Intubated Women

Last week I was on a panel at NYU titled, "The Gender and Sexual Politics of End of Life Care," an event hosted by NYU’s The Center for the Study of Gender and Sexuality, along with Amber Hollibaugh, Susan Gerbino and Ai-jen Poo, brilliant women doing phenomenal work in the areas of LGBT rights, palliative care and domestic workers’ rights. Click here to read the (rather rough) text of my talk, which addresses Catholic hospitals and the use of feeding tubes.

The Week in EOL News

In a recent article at The Catholic Sentinel, Richard Doerflinger, Deputy Director for the Secretariat for Pro-Life Activities continues to develop the church's argument against aid in dying by conflating it with assisted suicide and by citing disregard for the ill or disabled as causes for aid in dying's increasing support and legalization. (I interviewed Doerflinger about the church's new initiative to fight legalization of aid in dying in June.) From the Sentinel article:

The Oregon law carves out a class of citizens — those diagnosed with six months or less to live — and suspends statutes that protect them from getting help to kill themselves. For Doerflinger, it's like coming across two people about to jump off a bridge, one who has a diagnosis of six months or less to live. For one, society tries persuasion, mental health treatment and emergency intervention. But to the one who has a serious physical illness, Doerflinger explained, "We say, 'Jump. Can I give you a push?'" The issue, he said, is that our culture is uncomfortable with sickness and disability. "We don't see inherent dignity in people when thy have these conditions."

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The San Francisco Examiner has been covering the story of Hong Ri Wu, who is accused of killing two of his shop-owner rivals. Wu was determined unsound for trial and then he refused to eat. Local police officials, at the direction of Sheriff Hennessey took him to the hospital but the hospital refuses to put him on a feeding tube. The Examiner writes:

Hennessey insists his department has a mandate to provide for the safety of each inmate. But hospital officials have balked at force-feeding Wu, although spokeswoman Rachael Kagan declined to discuss Wu’s case specifically, citing patient privacy laws.

“As a hospital, we respect individual self-determination and include our patients in their health care decisions,” Kagan said in a statement. “When a patient is also in custody, that patient loses some rights, but not all of them.”

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Meanwhile, thousands of California inmates have resumed a hunger strike that is meant to draw attention to their inhumane conditions in that state's facilities. Prison officials are threatening "discipline."

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"Baby Joseph" Maraachli die this week. The child, born in Canada with a terminal illness, became a "pro-life" cause when the hospital there refused the family's request for a tracheotomy. The hospital deemed the operation futile. So Father Frank Pavone of Priests for Life and other Catholic and "pro-life" groups including the Terri Schiavo Life & Hope Network, raised the funds to have the child airlifted to the US. The first US hospital they sought care from refused, but a Catholic hospital took the child in and completed the procedure. After a brief stay in the US, Priests for Life then shipped the child and his family back to Canada. Pavone said the child and his family had, "fulfilled a mission from God." The case has caused some interesting fault lines to emerge that involve denominational health care, issues of futile care, the treatment of pediatric terminal patients, and, not least, within the Catholic Church regarding the finances of Priest for Life. Father Pavone has since been called back to his home diocese; the causes remain murky.

"Pro-life" groups have said that their objective was to allow the child to die at home, a statement that echoes both home hospice and aid in dying advocates, perhaps signaling broader acceptance that a home death is preferable to a hospital death.

