Australia by the Right to Life lobby group to lobby in Tasmania, Queensland, Victoria, New South Wales, and Western Australia.

Mr Smith says Tasmanian politicians' backing for a private member's bill could end in a voluntary euthanasia law that will lead to a broader range of people being eligible for assisted suicide.

He says that in Belgium and the Netherlands legislation has been gradually eased to allow sick babies, people with mental illness and healthy spouses of terminally ill people to be euthanised.

Mr Smith says there can be no legislative roadblocks to restrict who would be eligible for assisted suicide.

"Once you accept the precepts of assisted suicide, that suffering is a just cause for helping someone to end their life, it's not going to remain restricted," he said.

"That's the argument I think we should have as a society."

In other words, Smith's not interested in dialogue, he's already laid out his argument and expects others -- despite the horrors of end of life care, four decades of technical advancements that have changed the definition of death, rampant futile care, and failing health systems across the globe -- like the Australian government to toe his line.

We can say that Smith has a right to his opinion here in the U.S. -- the First Amendment exists for a vital reason -- but he must adhere to facts, an area where he prefers to move quick and loose. But playing the ambassador to other countries, even at the invitation of religious groups that espouse broad imposition of ideological medicine on all citizens, is really offensive. Particularly when he purports to be an expert, touting the horrors of the Netherlands' and Belgium's laws and health care systems. From a man who still claims Terri Schiavo was murdered. His broad-strokes, black and white approach to bioethics is embarrassing. His use of the controversial subject and the politically, ideologically motivated "right to life" organizations to get the limelight is irresponsible. Take the "Made in America" sticker off that export.

Rational Rationing.

Bioethicist Jacob Appel, writing at HuffPo, notes the recent Bentacourt case in New Jersey of futile care and distinguishes between rational rationing and irrational rationing. He writes:

The facts underlying the case are indisputably tragic. In 2008, Betancourt underwent cancer surgery at Trinitas Regional Medical Center, a Roman Catholic hospital in Elizabeth, and later suffered an irreversible anoxic brain injury when his breathing tube became displaced. By 2009, the seventy-two year old was unconscious, kept alive by a ventilator, artificial kidneys and tube feeds. Infected ulcers covered his body. Unfortunately, the patient left no advance directive stating what he wanted done under such circumstances. The team of physicians treating Betancourt determined that he was in a vegetative state and, reportedly in consultation with the hospital's ethics committee, sought to forgo extraordinary forms of therapy, such as dialysis and cardiopulmonary resuscitation. Betancourt's daughter, Jacqueline, who rejected the medical team's view that providing such treatment to her father was merely prolonging the dying process, then obtained a court order for additional care. While the hospital appealed on the grounds that continued interventions were both medically inappropriate and unethical, Betancourt died. However, as the questions raised by this tragedy are likely to arise again in other end-of-life cases, New Jersey's Superior Court is expected to issue an opinion in Betancourt v. Trinitas that will clarify whether physicians and hospitals may refrain from providing costly care that they believe to be unconscionable.

For much more on the case and the potential ramifications of the court's decision, read details at Thaddeus Pope's site Medical Futility Blog. Pope was a witness in the trial. He also discusses Appel's article at HuffPo.

Appel takes a lot of grief from the likes of Wesley J. Smith for his "practical" approach to allocation of medical resources. In the post Appel writes (and I quote a lot because I think it is important, particularly his clarification of how the definition of death has changed, something I write about often):

There is a fundamental difference, however, between asking to be permitted to keep a vegetative relative on costly machinery, and asking the taxpayers or society as a whole to pay for such machinery. Money spent on vegetative patients is money not spent on preventive care, such as flu shots and mammograms. Each night in an ICU bed for such patients is a night that another patient with a genuine prognosis for recovery is denied such high-end care. Every dollar exhausted on patients who will never wake up again is a dollar not devoted to finding a cure for cancer. While the visible victims may draw the headlines and attract indignant protests from so-called "pro-life" organizations, the invisible victims are people like you and me who will suffer from diseases that are never cured because funds are being poured down a healthcare sieve in order to maintain permanently-unconscious bodies on complex and costly forms of life support. I suspect that the vast majority of people, not knowing in advance whether they will either end up in a permanently vegetative state or be diagnosed with cancer, would prefer that any resources that would be spent on PVS care be reallocated to cancer research--or some similar enterprise that has the potential to help human beings who might actually recover.

The stark reality is that modern end-of-life ethics are on a collision course with themselves. As technology enables people to remain "alive" on ever more complex equipment, such as bilateral ventricular assist devices and extra-corporeal membrane oxygenation machines, the line between life and death blurs. Soon enough, a patient may be able to remain on such apparatuses for many months, long after meaningful brain function has ceased, until his skin and tissue begins to putrefy. When does such an existence transcend the barrier between living and dead?

