Assisted Suicide’s Moral Hostages

Bioethics-in-the-News-logoThis post is a part of our Bioethics in the News series

By Tom Tomlinson, PhD

This isn’t exactly news, but some of you may remember a ripple of controversy surrounding a proposal before the Dutch legislature to legalize assisted suicide (AS) for people over 75 who meet certain other conditions, as reported in October in The New York Times.

I was reminded of it in December, when I stumbled over an item in the UK’s Daily Mirror. (Yes, I’m an avid follower of British tabloids.) The item features a video interview with a 65-year-old man with multiple sclerosis who explains why he would want this option as he becomes more disabled by his MS. He complains he’s losing sight in both eyes, and has difficulty reading or writing. As he loses his independence, he finds it more difficult to be happy with his life. “Where are all the things that make life a pleasure, besides the people that I love?” he asks. “They’re all gone, one-by-one they’ve been stripped away…. I don’t see the point of waiting until one is a virtual corpse that simply breathes.”

Now of course assisted suicide for terminally ill patients is itself a controversial topic, although majorities support it in the U.S., Great Britain, and Western Europe. One can expect that a proposal to expand AS to those who have a collection of chronic and variously disabling conditions just by virtue of being old will be even more controversial, and indeed vigorous opposition is expected in the Netherlands, and the adoption of the proposed legislation is far from certain.

euthanasia-regulations-around-the-world

Image description: this map shows the legal status of Physician Assisted Suicide (PAS) and Voluntary Active Euthanasia (VAE) around the world. The map is a project of the Kennedy Institute of Ethics at Georgetown University. Visit the map on the web to explore its interactive features or to view a text version.

Speaking as a gradually disintegrating 71-year old, here’s a tentative defense. It starts with remembering what the Stoic Seneca taught. There is no need to fear death, since once you are dead there is no you to be afraid or to suffer. It’s the dying that we should fear—which is to say, the living we experience before we are finally released by death.

So if AS is justified for those who are dying from a terminal illness, it is because the quality of the life that remains has become intolerable for that person. But the terminally ill aren’t the only ones who struggle with losses to their capacities and their ability to find enjoyment and meaning in the life they are living. The old may well suffer the same kinds of losses as the terminally ill, as a host of chronic but not (yet) fatal conditions chip away at what before could be taken for granted, as friends and family die or move away and the social world shrinks, as the future begins to lose its allure, and there is nothing more in particular we want to achieve or do. “Dear World, I am leaving because I am bored. I feel I have lived long enough,” read George Sanders’ suicide note. A flamboyant actor, Sanders may have wanted his last lines to be good ones. But there was a lot more to the story. Sanders had suffered many losses before his death, which may happen to many of us in our later years. Under some perhaps narrow conditions, why shouldn’t we have the option of AS?

A common reply to this argument is that killing yourself is an awfully extreme solution to such problems, many of which could be ameliorated in other ways: better, more available primary and palliative care, assistive devices, meals on wheels, age-appropriate social activities and networks, visiting nurses and social workers, etc., etc. Once all this is provided, the need for AS will evaporate.

Now these are all fine options to be pursued in the individual case—when they are in fact available. But too often, these alternatives are used as reasons to not permit the option at all—as an argument against a policy allowing AS.

But when they are not readily available to all, or are not effective in the individual case, those who after due consideration believe that AS would serve their interests become moral hostages to an ideal world: a world where every deeply felt need motivating a desire for AS can be met in some other way. When we’re fixated on the ideal, the person in front of us is sacrificed to our vision of a better world. Paradoxically, the real world becomes a worse place as a result.

So I think this style of moral argument is deeply problematic. And assisted suicide is not the only context in which it’s found. For example, parents of children with familial short stature may want to use human growth hormone for children so their child may grow to something closer to the average height, and perhaps avoid the real social disadvantages short people face (men especially). Now there may be lots of good reasons to object to this treatment—e.g., it’s expensive, it is a crapshoot whether it will increase height by any significant amount, etc. But this use of growth hormone is also opposed on the grounds that what really needs to change are discriminatory social attitudes toward very short persons. By all means, let’s work on that. But in the meantime, what about this kid?

Another moral hostage, as we await the Millennium.

tomlinson-crop-2016Tom Tomlinson, PhD, is Director of the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine, and Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, February 9, 2017. With your participation, we hope to create discussions rich with insights from diverse perspectives.

