The End-Of-Life Movement and Medical Ethics

Posted on August 18, 2008
Filed Under General Rationing Issues |

Last week DrRich offered some friendly advice to health plans that would like to take advantage of the cost-saving potential of assisted suicide. DrRich was moved to help in this way upon witnessing the initial, typically ham-handed forays which health plans are making into this promising new arena of High Quality and Efficient Healthcare.

Among the sage recommendations which DrRich so kindly provided to directors of American health plans was the admonition to tone down their overt enthusiasm for assisted suicide, and to let the robust end-of-life movement do the selling for them.

DrRich finds the end-of-life movement to be an extremely interesting social phenomenon. These folks purport to act solely on the behalf of the autonomy of the individual, that is, to help people to preserve their freedom of choice, sense of control, and personal dignity when faced either with inevitable death, or with a life that is no longer worth living. They see the medical-industrial complex as an insensate machine which, for its own purposes (i.e., profit), will inevitably act to prolong the suffering and indignity of these unfortunate patients for as long as possible, long past the point where the individual sufferer would wish it to stop.

As with most passionate social movements, there is more than a grain of truth to their underlying premise. However, their own actions with regard to the three major issues they have taken up – assisted suicide, advance directives, and medically futile care – should make us suspicious of their true dedication to the precept of individual autonomy.

The stance the end-of-lifers have taken on advance directives and assisted suicide, of course, is entirely consistent with supporting the autonomy of patients who wish to forgo aggressive medical treatments, or even to hurry death along. It’s with the issue of medically futile care that the end-of-life movement reveals that its true motivation lies elsewhere.

For, when patients or families insist on continued medical care that even the insensate healthcare machine agrees is very likely to be unavailing, an end-of-life movement dedicated to preserving the autonomy of the individual would want that care to be offered anyway (since that is the explicit desire expressed by the affected individual). But instead, the end-of-life movement strongly favors withholding such care from these individuals, and indeed, seems anxious to expand the sorts of medical services that are to be considered futile.

One can argue logically about whether the position of the end-of-life movement with regard to medical futility is reasonable or not. But one cannot argue logically that this position is based on preserving individual autonomy. It is not.* Instead, their position is most consistent with wishing to limit spending on healthcare. Cost cutting, and not individual autonomy, accurately predicts the position the end-of-life movement takes on all three of its signature issues.

When reducing cost and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy.

(DrRich chooses to attribute the specific positions taken by the end-of-life movement to a desire to control costs, rather than to the other possibility suggested by their actions. Namely, he is reluctant to consider these fine people to be a death cult, of simply being in favor – due to some pathological or morbid fascination with death – of whichever action hastens it. DrRich is far too charitable to believe that.)

DrRich understands utilitarianism, though he most often does not agree with it. However, he finds it dangerous, and nearly reprehensible, to disguise utilitarianism as an ethical argument. If we as a society want to debate the hastening of death as a method of reducing spending on healthcare, then let’s have that debate.

But what the end-of-life movement seems to be doing is attempting to cut off this debate before it starts by claiming an ethical high ground that is actually inconsistent with its own positions. We should not treat the ethical argument advanced by proponents of the end-of-life movement any more seriously than they do themselves.

And we should avoid embracing assisted suicide (and other end-of-life solutions to the problem of healthcare rationing) until we’ve carefully considered the real ethical implications of doing so.

*Medical ethicists are actually much more subtle than this argument allows, and indeed have come up with an ethical system that permits us a way of preserving individual autonomy by (get ready) ignoring the clearly expressed desires of individuals! DrRich will address the medical ethicists’ support of the end-of-life movement in a later posting.

Comments

4 Responses to “The End-Of-Life Movement and Medical Ethics”

  1. BladeDoc on August 21st, 2008 4:27 pm

    Dr. Rich — totally agree on the government’s motivation in this debate but (ah yes the big but) I have an issue.

    I’m a surgical critical care doc and almost every day I round in the unit I find myself doing really cruel things to people that have a very small (albeit non-zero) chance at survival. Of course I try to provide pain and anxiety alleviation but as we all know the elimination of all discomfort is impossible in this setting. So here is my dilemma — at what percentage survival do we draw the line? 1/100? 1/1000? I don’t have an answer but it is heartbreaking for me to torture these patients knowing that I’m not doing a damn bit of good. And I’m going to hell for putting PEG tubes into 85 year-old Alzheimer’s patients.

  2. DrRich on August 23rd, 2008 10:01 am

    BladeDoc,

    Please know that I am not arguing in favor of delivering futile healthcare. I believe, as you do, that once medical care has passed the point of offering a realistic hope of reasonable improvement, it should be withheld.

    But in our culture, which overtly embraces the “no limits” mentality - where any medical care that offers even an infinitesimal hope is “owed” - then there’s no rational basis for withholding that care.

    For us to logically, ethically, and fairly withhold care when the utility of that care falls below a certain threshold, we need to agree (as a society) that we ought to do so. That is, we need to agree that there are limits. That is, we need to agree to ration.

    And until we make that agreement, then any limits we impose will necessarily be done arbitrarily, unevenly, and unfairly. And worse, the ethical arguments we manufacture to support our behavior will undermine the structure of our society.

    And that - supporting our behavior with trumped-up, utilitarian ethics - is the subject of this posting.

    Rich

  3. Red Baron on August 24th, 2008 5:38 pm

    To quote Inspector Renault from Casablanca “I am shocked, shocked there is gambling in this establishment” :-0

    :D

  4. Red Baron on August 25th, 2008 12:39 am

    And while you are absolutely correct Dr Rich, at some level you are prescribing a ’starve the beast’ treatment.

    I do wish you would think about fractals and healthcare spending a little more. They do hold the wisdom others seek (and I am looking for your charts).

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