Those who favor funding unlimited care for PVS patients tend to view the difference between these cases and other severe illnesses as a matter of degree. As a result, they worry about a slippery slope that might ultimately result in our pulling the plug on the cognitively intact but disabled. Yet PVS patients should instead be viewed as different in kind from other medical cases. In essence, the Betancourt court can decide that physicians and taxpayers only have a duty to provide unlimited care to patients who have a meaningful chance of returning to consciousness. Let us make no mistake about what this would mean: It would mean declaring that the lives of PVS patients are worth less than those of others. Rather than shying away from this outcome, progressive bioethicists should have the courage to acknowledge and to embrace this proposition.

Smith False History and Leaps of Faith.

It's hard to believe that Wesley J. Smith has been watching the assisted suicide movement for the past 17 years and still has to publicly ask the question, "Why Now?" Yet this is the shallow and disingenuous hook on which he hangs his new article at the Catholic magazine Legatus. After spending three paragraphs spinning the recent history of the aid in dying movement as a powerful force railroading the sanctity of life -- and seemlessly sliping in a new usurpation of social activism terminology, "sanctity/equality of human life"! -- he writes:

A question amidst all of this Sturm und Drang naturally arises: Why now? After all, 100 years ago when people did die in agony from such illnesses as a burst appendix, there was little talk of legalizing euthanasia. But now, when pain and other forms of suffering are readily alleviated and the hospice movement has created truly compassionate methods to care for the dying, suddenly we hear the battle cry “death with dignity” as “the ultimate civil liberty.”

With respect to Smith's long years on the euthanasia beat, this is a laughable misrepresentation of history -- and one that he certainly knows better of. While Smith's essay concoctions are typically junk-science based, they're at least sincere. But, as any reader of Ian Dowbiggin will tell you, the roots of the aid in dying (or euthanasia or assisted suicide) movement are far longer and deeper than Smith is letting on. Simply noting the rise of Christianity's condemnation of suicide and assisted suicide doesn't change the rates of each in pre-, modern, and post-modern society. Condemnation of practice is necessarily precluded by said practice....

He writes that there are two reasons why the aid in dying movement has scored some successes since 1994 (Death with Dignity is legal in two states, Oregon (1994), Washington (2008) and in Montana (New Year's Eve, 2009) the Supreme Court ruled that nothing in the state constitution prohibits doctor prescriptions of legal drugs for the terminally ill). Well, really he gives three:

First, the perceived overriding purpose of society has shifted to the benefit of assisted suicide advocacy, and second, our public policies are driven and defined by a media increasingly addicted to slinging emotional narratives rather than reporting about rational discourse and engaging in principled analysis. Add in a popular culture enamored with social outlaws, and the potential exists for a perfect euthanasia storm.

I've bolded the points. For someone lamenting the lack of "principled analysis" and "rational discourse," Smith seems to rely heavily on some "emotional narratives" himself! One can't combat poor logic with more of the same (The media promotes assisted suicide? Kevorkian (the assumed social outlaw, noted at the start of the article) is a boon to the assisted suicide movement?) Nor can one condemn "slinging emotional narratives" when advocating for Terri Schiavo's family and touting the "discovery" of Rom Houben, clear examples of Smith's own effort to sling "emotional narratives."

But let's play Smith's game of "Why Now?," but use facts like: the relatively recent advent of widely accessible palliative care and pain cessation; the lightening-quick advancement of technologies like defibrillators and respirators which have changed the definition of death (once the almost simultaneous cessation of lung, heart and brain function, now something that happens when machines are removed); the prevalence of CPR, 9/11 and other resuscitating procedures that, despite public understanding (thanks in part to medical shows) work about 15% of the time (to be released from the hospital) and often leave surviving patients with broken ribs and/or in persistent vegetative states; the rise of patient autonomy activism to give patients the ability to make their own decisions regarding health care, against the prevailing influence of a paternal medical system (women in the 70s were often given full mastectomies without being consulted); a medical and social culture that condemns dying patients as weak, unable to fight, and doctors as failures, as if death can be put off indefinitely; a "survivor" culture that celebrates those who recover from debilitating disease and, as with breast cancer, thus focuses fundraising and research on cures rather than preventions.

Yes, these developments have all occurred since the 1970s. Yes, they have jeopardized our economic stability by reducing health care to a privilege. Yes, they have been ignored by ideologically motivated individuals like Smith who would rather go on about emotional narratives, the fall of man, the horrors of media and Jack Kevorkian, a decline in human virtue, and the "culture of death." Yes, the powerful "pro-life" groups that have supported the rise of the Medical Right and the Legal Right have continued to cry persecution as they've worked to impose their idea of morality and ethics on the whole of society.

Smith's proof that he's right about the three causes of the movements recent escalation? Suffering! Virtue!