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The death of Troy Davis was not the act of a faceless state against a potentially innocent man. Amsterdam News writes about the company that was contracted to oversee the execution, the same company that is contracted to provide health care services to inmates in prisons. For-profit companies are increasingly called in to provide inmates with care in prison settings, in part because the incarceration industry is just that, an industry, with states spending big money to manage their prison populations and high-powered lobbyists pressuring local law makers to "protect" their state citizens by being strong on crime. As well, particularly in the South, prison populations are growing exponentially older and require more health care services. But the challenges for CorrectHealth and other such health care companies operating in prisons is that they are increasingly under fire for unethical and illegal activities, including the use of illegally-acquired execution drugs. Drugs like sodium thiopental, which is part of a three drug series used to execute inmates. It's no longer in easy supply because Abbot Laboratories, its sole US manufacturer, has stopped making the drug. For a while states were purchasing sodium thiopental from the UK but drug officials there have cracked down on it's international export. This scarcity has forced US prisons to beg and barter with each other or to find illegal sources. Writes the Amsterdam:

It was Dr. Carlo Musso, who owns CorrectHealth, a for-profit company that provides what they call "cost effective" health care to prisoners, who managed the process. He does this work under the umbrella of another company he owns, Rainbow Medical Associates, which, according to the American Civil Liberties Union, is contracted by the Georgia Department of Corrections to do its executions.

While some may defend Rainbow Medical Associates as capitalism in action, Musso might find himself in a heap of trouble-of the legal kind-that could do more damage than the backlash from the Davis execution.

Earlier this year, the Southern Center for Human Rights filed a complaint against CorrectHealth, accusing them of illegally importing and distributing sodium thiopental, the drug they use in carrying out the execution of convicted felons.

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The Atlantic this week wrote about a new documentary that examines the "unique subculture of hospice volunteers as they contemplate their own philosophies of life and death." (h/t Scott Korb)

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The Guardian reports on a case in the UK that was brought by the family of a minimally conscious patient to remove her feeding tube. The family of "M" held that she would not want to be kept alive with a feeding tube, but the court did not decide in their favor, stating that her level of consciousness allowed that she may feel discomfort if removed. From the article:

The case raises deep existential and moral questions – questions that law is not well equipped to answer. The Mental Capacity Act does at least, provide a framework for discussion but it offers no guidance on how each factor should be weighted. For the family, the key factor was that M's continued existence was not what she would have wanted. For Mr Justice Baker, the decisive factor was the preservation of life.

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As with abortion, the language used to discuss end of life and patients' rights continues to be muddied up, with each side claiming to stand for the patient. Wesley J. Smith's recent scree against futile care is telling. He's taken up the rubric of patients' rights, claiming that a patient who wants just one more chance at beating cancer should be able to make that decision for themselves, regardless of limited health care resources, the doctor's recommendations, or that of the hospitals where the patients are treated. I've said very much the same thing myself, here, repeatedly. But what Smith and others fail to miss -- and this is a conservative blind spot that we see exploited often -- systems and culture affect how patient's view their health care choices. Those concerned with futile care recognize that a culture of "do everything" is responsible for the increase of treatments and services that won't save lives and often prolong death. Those of us who stand for patient's rights -- a person's right to choose what their best path of treatment may be -- must be careful to recognize that cultural influences and not just the individual's ideas about their fate can play a role in the patient's choice. If you want to stand for choice in all cases, abortion advocates have long known, you have to stand for even the choices you don't agree with.

Don't miss Smith's knock of the Veteran's Administration, the largest provider of health care in the US and conservative's primary example, after medicare, of how the government mismanages health care.

Patient's rights is a term I use often but independence and individual rights are only half the conversation. We're also members of a community and creators of a culture that establishes values even as we espouse them. Simple calls for patients' rights (or women's rights, etc.) are only part of the challenge those who wish to address the vagaries of our health care system (or it's absence) must consider.

Smith, who claims to be a bioethicist, often blames greed for what he says is a pervasive "culture of death." With many issues like pentagon spending, incarceration, and social services, I've said pretty much the same thing. But what Smith misses is the responsibility that society has to the patient to prepare them for death and to do no unjust harm. Futile care often stymies both. And it's preventing us from talking about death and health care in practical, dignified ways.