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What are key ethical concerns surrounding the use of psychiatric deep brain stimulation?

bbag-icon-decRecurrent and Neglected Ethical Issues in the Psychiatric Brain Stimulation Discussion

Event Flyer

What are key ethical concerns surrounding the use of psychiatric deep brain stimulation (DBS)? Are those concerns shared broadly for all aspects of DBS or alternatively are they specific to the intended targeted use of that intervention? Dr. Cabrera will discuss results from a recent study conducted by a multidisciplinary research team in which they examined ethical issues discussed in both the scientific and ethics literature around psychiatric DBS. Dr. Cabrera will make the case that understanding the ethics of DBS for psychiatric interventions provides important insight into the way in which ethical concerns for a single technology might vary depending on their intended use.

feb15-bbagJoin us for Dr. Cabrera’s lecture on Wednesday, February 15, 2017 from noon till 1 pm in person or online.

Dr. Cabrera is an Assistant Professor of Neuroethics at the Center for Ethics and Humanities in the Life Sciences. She is also a Faculty Affiliate at the National Core for Neuroethics at University of British Columbia. Her research focuses on the exploration of attitudes, perceptions and values of the general public toward neurotechnologies, as well as the normative implications of using neurotechnologies for medical and non-medical purposes. She received a BSc in Electrical and Communication Engineering from the Instituto Tecnológico de Estudios Superiores de Monterrey (ITESM) in Mexico City, an MA in Applied Ethics from Linköping University in Sweden, and a PhD in Applied Ethics from Charles Sturt University in Australia. Her career goal is to pursue interdisciplinary neuroethics scholarship, provide active leadership, and train and mentor future leaders in the field.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lectures. To receive reminders before each webinar, please subscribe to our mailing list.

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Coworker Stigma Towards Lactating Mothers in the Workplace

bogdanlovis-crop-facLibby Bogdan-Lovis, MA, Assistant Director of the Center for Ethics and Humanities in the Life Sciences, was recently awarded funding for the project “Coworker Stigma Towards Lactating Mothers in the Workplace” by Science and Society at State (S3). Ms. Bogdan-Lovis is a team member on the collaborative project.

The project’s team is led by Mary Bresnahan of the Department of Communication, and members include Steven Haider of the Department of Economics, Joanne Goldbort of the College of Nursing, and Jie Zhuang of the Department of Communication.

Learn more about “Coworker Stigma Towards Lactating Mothers in the Workplace” on S3’s 2016-2017 Funded Projects page.

S3 is an interdisciplinary research institution at Michigan State University. Learn more about their mission.

Learn more about Libby Bogdan-Lovis’ research.

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Covert Costs of Racial and Ethnic Concordance in the Medical Workforce

bbag-icon-decCovert Costs of Racial and Ethnic Concordance in the Medical Workforce

Event Flyer

Over the past century US medical workforce demographics have shifted. Moving away from a white male dominated profession, there is a welcomed push towards increasing gender, ethnic, racial and linguistic representation. Commonly, that push is linked to notions of desirable doctor/patient identity matching – described here as “concordance.” That demographic shift is accompanied by policy initiatives and rhetoric shaping the professional futures of Native American, African American, and Latino underrepresented minority (URM) physicians. Do these policy initiatives carry social costs that inadvertently influence URM’s futures in the medical workforce? This analysis considers the nature of medical workforce policy strategies. Findings suggest that selectively placing service expectations not similarly placed on their non-minority physician colleagues along with unexamined assumptions of racial/ethnic concordance between patient and physician may place an undue burden on URMs.

jan18-bbagJoin us for Ms. Bogdan-Lovis and Dr. Kelly-Blake’s lecture on Wednesday, January 18, 2017 from noon till 1 pm in person or online.

Dr. Kelly-Blake is an Assistant Professor in the Center for Ethics and the Department of Medicine. Ms. Bogdan-Lovis is the Assistant Director for the Center for Ethics. Bogdan-Lovis and Kelly-Blake are co-leading a multi-institutional research project on Doctor-patient Race/Ethnic Concordance in the Medical Workforce. They are interested in unpacking the complexities surrounding underrepresented minority service to the underserved and how that service may distract those physicians from pursuing other medical professional opportunities.