Social commentator Yuval Levin, a protégé of ethicist Leon Kass, described the new societal zeitgeist in his recent book Imagining the Future: Science and American Democracy. While not about assisted suicide per se, Levin hit the nail on the head when he described society as no longer being concerned primarily with helping citizens to lead “the virtuous life.” Rather, he wrote, “relief and preservation from disease and pain, from misery and necessity” have “become the defining ends of human action, and therefore of human societies.” In other words, preventing suffering and virtually all difficulty is now paramount.

Smith's extrapolation from that elegistic longing for (persistent) paternalistic, white, Christian-dominated, authoritarian times? "In such a cultural milieu, eliminating suffering easily mutates into eliminating the sufferer." How? He doesn't say. And he doesn't show examples beyond his own fact-less assertions. But he is toeing the same illogical line that we often hear from those who find glory in suffering (of the dying, of sexually active teens, of coerced women, of gays.) "If we could only save these sinners from themselves?!" he seems to say. Because ultimately, Smith and those who refuse to examine the effects of their "pro-life," discriminatory advocacy are really working to make all of society ascribe to their values, their rules, their false narratives and their beliefs. The fight over aid in dying (and abortion and gay rights, etc.) is really a fight for power; power for a select and moralistic few to tell all the citizens of our country what we should be doing.

As Tony Judt writes, there's another objective behind obscuring facts and thwarting serious, statistics-based discussion in the public square:

Today, we are encouraged to believe in the idea that politics reflects our opinions and helps us shape a shared public space. Politicians talk and we respond—with our votes. But the truth is quite other. Most people don’t feel as though they are part of any conversation of significance. They are told what to think and how to think it. They are made to feel inadequate as soon as issues of detail are engaged; and as for general objectives, they are encouraged to believe that these have long since been determined.

The perverse effects of this suppression of genuine debate are all around us. In the US today, town hall meetings and ‘tea parties’ parody and mimic the 18th century originals. Far from opening debate, they close it down. Demagogues tell the crowd what to think; when their phrases are echoed back to them, they boldly announce that they are merely relaying popular sentiment.

Ultimately, Smith tries to accomplish a number of things in his article, though his success is reliant on his readers' lack of curiosity about the real changes that have heightened discussion about futile care, aid in dying, living wills and advance directives, provider refusals, patient autonomy, organ donation and discrimination in health care. If he can paint them all as an offense to the "sanctity of life" he mis-frames and misleads the discussion from the facts. The agenda of his article is:

- make a case for "virtuous" suffering, as if "virtue" and "suffering" are clearly defined by all members of our racially, culturally, functionally diverse society

- conflate Kevorkian with the aid in dying movement when, while supporters of each may overlap, they are hardly a monolithic advocacy movement

- usurp rights, equality, and autonomy language (long the province of left-leaning advocacy) to his own "pro-life" purpose; this conflation of terms (particularly regarding abortion and feminism) has proved a successful "pro-life" juggernaut for true rights advocates

- stymy meaningful, substantive public discussion by narrowing, limiting, falsely framing the ways in which we discuss human autonomy, suffering, futile care, life, faith, and death; Smith has no interest in examining the facts surrounding superior end of life treatment and planning in states where Death with Dignity is legal; in looking at the ways medicine has until recently failed those who faced painful deaths; no facts on the cases of suicide or mercy killing that occur in the US because of extreme suffering; no discussion of futile care "tracks" that push suffering patients into one unhelpful treatment after another

- he pretends that history is static, that the idea of "traditional values" actually once represented the whole of society; an old tactic by those who wish to continue discrimination against gays, women, elders and those who do not live by dominant culture's rules

I often tackle Smith's vacuous, over-simplified articles; we can hardly ignore him when he has so much influence and plays such an important -- if self-aggrandized -- role in the "pro-life" movement. But I think singling out Smith is instructive for those of us who believe in human rights and liberty. He represents the larger thinking in anti-choice movements; he works for the Discovery Institute, a well funded promoter of bunk science like "Intelligent Design"; and he serves as a case study for how organized, influential, well-funded and well-promoted foes of individual rights are. He and others can cry persecution all they want; but I'm hopeful that the increasing prevalence the aid in dying (and other human rights) movement(s) will help the public discourse. We can't deny death forever.

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]

Schiavo v Schindler

More noise from the destructive relationship between Michael Schiavo and the Schindler family: A new report out of Florida called the Terri Schindler Schiavo Foundation's finances into question last week; now Michael Schiavo is threatening to sue the Schindlers for using Terri Schiavo's name to raise money.

The news, first reported at conservative LifeNews by ridiculously prolific Steven Ertelt, immediately spread across the "pro-life" blogosphere causing all of the Schindler's tried-and-true supporters like Wesley J. Smith to weigh in. The article is rife with misconceptions regarding Schiavo's death; misconceptions that the Schindlers (and Smith and Ertelt) have worked tirelessly to maintain in their fight against patients' rights to removal from artificial nutrition and hydration. The renewed animosity should prove interesting to watch, particularly as it plays into state-level discussions regarding end of life care, health care reform, and patients' rights. The Schindler family, particularly Bobby Schindler, have worked in the past few months to fashion themselves as advocates for the disabled. Other disabled rights activists view this terminology creep as somewhat suspect.