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Read Catholics for Choice's recent open letter to Kathleen Sebelius, posted at Politico, here. The group is fighting The Catholic Church's heavy lobbying for less restrictive conscience laws in the new insurance coverage guidelines. The Church claims that allowing insurance programs to cover contraception is an offense to their religious conscience and that clauses in the new regulations are far too narrow for their health care providers to work according to their faith. In other words, Catholics for Choice wishes to remind the government that the influential priests who have mobilized against the regulations do not speak for the US's Catholic community but for the Vatican. Or rather, their male dictatorial selves.

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Funny how long it took the Wall Street Journal to pick up this study about the public's views of those in persistent vegetative states.

I'm Having a Moment.

It's a great day! Not only am I on the radio tonight but a friend, Jeff Sharlet, has a new book out with an essay in it about yours truly and--this is big--I've been awarded a fellowship with USC's Annenberg School of Journalism, the Knight Grant for Reporting on Religion in American Public Life, to write about how American's die. Now if I could just get a date....

Details!

11 pm tonight on WBAI (99.5 FM) I'll be talking to the amazing Barbara Glickstein about how Americans die, denominational healthcare, and hospice. Here are the details--and a picture of me in WBAI's studio. Catch the second segment of this two-part series same time and place on August 25th.

A new book of essays by New York Times bestselling author Jeff Sharlet, a friend and my predecessor at The Revealer, is not only cover-to-cover full of brilliantly written essays about "faith and faithlessness," but one's even about me. Buy Sweet Heaven When I Die: Faith, Faithless, and the Country in Between here. Right now. Hurry up. Chop-chop.

And here's exciting news: I've been given a fellowship by USC's Annenberg School of Journalism, the Knight Grant for Reporting on Religion in American Public Life, to report about how American's die--prison, end of life and hospice care, denominational health care. Over the next nine months I'll be traveling to Montana, California, Arizona and Alabama to investigate how state and religious regulation effect health care choices by the dying. Here's more on the fellowship and the humbling field of other winners.

Christian Corrections.

Howard Friedman at Religion Clause writes that a few states have considered Christian prisons, particularly Oklahoma. He writes:

As reported last November, a non-profit Texas-based prisons ministry, Corrections Concepts Inc., plans to build a private all-Christian 600-bed prison in Wakita, Oklahoma. The facility will be for men near the end of their sentences who volunteer to be housed there and agree to participate in its program. The ministry has recently announced that discussions are underway with Oklahoma, Kansas and California regarding contracts to house their prisoners in the new facility. In a press release yesterday, Americans United said that it has written officials in the three states urging them to refuse to send prisoners to Corrections Concepts. The identical letters argue that state funding for prisoners in religious facilities would violate the Establishment Clause. The Oklahoma Department of Corrections has already decided not to send prisoners, bu discussions are continuing with the Oklahoma Office of Juvenile Affairs.

Sanctioning Doctors Who Kill Prisoners.

The American Board of Anesthesiologists will now sanction doctors who participate in prisoner executions. From the Washington Post:

A national physicians organization has quietly decided to revoke the certification of any member who participates in executing a prisoner by lethal injection.

The mandate from the American Board of Anesthesiologists reflects its leaders' belief that "we are healers, not executioners," board secretary Mark A. Rockoff said. Although the American Medical Association has long opposed doctor involvement, the anesthesiologists' group is the first to say it will harshly penalize a health-care worker for abetting lethal injections. The loss of certification would prevent an anesthesiologist from working in most hospitals.

About half of the 35 states performing executions, including Virginia and North Carolina, require a doctor to be present. Other states have also recruited doctors, including anesthesiologists, to play a role in executions involving lethal injections. In some jurisdictions, anesthesiologists consult prison officials on dosages. In others, they insert catheters and infuse the three-drug cocktails.

While death penalty opponents welcome the move because it raises yet more questions about lethal injections, capital punishment supporters contend that doctors are not needed during the procedures, which can be administered by prison employees. But as questions mount about the types and combinations of drugs used and whether they cause undue suffering, states have been turning to doctors for advice and assistance. With 3,200 prisoners now on death rows across the country, most of the 50 executions performed each year since 2008 have used lethal injections.