In person: This lecture will take place in C102 East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lectures. To receive reminders before each webinar, please subscribe to our mailing list.

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Dr. Stahl presents at American Academy of Religion Annual Meeting

Devan Stahl photoCenter Assistant Professor Dr. Devan Stahl is currently the Vice President of the North American Paul Tillich Society and the Co-Chair of the Tillich: Issues in Theology, Religion and Culture Group at the American Academy of Religion. In November Dr. Stahl attended meetings held by the North American Paul Tillich Society (NAPTS) and the American Academy of Religion in San Antonio, TX. Dr. Stahl gave a paper for NAPTS titled “Tillich and the future of interdisciplinary ethics,” discussing the difficulties in doing Christian ethics in non-religious fields, such as medicine, business, and law. Dr. Stahl discussed both why ethics is becoming an interdisciplinary field in the academy and why it is difficult for Christian ethicists to engage in interdisciplinary work. Dr. Stahl proposed Tillich’s method of correlation can help Christian ethicists be true to their Christian message while adapting it to the current situation and culture in which they live.

Dr. Stahl also gave a paper at the American Academy of Religion in a joint session between the Human Enhancement and Transhumanism Group and the Religion and Disability Studies Group titled “Does Transhumanist eschatology eradicate disability?” Dr. Stahl contended there is a tension at the heart of the transhumanist agenda and disability theology: transhumanists aim to enhance “normal” human traits through novel biotechnologies, whereas disability theologians desire a world wherein disability is accepted rather than eradicated. However, because both disability theologians and transhumanists believe bodily variation or modification cannot sever our connection to God, there is room to creatively imagine ways to modify the body that might be beneficial to persons with disabilities. Dr. Stahl argued “radical prosthetics” might be a point of convergence between the two camps and a way to creatively and jointly signal the kingdom of God through human creations.

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Announcing the Spring 2017 Bioethics Brownbag & Webinar Series

bbag-icon-decThis year’s Bioethics Brownbag & Webinar Series will resume on January 18, 2017 with a lecture from Center Assistant Professor Dr. Karen Kelly-Blake and Assistant Director Libby Bogdan-Lovis on “Covert Costs of Racial and Ethnic Concordance in the Medical Workforce.” Each lecture can be streamed live online, or attended in person in East Fee Hall on MSU’s East Lansing campus. Information about the spring series is listed below, and you can visit our website for more details, including the full description and speaker bio for each event.

Spring 2017 Series Flyer

jan18-bbagCovert Costs of Racial and Ethnic Concordance in the Medical Workforce

Do policy initiatives carry social costs that inadvertently influence underrepresented minority physicians’ futures in the medical workforce?
Wednesday, January 18, 2017
Karen Kelly-Blake, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine; Libby Bogdan-Lovis, MA, is Assistant Director of the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine at Michigan State University.

feb15-bbagRecurrent and Neglected Ethical Issues in the Psychiatric Brain Stimulation Discussion
What are key ethical concerns surrounding the use of psychiatric deep brain stimulation (DBS)?
Wednesday, February 15, 2017
Laura Y. Cabrera, PhD, is an Assistant Professor of Neuroethics in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Science & Molecular Medicine in the College of Human Medicine at Michigan State University.

mar22-bbagThe Choice to Become a Research Subject: A First-Person Perspective
Did I have a responsibility to contribute to a study that could help future patients in my situation?
Wednesday, March 22, 2017
Rebecca Dresser, JD, is a Professor of Law at Washington University in St. Louis.

apr19-bbagSocial Determinants of Behavioral Health
Wednesday, April 19, 2017
C. Debra Furr-Holden, PhD, is a C.S. Mott Endowed Professor of Public Health in the Division of Public Health, and a Professor in the Department of Epidemiology and Biostatistics in the College of Human Medicine at Michigan State University.

In person: These lectures will take place in C102 (Patenge Room) East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? Every lecture is recorded and posted for viewing in our archive. If you’d like to receive a reminder before each lecture, please subscribe to our mailing list.

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Bioethics for Breakfast: Advanced Dementia and the ICU Siren’s Song: When We Build It, Why Do They Come?

bioethics-for-breakfastKevin Foley, MD, and Leonard Fleck, PhD, presented at the Bioethics for Breakfast event on December 8, 2016, offering perspective and insight on the topic, “Advanced Dementia and the ICU Siren’s Song: When We Build It, Why Do They Come?”