From Alex Schadenberg at Euthanasia Prevention Coalition, a friend of the Schiavos.

Ashes and Compassion.

Dignitas, the Swiss assisted suicide organization, should be penalized according to the law if they wrongfully disposed of cremation ashes. If they promised the dying and their loved ones that their ashes would be scattered in the lake, Dignitas should have had the proper permission and methods down.

But a couple of notes: how we treat the dead should be according to how they wish to be treated (and within legal parameters). Not all cultures and people see value in ashes, ashes are not unhealthy or polluting (urns are another issue), and I don't see scattering ashes into the lake to necessarily be disrespectful, as many are claiming as a sign that Dignitas is really just a killing machine without compassion.

Here's Wesley J. Smith's take on the incident, however, posted at The Human Future, the personal site of Jennifer Lahl, national director of the Center for Bioethics and Culture Network (a Medical Right organization) where Smith is a special consultant:

Ah, those compassionate people atDignitas, the Swiss assisted suicide clinic that will make you dead for about $10,000. Allegedly, they dumped the ashes of former “clients” in a lake. From the story:

BOSSES of Swiss suicide firm Dignitas were facing jail today after the discovery of up to 300 urns containing human remains in a lake. British “suicide tourist” ashes are believed to be in some of the caskets found at the bottom of Lake Zurich by police divers. Authorities were first alerted in 2008 when Dignitas staff were caught pouring the ashes of 20 clients into the water.

But “piles” of urns bearing the logo of the company’s cremation service have now been found by chance on the lake bed. Dignitas boss Ludwig Minelli now faces up to three years jail and a £3,000 fine for carrying out unauthorised burials.

So, facilitating the suicides of these people is perfectly fine, but burying them wrongly–that gets Minelli in trouble! The word irony fails to adequately characterize the situation–particularly as the country’sSupreme Court created a constitutional right to assisted suicide for the mentally ill.

Assisted suicide advocates often claim the mantle of compassion–as Minelli often has. But as with Kevorkian, that is often a mask for indifference and abandonment.

The V Word Is the New N Word.

Wesley J. Smith on an interview on Larry King Live with the creator of Family Guy, Seth McFarlane:

MacFarlane’s elliptical answer indicates to me that he has never considered the question. He wasn’t asked about the show, he was asked about the epithet. Moreover, the scene did not have people appalled: The audience of the supposed play laughed uproariously when, “Terri” having been called a V, responded, “We hate vegetables!” Moreover, if the show had the kids put on an old fashioned minstrel show that used the N-word–which he almost certainly would never do, and if he did, it is unlikely it would ever be aired–would he ever just reply that the denigrating nature of the word is “for the viewer to judge?” Not on a bet.

Some concerted consciousness raising is clearly required. We have to help people understand that using the V-word to describe people with serious cognitive disabilities is as hateful and dehumanizing to them as using the N-word is to people of color, the F-word to gays, or the C-to women. The time has come to retire it from common and acceptable usage, just as we have (or are doing) with the others.

Family Guy and the Fifth Anniversary of Terri Schiavo's Death.

A recent episode of The Family Guy on Fox featured a musical segment based on the death of Terri Schiavo. Everybody has been weighing in on the controversy. Here are a few places where you can read more about it:

The Family Guy episode at hulu

Thaddeus Pope's Medical Futility Blog

Deacon for Life

WTSP news in Tampa Bay, Florida notes that the Schindler family is calling for Fox to drop the Family Guy program

From TampaBay.com

Wesley J. Smith at Secondhandsmoke

Press Release from the Schindler family at ChristianNewsWire

And for those of you interested, Family Research Council will host a panel on Terri Schiavo on March 31, the anniversary of her death, in DC. Robert Schindler, her brother (and now the title of full-time "pro-life" and disability rights activist) and other pro life voices will be there. You can find the link for a live webcast (11 am) here.

Debunking Mr. Smith on the Washington Numbers.

A recent column from Wesley J. Smith comments on the new report out of Washington on how Death with Dignity is working there. I comment on his posts so often because he's so good at perpetuating lies about Death with Dignity and assisted suicide - on all end of life care. Here are some things he again gets wrong:

The first dehumanizing assisted suicide “statistics” from Washington are in, with 36 people reportedly overdosing themselves via lethally prescribed drugs in the first year. Washington voters were “sold” on assisted suicide, as is always the case, with the fear of being in pain that cannot be alleviated. But, as in Oregon, assisted suicide in practice is mostly about existential fears. These are serious issues to be sure, but they are not demises of writhing agony used by assisted suicide advocates to sell hemlock as if it were honey.