Locking Women Away.

At DailyKos, a review of my friend Lynne Haney's new book:

Offending Women: Power, Punishment, and the Regulation of Desire
By Lynne A. Haney
University of California Press: Berkeley
Softcover, 304 pages, $24.95
Feburary 2010

Money quote:

The policies of mass imprisonment, which systematically remove so many women from their communities, seem to signify a shift in how state regulation is conceptualized and practiced. While poor women have always had their lives regulated by the state indirectly, through social policies, laws, and encounters with caseworkers, more of them are living and raising children quite literally within the state--often for long stretches of time. Moreover, through parole, probation, and "community-based" corrections, the penal system remains in these women's lives for years after release. The state's methods of control also seem to rely more heavily on direct modes of intervention characteristic of total institutions. And these modes of intervention appear to be based on restrictive models of citizenship and forms of claims-making.

Author: A professor of sociology at New York University, author of Inventing the Needy: Gender and the Politics of Welfare in Hungary.

Basic premise: The author looks at two programs set up in California as "community-based prisons" for mothers to be housed with their children in alternative, less institutionalized settings. One program, Alliance, was researched in the early 1990s, when the focus of social programs was moving toward insistence on self-reliance instead of the "welfare state." With this cultural imperative in the background, the program focused on emphasizing job and life skills acquisition in a boot camp-like setting (punctuality, chores, classes were all emphasized). In the second program examined a decade later, Visions, the author notes the shifting of cultural priorities--instead of prepping individuals for the basics of taking responsibility for themselvespractically in society, now young mothers are coached in a brand of therapeutic self-governance, heavily reliant on 12-step methods and confessional mode. In both cases, society-wide injustices are swept under the rug; solutions are located in the individual alone, in the case of Alliance as a lack of job/life skills, in Visions as a pathologized internal child. The author examines the daily routines of both programs, their effects on the women and the growing hybrid of public/private institutions that make regulation and benchmarking difficult.

Readability/quality: Relatively free of jargon, engaging when exploring the daily routines of these young mothers in each setting, thoughtful about the implications for wider society, the book is a relatively smooth read from an assured expert who clearly has spent a career looking at the issues tackled.

Who should read it: Same as for Interrupted Life (in fact, one of the essays in the previous book is by this author, short and focused on only one aspect of one of these programs)--those interested in women and society, incarceration, alternative programs, children's issues.

Bonus quote:

It matters that the women in Visions confronted a discourse of desire as opposed to a discourse of need. First and foremost, it matters because of the institutional practices that accompanied this discourse; the women at Visions received counseling not education, group therapy not job training, and treatment for personal addiction not preparation for social integration. While not all women accepted these practices, few could disrupt them in a consistent or collective way. Unlike the young women at Alliance, who used the prevailing needs talk as they challenged it, the women at Visions turned on themselves and one another. Although some Visions inmates tried, few were able to move the emphasis from personal to societal failings. At Visions, the discourse of desire seemed like a channel through which claims to social justice and fairness were silenced; the women subjected to this discourse seemed one step closer to a state of disentitlement.

Both Alliance (skills-based) and Visions (therapeutics on steroids) sound like a nightmare. Alliance, presented first in the book, has an understandable rigidity given that these women were convicted of something (mostly drug crimes), but Haney points to the inherent contradiction in the program--even as counselors and staff are harping non-stop on self-reliance to these women, they are confiscating their AFDC aid and pooling it for survival. The women, once they get a few skills under their belts, recognize this and being reporting conditions to public agencies, spurring investigations. From a sociological point of view, Haney was in the right place at the right time to document the formation of blocs of resistance, but alas, they come to naught for various (predictable) reasons. As bad as Alliance comes across, Visions is much worse--the constant pressure to confess confess confess and to have more horror traumatic abuse stories than your fellow prisoners is appalling; women turn on each other viciously, using information gleaned in group self-help sessions, and the whole program comes across as a Jerry Springer-like emotional "Lord of the Flies."

