The Implosion Cometh, OR, It's Only Fear-Mongering if it Contradicts Your Ideology.

The fight for quality health care has been framed by conservatives (with time-honed fear of government programs and ideological adherence to "pro-life" but futile care policies) as an either/or financial and "sanctity of life" apocalypse. Either we as a society recognize "human exceptionalism," a term bandied by the likes of Wesley J. Smith and meant to codify a "pro- life" ideology that means, particularly regarding end of life care, irrational expenditure for treatments that do nothing to cure or extend life or -- and here's the implosion scenario used -- we start killing the vulnerable.

What a tragic debacle that will cause suffering beyond comprehension. And this is is the milieu in which legalizing assisted suicide is being seriously contemplated! Unbelievable.

It's a black-and-white view of a much more complicated challenge faced by westernized countries the world over, one that does little to problem-solve loss of patient autonomy, the impossible rising cost of health care, discrimination in health care delivery, lack of corporate regulation, nor the very necessary discussion of death and palliative care that desperately needs to take place. But, as you'll notice in the comments to WJS's fear-mongering post and as I mentioned at the beginning, there are political and ideological objectives that are met by fanning fear among the elderly, disabled, and poor. Smith and others are willing to call recognition of a crisis fear-mongering when it contradicts their objectives.

Regarding climate change, another challenge with political and ideological framing but one that pitted "alarmists" against climate change deniers, Ross Douthat writes today at the New York Times:

The Seventies were a great decade for apocalyptic enthusiasms, and none was more potent than the fear that human population growth had outstripped the earth's carrying capacity. According to a chorus of credentialed alarmists, the world was entering an age of sweeping famines, crippling energy shortages, and looming civilizational collapse.

It was not lost on conservatives that this analysis led inexorably to left-wing policy prescriptions -- a government-run energy sector at home, and population control for the teeming masses overseas.

Social conservatives and libertarians, the two wings of the American right, found common ground resisting these prescriptions.

I quote Douthat, though I dislike his politics greatly and find his own prescription for climate change -- do nothing and see what happens -- to be terribly irresponsible, because he makes an important point.

Social conservatives and libertarians are denying on-the-ground facts regarding delivery of health care (and climate change) not because they don't think we need to solve the problem but because the only viable solutions belong to the opposing political party.

An interesting bit about this post: I came to the Smith hand-wringing post via a fundraising email from the activist organization founded by Terri Schiavo's family, dedicated to legislating that patients like Schiavo not be removed from life support.

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.

Idaho and Patients' Rights

The two great opening sentences of Maureen Dolan's CDAPress article on a new Idaho Law:

A new law goes into effect July 1 giving Idaho health care workers the right to refuse to provide end-of-life care they find morally objectionable.

Some fear the legislation places the conscience of a caregiver ahead of a dying person's rights.

I'm constantly amazed at how the media report down what they call the center line on end of life rights. Now, it's actually questionable whether a doctor making your health care decisions for you - despite your advanced directive, living will or other statements regarding informed consent for care - is a violation of your rights or not.

I think two factors feed into this odd kind of reporting; lack of knowledge of the dying process and reporters working to make end of life care stories contentious.

Of course, a doctor or nurse denying a patient legal, medically proven services is a violation of rights. But because religion's last bastion is the death bed, few are willing to call it what it is: a patronizingly old fashioned provider refusal law that pushes paternalistic ideas of faith and medicine on elder patients as a way to deny them autonomy. Just ask women. They've been up against such discriminatory laws for 4 decades. Let's see what baby boomers do with them.

Supreme Court Asks, "When Is The Best Time To Kill Someone?"

Oh that Clarence Thomas! Working hard every day to ensure that the state's right to impose suffering on subjects is not impeded by silly, liberal, humane Stevens.

What's that I hear? Crickets? No church standing up for the sanctity of life? No doctors protesting the mental and physical abuse? Or the method of torture used? Oh, that's right. INNOCENT life is sacred. Glad God's allowed to be the judge of that one.

Stevens said he remained “steadfast” in his view that execution after such delay is unacceptably cruel because it subjects death row inmates to decades of severe, dehumanizing conditions of confinement. Delaying an execution, he added, also does not further the public purposes of retribution and deterrence.

Justice Clarence Thomas, in a spirited response, said Johnson spent 29 years challenging his conviction and sentence and “now contends that the very proceedings he used to contest his sentence should prohibit the state from carrying it out.”

Thomas said Stevens first proposed his “novel” Eighth Amendment argument 14 years ago. There was no support for the argument then and there is no support now, wrote Thomas.

Noting Stevens’ dissent and his criticism last week of states executing inmates before their appeals process has concluded, Thomas added, “In Justice Stevens’ view, it seems the state can never get the timing just right.” The reason, he said, is that Stevens believes the death penalty is wrong.

“But that is where he deviates from the Constitution and where proponents of his view are forced to find their support in precedent from the `European Court of Human Rights, the Supreme Court of Zimbabwe, the Supreme Court of India, or the Privy Council.’”

There are alternatives to current procedural safeguards, added Thomas. As Blackstone observed, he said, the principle that punishment should follow the crime as early as possible was expressed in an English statute decreeing that “in case of murder, the judge shall in his sentence direct execution to be performed, on the next day but one after sentence passed.”

Thomas wrote, “I have no doubt that such a system would avoid the diminishing justification problem Justice Stevens identifies, but I am equally confident that such a system would find little support from this Court.”

via HarryAllen on twitter.