I'm afraid that Smith is out of line with the majority of voters in Oregon who have long had public-square, in-depth discussions about end of life care. I don't think democracy or laws always work to protect individual rights but I have to say that Washington has proven that all the doomsday scenarios painted by opponents of the laws have not come to bear.

What's at contest is how Smith defines death and human life. From his continued involvement with the Schindler family, the Catholic church, and from his writings, it's obvious that he's determined that death - defined until the 60s and 70s as the rather simultaneous end of breathing, heart beat, and brain function - now must be redefined because of technology that can perpetuate the first two artificially.

The latter, brain function, according to Smith and his fellow "pro-life" advocates, is unimportant. (Except when a big news story like the recent finding of brain activity in some PVS patients (though not any patients who suffered anoxia as Terri Schiavo had) comes along as a possible hook that they can hang their insensitive claims of murder on.) But brain function is not unimportant to elders. For many, it defines who they are. In many ways so does physical competence, mobility, living. These values in no way slight the lives of those with less mobility but simply reflect human ideas of what it means to be alive.

Yet, Smith's attempts at redefining death are incongruent with the majority of society and the laws that are constantly evolving to address new technology. Autonomy was cited in the report as the top reason for patients to request aid in dying. That's a statistic, not an opinion. And it signifies that loss of autonomy means something to a lot of people, whether Smith wishes to call it "existential" or not. What's at issue is that his definition of dying - all aggressive care all the time, regardless of the wishes of the patient or their family - is not the definition that society wishes to work from.

I'll let his juvenile attempts to discredit the report - a long-time tactic of end of life care opponents, science-deniers, ideologues, and conservative religious groups bent on dictating how we should live - and his portrait of proponents of aid in dying as killers slide. No one is out to cut down terminal patients but to treat them as they wish to be treated at the end of life, not as someone else thinks they should be treated. Hemlock as honey? "Sold" on assisted suicide? Fear of end of life "quality of life" is real and great. We are inhumane fools to ignore them. But Smith has an agenda. And the fact that the report doesn't show his predictions of old ladies being coerced into ingesting lethal drugs for their money, minorities and the disabled being preyed on, the "culture of death" devouring the most vulnerable in society, makes him more surly than usual. He's got a "slippery slope" argument to prove and unfortunately, the statistics don't work in his favor. So what does he do? He goes after hospice.

From the story:

Doctors said loss of autonomy was an end-of-life concern for all 47 patients. Ninety-one percent were also concerned about losing the ability to participate in activities that made life enjoyable, and 82 percent were worried about “loss of dignity,” their doctors said. The report also said that more than 40 percent were worried about losing control of bodily functions, 23 percent about being a burden on family, friends or caregivers, and 25 percent were concerned about inadequate pain control. Only one person was concerned about the financial implications of treatment, according to the doctors’ reports.

The report also states that 72% of people who committed assisted suicide were in hospice. This marks the continues assault by assisted suicide consciousness on hospice medicine. Suicide prevention is one of the important services hospice is supposed to provide, along with other interventions, to help a suicidal terminally ill patient get past the darkness to live the rest of his or her life.

Uh, what's 72% of 36? That hospice is being taken over by AS advocates is silly. The common practice in hospice is to treat a terminal patient's paint - indeed that's why it was founded. The issue here is that treating pain often means sedation, often until death. That's not an option that some like. Conflating suicide with with assisted suicide is a disingenuous trope. As Death with Dignity works in Oregon and Washington, the patient is dying from a terminal disease. That disease is the killer, not terminal illness.

It works, too. Several years ago, St. Christopher’s Hospice, founded by the great medical humanitarian Dame Cecily Saunders, released a report showing that of 1700 AIDS patients, only two had requested assisted suicide and none had killed themselves, a remarkable figure since this was when the epidemic was at its worst. The point of the report was to show that quality of their care could overcome the worst situations. But with legalized assisted suicide, this essential service is often (or always, who knows?) denied to patients, particularly since the ideologues of Compassion and Choices are usually involved in facilitating these deaths.

Saunders founded her hospice at a time when technology was just starting to change the definition of death. And she's been quoted as saying, as a staunch Catholic and following of C.S. Lewis, that she founded hospice in part to combat euthanasia. Modern assisted suicide is divorced from early definitions of euthanasia, both Socrates-type and the Nazi-type. Hospice is a brilliant and humane approach to end of life care; by proclaiming it as a service that reduces patients' options, as subject to "the culture of death" is absurd. But it's a common method of scaring the dying into spending their last days, weeks, months in hospitals, exactly where 80% of them say they don't want to be. We know that Oregon, since the legalization of Death with Dignity, has the highest percentage of in-home deaths of any state in the country. For all his claims at knowledge of this subject, he is woefully uninformed or dishonest about hospice use in states where DwD is legal. I won't even touch Saunder's AIDS report. The AIDS movement is responsible for reviving the assisted suicide movement. Yes, ending suffering at the end of life is sufficient to give some terminal patients the peace they want. Others see no difference between sedation to unconsciousness and ending their suffering.