When nursing home patients with late-stage Alzheimer’s or other advanced forms of dementia develop sepsis or pneumonia, should they be sent to an ICU and hooked up to a ventilator? This is the question that was posed in a couple recent medical journal articles. This question can be seen as a medical care issue, an ethics issue, and a policy issue. Is this practice in the best interest of these patients? Why does this seem to be happening with greater frequency? Is there an ethically preferable alternative? Given the relative scarcity of ICU beds, is this a good use of an ICU bed? Are there changes in policy and practice that need to be considered? What should those changes look like?

We start with a statistical picture. About 7.4% of adults over age 75 live in nursing homes; that rises to 16% for adults over age 85. Somewhere between 50% and 70% of nursing home patients have some form of dementia. For the vast majority of these patients who have dementia, their caregivers see comfort care as the goal of care. In spite of that, many of these patients receive more aggressive care than they desire. A common enough scenario is that these patients in late-stage dementia (no longer able to take food by mouth) develop a pneumonia, perhaps related to aspiration as a result of trying to provide food by mouth, and staff at the nursing home cannot provide what they see as necessary medical treatment. Such patients are then sent to a hospital Emergency Department. A palliative care consult would be appropriate at this point but most Emergency Department physicians are reluctant to request such a consult because of pre-existing beliefs and lack of knowledge. This deficiency has more recently been addressed in two publications, one of which is a consensus statement from the Society of Academic Emergency Medicine. See Naomi George et al. “Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda.” Academic Emergency Medicine 23 (2016): 1394-1402. See also Jason Bowman et al. “Acceptability and Reliability of a Novel Palliative Care Screening Tool Among Emergency Department Providers.” Academic Emergency Medicine 23 (2016): 694-702.

If these patients with late-stage dementia reach the ICU, then intensivists in the ICU are faced with another set of ethical issues. Very often they will judge that these patients have a very poor prognosis that can be made worse by the surgical placement of feeding tubes to correct for the inability of these patients to be fed by mouth. But the intensivists may have to deal with a family member who is a surrogate decision maker or a court-appointed guardian in the case of an unbefriended patient, and those individuals may, for various reasons, insist on more aggressive life-sustaining care. Those decision makers might represent the earlier expressed wishes by that patient, or fears of legal repercussions in the case of court-appointed guardians. Physicians then might need to be extraordinarily persuasive to prevent what they regard as choices that are contrary to the best interests of those patients. They may feel that they are being paternalistic in considering overriding what might be the preferences of that patient (albeit likely less informed than desirable at the time). Still, the American Medical Association Council on Ethical and Judicial Affairs says explicitly that physicians have as a first obligation not harming their patients in these circumstances. Consequently, they have the professional responsibility to act against the expressed wishes of that surrogate decision maker when that individual wishes to make a medical decision clearly contrary to the best interests of that patient. Obviously, the physician should make every effort to explain sensitively why such decisions are necessary.

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Left to right: Len Fleck and Kevin Foley pose for a photo following the event. Photo courtesy of the Center for Ethics.

These sorts of conversations can be very painful and confrontational. It is clearly better to avoid them through a more preventive approach. At the very least when patients are first diagnosed as being in the very early stages of dementia, conversations regarding various scenarios in late stage dementia should be addressed with both the patient and any surrogate decision maker. It may be difficult for those individuals to imagine vividly enough and accurately enough what those late stages might really be like when the issue of feeding tubes, ICU care, or use of ventilators might be broached. What some research has shown is that videos of patients in late-stage dementia allow for a much more accurate understanding of what choosing life-sustaining care might mean, the consequence of which is that virtually no one is then motivated to want such care in those circumstances.

Kevin Foley, MD, FACP, AGSF
Associate Professor and Associate Chair for Senior Health
Department of Family Medicine
Michigan State University College of Human Medicine
Director of Education and Clinical Operations
Division of Geriatrics and Gerontology
Michigan State University Clinical Center

Leonard M. Fleck, PhD
Professor of Philosophy and Medical Ethics
Center for Ethics and Humanities in the Life Sciences
College of Human Medicine
Michigan State University

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
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