Ironically, both programs were conceived with the best of intentions: to allow women to serve time with their children, in a softer setting than normal, in a place of emotional safety and practical learning. Both programs were supported by staunch women's advocates. And both ended up mired in truly appalling dynamics. The bottom-line problem with both is the diminishment of the role of connection and empowerment; problems are always and forever seen as individual crosses to bear and hurdles to overcome. Haney's book is also a warning about the blurred area of unaccountability created by these public/private entities.

Not the subject of the book, but one that would be a welcome follow-up by some author: the effect on the children of growing up in these programs.

Prison Hospice.

Over the summer the New York Times did an illuminating story on prison hospice facilities. Today the USAToday newspaper follow up with their own. Here's a clip:

The hospice programs underscore the challenges prison officials face in taking care of a rapidly graying prison population. The number of state and federal prisoners age 50 or older has soared from 41,586 in 1992 to more than 167,000 in 2005, McAdoo said. About 3,300 inmates die in prisons each year, she said.

"Tougher sentencing laws have created a huge growth in the number of aging inmates and people who aren't going to get out before they die," McAdoo said.

Before the programs, inmates died alone in prison medical wards and often suffered through painful ailments, said Fleet Maull, a former inmate who helped start the nation's first hospice program at the Medical Center for Federal Prisoners in Springfield, Mo. The programs also save money by reducing hospital visits, he said.

"When we started, people were being given aspirin for bone cancer," said Maull, who served 14 years on drug trafficking charges. "Today, people can have a self-administered morphine drip. We've figured out how to do these things in a safe and a compassionate way."

No prison in the USA houses more life-term inmates than Angola, where 3,712 inmates — 74% of the prison population — are serving life sentences, Assistant Warden Cathy Fontenot said. More prisoners die a year at Angola (32) than are paroled (four).

Inmates volunteer for the program, which has served 134 prisoners since it began in 1997. They are taught basic hospice practices and how to counsel a dying inmate. Gary Tyler, 51, who's serving a life sentence for first-degree murder, joined in 1997 after witnessing four of his friends die.

"I didn't want the situation I'm in to dehumanize me," he said. "Everything I thought about life has changed. This program has reassured me of my humanity."

The Legality of Forced Feedings in Hospitals and Prisons.

The fight for patients' rights is up against three primary forces in US society: the church, the state and the medical industry. (It's my contention that these three entities are vying for jurisdiction over suffering, but I'll leave that to another post.) Any one of them is damaging enough to patient autonomy, but when two of them collude, the imposition on the rights of patients is most egregious.

For instance, I hope to have an article out soon at AlterNet which looks at the Catholic church's imposition on patients' rights at the 600 hospitals they manage throughout the US. The church manages these facilities (and hospices, long-term care homes, and health care networks) according to Ethical and Religious Directives (ERDs) that are written and enforced by the US Conference of Catholic Bishops (recently in the news for having their way with Stupak-Pitts and health care reform). At these health care facilities, patients must abide by the church's doctrine, even though these organizations are about 50% funded by the US government. (Note the hypocrisy of the church for working to prevent public funds usage for abortion, yet collecting a majority of its revenue from the public and using it to impose discriminating health care practices.)

Sterilizations, tubal ligations, STD and AIDS prevention, contraception, fertilization treatments for lesbian or unmarried women, and advance directive requests are all discluded from hospitals' service rosters because of Catholic management. These are not services which only restrict women's autonomy - though abortion does raise the most noise and reduces the conversation to a contested service - but the autonomy of patients on the whole. Forty-eight Catholic hospitals are the sole providers for their communities. And Catholic hospitals are merging with secular ones every day because of the difficult economy.

The USCCB recently revised their ERDs to change artificial nutrition and hydration (ANH) usage. Despite the legality in all 50 states of the removal of a patient from ANH, either by the patient's request or their medical proxy's, the Catholic church will now refuse such removal, claiming that ANH is "obligatory" care. Further, a patient who does not wish to be put on ANH will be, a practice essentially asserting that the Catholic Church has precedent over the rights of every patient.