So, Washington looks like Oregon, redux. And that’s too bad. Terminally ill patients deserve better than to have their worst fears verified by doctors issuing lethal prescriptions instead of vowing to stay with the patient to the end caring for their pain, validating their dignity, and supporting the importance of their lives.

Dignity, pain, suffering, autonomy, "quality of life" are not the same for all terminal patients. That the Washington report confirms Oregon's results is fantastic news! These bills have encouraged the elderly and ill to discuss how they die; have perpetuated humane treatment of the dying; have moved more patients into hospice; have allowed patients to die where they want, at home with their family; have established successful "do not resuscitate" laws and practices; have encouraged families to work together to ensure that patients have the treatments they want at the end of life. Think what you want about assisted suicide. These bills have proven that accepting death and working to give patient's their choices in treatment are imperative, life-affirming, humane, and encouraging signs.

Suicide Prevention and Assisted Suicide.

There's a clinical reason why advocates prefer to call it aid in dying and not assisted suicide; they recognize that there's a difference between grief, a normal and emotional reaction to trauma, and depression, an illness that with medical and psychiatric treatment can be addressed.

Yesterday Michael Gerson at the Washington Post had a well-meaning column on the prevalence of suicide in the U.S. He starts the column by noting a number of celebrities who have recently committed suicide and works to explain what it is and what signs we can detect in loved ones who may be isolated, depressed and suicidal.

Suicides outnumber homicides in America, making self-hatred more lethal than violence by others. In 2009, the Substance Abuse and Mental Health Services Administration reported that 1.1 million Americans had attempted suicide during the previous year. By one estimate, "successful" suicides have left behind 4.5 million family survivors, who live with ghosts each day.

He encourages us to reach out to those in our community who may be depressed and at risk (The National Suicide Prevention Lifeline is 1-800-273-TALK.) It's not a bad column and while Gerson is not my favorite columnist, I am pleased to see those with soapboxes addressing a tragic issue.

But then along comes Wesley J. Smith who takes up Gerson's column and does what he does best: applies absolutist and convoluted pseudo-rational thinking to conflate the idea of depression (which can cause suicide) and terminal disease. To Gerson's sentence, "For those who yield to the logic of the nightmare, it is difficult to be harsh or judgmental. Empathy, like grace, can reach to the grave," Smith writes:

But that doesn’t mean we shouldn’t criticize those pushing suicidal people toward different conclusions about self destruction. And that’s where Gerson misses the obvious–as so many similar articles do these days. There is a multi million dollar suicide promotion campaign ongoing in the country and around the world–aided and abetted by the mainstream media–that says that if you are sick, or disabled–suicide is empowering and rational. Indeed, it claims that such suicides are so right and worthy of being honored that the state should permit third parties to help make sure the suicidal person is made dead. As far as I am concerned, that is the express and implied fundamental message of assisted suicide advocacy.

It seems to me that society can’t be half against suicide and half for it. You can’t have suicide prevention and assisted suicide promotion at the same time. The former message is subsumed by the latter. Suffering suicidal people don’t think that the quality or reasons for other guy’s suffering makes suicide okay, but theirs does not.

It's an old rhetorical schtick for Smith - and other "pro-life" activists - who make their living subtracting nuance from bioethical debates for their own ideological purpose. For decades, Smith has been writing about "the culture of death," dropping anyone into that category he can and pretending that a growing segment of society is out to kill minority groups like the disabled, the brain dead, the terminally ill, the suffering, the elderly.

By confusing suicide and clinical depression with aid in dying, he capitalizes on the common use of the term "assisted suicide" to attack aid in dying supporters, much as those who deny evolution conflate the scientific term "theory" with the common use of the term meaning "unproven supposition." ("Theory" to scientists means proven fact that needs to have some details flushed out.)

I'm not personally opposed to the use of the term assisted suicide (for the medical practice as it is legalized and strictly regulated in Washington and Oregon) but I do contest the way that Smith and others use it: to perpetuate the terminal suffering of others. As medical advancements have created new definitions of death (end of a heart beat? end of consciousness? end of breathing?) so too has it created new definitions of suicide. (And pregnant, but that's another post. The definition of murder has long been understood to have many meanings.) Ignoring this fact is an absolutist, and frankly, unworkable approach to contemporary bioethical debates. Pretending that we live in a less complicated world does not move us toward ethical discussions of medicine.

This work of Smith's is irresponsible (and disingenuous) for a host of reasons, most importantly because it allows those who oppose assisted suicide to think they are addressing the important issue of suicide. And it removes the focus among his constituents from addressing the very real problem of depression to fighting the right that terminal patients should have to determine how their disease will end their lives.

The aid in dying movement in the U.S. seeks to make Death with Dignity (as the laws in Washington and Oregon are called) legal: a terminal patient with six months to live, one who is going to die because of multiple sclerosis or Lou Gehrig's disease, who is determined of sound mind and who has received the opinion of two doctors, to receive a lethal dose of medication from their doctor which they may then choose to take themselves to end their life before the disease makes it unbearable.

In every case of Death with Dignity, immanent death is certain. The patient has endured most likely years of fighting their disease with a concerted will to live. The patient does not want to die but they have realistically accepted the fact that their disease will soon kill them. Their grief at the loss of life has an absolute physical cause. And their simple objective is singular: to end suffering.

Smith's point that society is pushing isolated individuals to suicide is only correct in that we fail to distinguish the serious difference between suicide-causing depression, and say, a bad day or the natural process of grief that follows a death or an end of marriage. "I'm depressed," we say when our car breaks down. "How depressing," we say when an election is lost or a friend snubs us, detracting semantically from our ability to discern the downward spiral of serious grief that can lead to dangerous depression.

Grief is an emotional process that facilitates recovery from a loss. Depression is an illness. There's a significant and important difference that Smith misses. What he calls "half against suicide and half for it" is a false construct. "The culture of death" is a rhetorical tool used to create fear among the vulnerable and to assert influence over the easily swayed. It takes autonomy away from various patient groups like women, the disabled, the ill. "Culture of death" fear-mongering is prevalent among those who wish to assert their largely religious ideology on our pluralistic society; it seeks power and it imposes suffering.

Accepting death, as Death with Dignity patients do, is not a depression that can be cured. It is a factual analysis of the physical body in immanent, unpreventable demise. Yes it's sad, for both family members and the patient. But statistically, Death with Dignity does not leave behind the same scars as suicide from depression does.

Smith and others only distract from the serious consideration that must be given to treatment of depression.

Politics and the Persistent Vegetative State.

The big news in medicine this week is the anticipated release of a study, published in the New England Journal of Medicine, that looks at brain activity in persistent vegetative state patients, showing that in - let's admit - very qualified cases a patient shows adequate brain activity to respond to questions via brain scan.

This communication works accordingly: A patient who shows normal or close to normal brain activity is told to visualize two separate activities, playing tennis or walking around at home, as correlating to yes or no answers to questions. The patient's brain was then monitored for the proper response (activity representative of tennis or home) to six yes or no questions. One example cited that a patient "answered" 5 of the 6 questions properly. In other words, their brain, a majority of the time, acted out the activity associated with a yes or no answer in response to a question.

It's a very encouraging study, one that shows opportunity to "reach" patients who have heretofore been thought inaccessible, locked-in, in a coma or "brain dead."

A glimpse of the study and how it would be received was had in January when the media ran away with the story of Rom Houben, a Belgian man who was said to be "discovered" after 23 years in a coma. Steven Laureys, one of the primary writers of the study, has displayed some bashfulness regarding the initial overblown reaction to Houben's media attention. TV and newspapers overplayed the drama - no one could resist the feel-good "discovery" of a man thought to be brain dead, of a mother remaining hopeful for 23 years, of disabilities overcome to where Houben could type on a keyboard. Houben's means of communicating, however, have since been seriously questioned. Yet, Houben's story, however questionable, is one of hope and when it comes to caring for a loved one - for 23 years! - the hope that they are still "in there," is what keeps one going.

What the study is not is an indictment of current policy regarding the decision-making process for patients in persistent vegetative states. But politics are at play and the findings are being used to promote a particular agenda, with various politicized groups and noise-makers working to play it for their own purposes.

GeriPal has already commented on what the media interpreted the study to mean, citing the following headlines as examples of the exaggerated spin:

Take a guess though what the media headlines focus on:

*Scientists read the minds of the living dead (New Zealand Herald)

*Patients in 'vegetative' state can think and communicate (The Telegraph)

*Brain scan shows awareness in vegetative patients (BBC News)

*Brains of vegetative patients show life (LA Times)

*Study Finds Cognition in Vegetative Patients (Wall Street Journal)

These headlines are just wrong. They give the impression that all patients with PVS are aware and can communicate. In truth, this study showed that a minority of patients with PVS showed some signs of awareness, and those happened to only be in those who suffered from a traumatic brain injury (not from other causes such as anoxic brain injury).

As I noted earlier this week, using the example of Terri Schiavo, the media reports were rather over the top but consistent (despite their titles and spin) in their description of what ramifications the study had for patients like Terri Schiavo: None. Hers was an anoxic brain injury caused by lack of oxygen, not a traumatic injury as those who showed brain activity and response to the study's tests.

The media's objective is clearly to convey an attention-getting, emotional, sensational story of hope. Use the cultural ignorance of scientific studies to inflame the cultural divide. It gets ratings. Other's have another purpose.