Another area of society that witnesses the collusion of two of these forces (state, church, or medical industry) in opposition to patient's rights is the penal system. The Lancet, a British medical journal, has two brief articles in their November 21 publication on the issue of force feeding of inmates that I believe greatly resonates with issues of patients' rights in general society, though, as I mentioned, the actors are not church and state but medical profession and state.

The first article by George Annas reviews two new books: Military Medical Ethics: Issues Regarding Dual Loyalties, Workshop Summaries (National Academies Press, 2009) and Interrogations, Forced Feedings, and the Role of Health Care Professionals: New Perspectives on International Human Rights (Harvard University Press, 2009). In part, the article reads (free registration required):

Interrogations, Forced Feedings, and the Role of Health Professionals grew out of another workshop sponsored by Harvard Law School's Human Rights Program. Like the IOM report, the most striking feature of the book is the contrast between the views of the US military and those of human rights groups. Edmund Howe, a leading expert on US military medical ethics, argues that the strongest rationale for military physicians to force-feed hunger strikers is that it respects the prisoners by respecting “the sanctity of their lives”, albeit at the expense of their autonomy. Although he believes that saving the hunger striker's life is the only real argument in favour of force-feeding, Howe concedes that under current protocol force-feeding is initiated long before the hunger striker is in any medical danger, and he has a difficult time justifying force-feeding before it is medically necessary to preserve the prisoner's life or health. By contrast, James Welsh of Amnesty International summarises his organisation's 30-year involvement in the prison hunger strike question, beginning with the Red Army Faction's hunger strikes in West German prisons in 1977. All hunger strikes have their own unique settings and provide ample opportunities for clashes between physicians and prison officials. Welsh's conclusions on Guantanamo are, nonetheless, unequivocal. He describes the methods used to break hunger strikes there as “transparently oppressive” and as constituting “a form of cruel, inhuman, and degrading treatment intended to break the strike and to form part of the stripping away of prisoners' human rights”.

The US Military (the state) is currently ending hunger strikes in Guantanamo and elsewhere (I'll get to a non-military example in Connecticut in a minute) by claiming, "sanctity of life," an argument long used by Catholic and evangelical groups against women's autonomy (reproductive rights) and autonomy of the dying (end of life rights to aid in dying and removal from ANH) to assert that the claiming body (the church) has jurisdiction over the patient, and not the patient. Inmates are strapped down in chairs and via nasogastric tubes, fed Ensure (in three flavors, strawberry, butter pecan, and chocolate, the article states.) The Red Cross and Amnesty International have long considered force feeding as torture. Yet the practice continues.

The issue of "dual loyalty" most resonates with me for it's application to Catholic practices regarding ANH and lobbying for strong a conscience clause in health care reform. Is a physician required to be loyal to the patient, as their profession dictates, or to the state or the church?

The article also asserts that while forced feedings may end at Guantanamo when it closes, those patients on hunger strike will be moved to prisons in the US.

...there are several cases in US courts in which prisoners currently being force-fed are challenging their force-feeding as unconstitutional. These cases raise the question of whether force-feeding is “cruel and unusual punishment” under the 8th amendment, or done in a way that “shocks the conscience” as prohibited by the 5th and 14th amendments—not, as in Guantanamo, whether it is a violation of Common Article 3 of the Geneva Conventions.

Two solutions to the torture of forced feedings are suggested by the article: the Department of Defense of the Obama administration's rescinding of current "guidance" and reassertion of "traditional US military doctrine that no physician in the US military need compromise medical ethics to serve their country," and "the opposing positions of the Department of Defense and the World Medical Association should be brought to a neutral authoritative body, such as the state boards that license US civilian and military physicians" for resolution.

The second brief Lancet article cites a case brought to the Connecticut courts regarding Corrigan-Radgowski Correctional Center inmate William Coleman.