Bobby Schindler, brother of Terri Schiavo, full time "pro-life" speaker, and co-founder of the Terri Schindler Schiavo Foundation, has long called for a reexamination of the persistent vegetative state diagnosis because he wishes to prevent removal from artificial nutrition and hydration of any PVS patient, despite their living will (advance directive) or the wishes of their medical proxy. At the foundation website today is a story that claims more tests should have been done on Schiavo before the court upheld her husband's wishes to remove her from ANH. It's a disingenuous position, a case of hope perpetuated too long, used only to prevent other patients from having a say in their medical decisions.

Then there's the conservative Discovery Institute Fellow Wesley J. Smith, amusingly called a "top bioethicist" by Catholic blogs, who was wrong about Rom Houben's media attention, too blinded by the report's ability to support his "pro-life" case to see the junk science parlayed by the media. Smith, a close friend of the Schiavo family, specializes in demonizing those who desire a science- and patients' rights based approach to end of life decisions as the "culture of death." Want to remove your loved one from ANH? You must be a killer. The judge in the Schiavo case? He wasn't using judicial precedent to determine who should choose Schiavo's medical options, he was, as Smith says, eager to let the bad people "kill" her:

"Indeed, when it was clear that Terri would be lying in bed for a year pending appeals, the family begged Judge Greer to permit sophisticated brain scanning that had never been used on her before," he recalled. "It couldn't have hurt her, and it might have shown something. But stubbornly, he refused. I will go to my grave believing the judge knew what he didn't want to know."

And then you have the Catholic Church, powerful, organized, rich in resources, motivated as the aid in dying movement brings end of life decisions to the forefront around the globe, to increase its efforts to oppose patient's rights.

In November the Church changed its Ethical and Religious Directives - which govern treatment of 1/5 of patients in the US - to prevent patients or their families from requesting removal from artificial nutrition and hydration. In fact, those who do not want the insertion of feeding or hydration tubes would now only be abided by when the Church decided.

The media may be looking for good ratings, but other constituents like the Schindlers, Smith and the Catholic Church are working for something much more nefarious: to take away your rights.

Living Forever.

Last week, the New York Times continued their series on end of life decisions, Months to Live, with a dissection of the commonly used Dartmouth stats regarding end of life costs. The UCLA medical center has refuted the Dartmouth study and done their own, saying that they prefer to do everything necessary to prolong life, or death. Fran Johns at True/Slant takes issue with the article and the UCLA premise that can life forever:

Why is this not an encouraging word? In a front page article, part of a Months to Live series, New York Times writer Reed Abelsonleads with a glimpse into the Ronald Reagan U.C.L.A. Medical Center, a top-rated academic hospital noted for extensive, aggressive end-of-life care (and very high costs):

‘If you come into this hospital, we’re not going to let you die,’ said Dr. David T. Feinberg, the hospital system’s chief executive.

Feinberg’s commitment to “success” might be admirable, but the statement is patently false; people die at U.C.L.A. Medical Center. This is what people do: we die. Until this culture gets its act together on that subject our health care system — whatever the reform bill eventually looks like — will continue to flounder.

Difficult as it is to talk dollars when you’re talking lives, the issue of cost has to be factored in. There are only so many dollars, and there are countless lives needing care those dollars can buy: infants, children, young adults, boomers, elderly. In each of those care-needing groups, some die. Feinberg’s philosophy somewhere has to encounter reality.

…that ethos (keep testing, treating, keeping alive no matter what) has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

No one, not the doctors, not the patients, not the best crystal ball reader around can guarantee that this patient will die or that patient will live. If there is a good chance a patient will survive — and it would be nice to add “with a reasonable quality of life” here — everything possible, and affordable, certainly should be done. Abelson’s carefully balanced article details the arguments for going to extraordinary lengths to save lives, as well as the arguments to draw the line on end-of-life expenses.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

So…. to spend that $25,000/$50,000 or not to spend? Unless we the people somehow face the reality that living forever is not a human option, the dilemma will continue.

The benefits of coming to terms with non-optional dying could be huge. We could focus on quality living. On palliative care and hospice care and end-of-life peace and comfort. Advances in palliative care now make it possible for most of us to spend final months at home (or in special hospital rooms), in comfort, surrounded by loved ones; given the choice, would you prefer a few weeks or months in a bright-lit sterile room with a lot of tubes and wires keeping you alive? U.C.L.A. now offers the choice of palliative care. Not everyone in charge, however, is convinced.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

We the people would do well to quit being the bad guys. To quit behaving as if death were always preventable. We could learn about the options to spending all those thousands of dollars on exhaustive, often futile treatment. We couldtalk about what we would or would not want for ourselves, write things down, make choices.

If more of us would do that for ourselves, the House and Senate wouldn’t have such a time trying to do it for us.

And to continue the "life forever" thread, you can catch my favorite impractical blogger, Wesley J. Smith, on the same issue here. Of course Smith doesn't believe in global warming either.