Coleman and his lawyers argue that he has a constitutional right to determine what happens to his body, and the right to refuse medical treatment including resuscitation or assisted feeding. He has been force-fed via a nasogastric tube inserted by a physician on occasions since January, 2008, when Judge Graham issued a temporary injunction that allowed the state to feed Coleman by force. This case is one of several in which prisoners in US states are challenging force-feeding as unconstitutional on varying grounds.

Physicians throughout the world continue to be involved in force-feeding despite its prohibition by the World Medical Association (WMA) in Declarations (to which the American Medical Association is a signatory), and despite the provisions of the Geneva Conventions. The WMA states that the autonomy of prisoners who decide, voluntarily, to refuse food must be respected, provided that their mental capacity to make the decision is unimpaired. Physicians such as military doctors, who might have dual loyalties, should make patients their priority, according to the WMA.

Cases of forced feeding in military prisons like Guantanamo and in civilian prisons like the Connecticut correctional facility resonate greatly with the Catholic church's "forced feeding" in hospitals. Inserting a feeding and hydration tube, an invasive procedure, when the patient or his or her medical proxy deny the procedure is in essence forced feeding. The legal application of these cases to denial of patients' rights in US hospitals is in my mind direct.

Yet, the US has not considered Catholic entities as agents of the state, despite their license to provide social services and their federal funding. However, the state's collusion in "forced feeding" of patients in Catholic hospitals should not be overlooked.

Redemptive Suffering: Pain, Prison, and Assisted Suicide.

Garrett Keizer wrote in a 2005 essay for Harpers on physician assisted suicide titled, "Life Everlasting: The religious right and the right to die," that those who oppose aid in dying in the US are "protecting pain."

The first reason he notes for why opponents fight to protect pain is religious; the church deems suffering and pain to be redemptive.

The second reason, which can always be counted on to exploit the first, is political: the belief that pain is fundamental to justice, which makes perfect sense if justice is conceived as nothing more than a system of punishments and rewards. The essence of punishment is pain. Whoever owns pain owns power.

It's a chilling assessment (and essay) that I return to again and again as I think through and write about the aid in dying movement.

I wrote about a month ago regarding the pending Baxter v Montana appeal case before that state's supreme court which, if upheld, will determine aid in dying constitution in Montana:

But this isn’t a case about who’s responsible for ending a life. All patients who seek a death with dignity have already been meted out a sentence of death, either by cancer, multiple sclerosis, or some other painful, debilitating disease. Who ends a life that is already ended is not what advocates on both sides are contesting. The heart of Baxter v Montana – and the assisted suicide movement in the US – is really: Who has jurisdiction over suffering?

There are at least four bodies within society that have historically laid claim to the realm of suffering, either directly or indirectly: the state; the medical profession; God (or the church); and the individual patient.

From ReligionDispatches today comes an interview with Caleb Smith, the author of the new book, The Prison and the American Imagination, that, when viewed through the lens of the aid in dying movement, sheds much new and needed light on religion, suffering and redemption. In it Smith states:

The reformers who built the model institutions of the early nineteenth century called them penitentiaries, to compel penitence. They drew from Christian traditions—Quaker tenets of nonviolence, Catholic and Calvinist varieties of asceticism and moral rigor—and they often represented the cell as a place of spiritual rebirth. As a precondition for that resurrection, they led convicts through mortifying processes including “civil death,” a loss of legal personhood with origins in European monasticism. The Philadelphia reformer Benjamin Rush quoted scripture in describing the rehabilitated convict as a man who “was lost and is found—was dead and is alive.” My book is animated by my fascination with this resurrection plot and all of its contradictions.

Can hospitalization be considered a form of incarceratin? Smith reminds us of the interwoven nature in Western society of state power and church theology.

Ideas of salvation and redemption not only govern how we treat those who have offended society in criminal ways, but of those who, as Susan Sontag might put it, offend society by contracting terminal illnesses.