Saturday, June 02, 2007

Kill Me Now

[Before Dinah inserts this I'll do it myself. Click here to comment on Double Billing. I've decided I should change the name of my story to Double Celling.]

I've been neglecting the blog horribly lately and I apologize. I have no excuse except to say that I've been either out of town or pleasantly distracted. I'm back now.

The thing that got me blogging again was the news report that Jack Kevorkian has been released from prison. As Dinah would put it, that's a Clinkable topic if there ever was one.

The idea of physician-assisted suicide began historically in the idea of informed consent. Usually treatment decisions are made by competent patients after proper informed consent. Medical decision-making for incompetent patients is sometimes made by third parties using something called a "substituted judgement" model, meaning that the decision-maker makes a choice that is consistent with what the patient would have wanted if he had been competent. In 1976 the New Jersey Supreme Court decided that substituted judgement could also be used when the medical decision involved life-sustaining procedures. See In Re: Quinlan for details.

In 1990 the U.S. Supreme Court decided Cruzan v. Director (497 U.S. 261). Nancy Cruzan was in a persistent vegetative state and her parents asked the hospital to remove the parental nutrition and fluids that she was receiving. The hospital refused to do so without a court order. Cruzan didn't have a living will, although Missouri had a statute providing for this. She had previously made statements to housemates that she would not want to live under these circumstances. The trial court ruled that the treatment could be removed, but the state supreme court reversed this because they felt that Cruzan's statements to housemates did not rise to the level of the "clear and convincing" evidence required under the living will statute. Thus, the Supreme Court stepped in. This was a case of high national interest---at least 17 amici briefs were filed by religious, medical and right-to-life organizations. At issue was the question of whether or not the incompetent patient's wishes---what the patient would have wanted if competent---had to be proven to a level of clear and convincing evidence. The Supreme Court found that this standard was appropriate, and also clearly stated for the first time that incompetent patients had a right to refuse life-sustaining treatment.

Now we get to physician-assisted suicide. Previously the issue was the withdrawal of care. Now we come to the idea of permissively providing a means to die. Quite a different scenario indeed. The two cases relevant to this are Vacco v. Quill and Washington v. Glucksberg. It was clear that physician-assisted suicide was a new legal issue emerging on both the East and West coasts, so the Supreme Court waited for the cases to percolate up their respective appellate systems and decided them together.

Vacco is a 1997 case arising from New York in which three physicians claimed that it was appropriate to provide a means of suicide for patients wishing to end their lives. In New York there was a law against helping someone commit suicide. The physicians alleged that there was no difference between withholding life-sustaining treatment and providing a means of death, and that banning this was a violation of due process and equal protection. The Supreme Court disagreed: "Logic and contemporary practice support New York's judgment that the two acts are different, and New York may therefore, consistent with the Constitution, treat them differently."

In Glucksberg four physicians and three terminally ill patients posed essentially an identical argument: that Washington's ban on assisted suicide was a violation of equal protection. Again, the Supreme Court disagreed stating that to overturn this law would go against decades of legal tradition and the prevailing policies of most U.S states. The Court also expressed concern about the potential consequences of such a decision:

"These interests include prohibiting intentional killing and preserving human life; preventing the serious public health problem of suicide, especially among the young, the elderly, and those suffering from untreated pain or from depression or other mental disorders; protecting the medical profession's integrity and ethics and maintaining physicians' role as their patients' healers; protecting the poor, the elderly, disabled persons, the terminally ill, and persons in other vulnerable groups from indifference, prejudice, and psychological and financial pressure to end their lives; and avoiding a possible slide towards voluntary and perhaps even involuntary euthanasia."

In summary, there is presently no constitutional right to assisted suicide. States are left free to ban or regulate this as they see fit. Oregon has a law allowing assisted suicide, the Death With Dignity Act.

And now for the correctional twist. (C'mon, you know there had to be one.) In our last podcast, Forced Treatment, we talked about physician participation in executions. For those of you who like to meditate on ethical dilemmas, comment on this: Considering the information presented here, what do you think about death row inmates who competently waive their right to appeals and volunteer for execution? As a matter of law, should physicians be allowed to participate in this?


And thanks to OmniBrain for putting up the cat picture. It was just the thing I needed for this post.


Anonymous said...

Husband looked at photo and exclaimed, "Clink! What is wrong with her!?!")

Anonymous said...

What a triggering picture.

Gerbil said...

I have to wonder whether your hypothetical inmate, by waiving his/her right to an appeal and volunteering for execution, would actually be considered competent.

ClinkShrink said...

Dinah: The cat pic is in memory of a fictionally euthanized cat who exists only in our imaginations.

Gerbil: Most people assessed for competence to be executed actually are competent. A death row inmate may decide that execution is preferrable to a lifetime of incarceration and this decision can be independent of clinical depression, medical illness or other 'quality of life' issues. In Maryland the legal test for competence to be executed is quite low. You only have to know that you're being put to death and that you're being put to death as a punishment for a crime.

Gerbil said...

Clink: I was making a snark :) based on the prevailing societal notion that suicide is always an irrational act.

(I know that rational thought and competence are not necessarily synonymous.)

Anonymous said...

The way to go

Midwife with a Knife said...

I love the picture! It totally made me smile. I'm not a big fan of capital punnishment.

I do, however think that it should be ok if a death row inmate decides that they don't want to spend 40 years (or however long) in the appeals process.

I was discussing this issue with my brother who feels that life in prison without the possibility of parole is the most inhumane thing you can do to a person. He feels that those individuals should have the right to volunteer for execution.


Zoe Brain said...

I can't comment on the Death Row hypothetical. I don't regard someone sentenced to die as being terminally ill though, the situations are morally different. I can't justify that belief, just call me a Kantian Realist.

"Hi Kantian Realist!"

As regards assisted suicides - sometimes, rarely, suicide is a rational and moral act. But it has to be the result of cool calculation, with peer review and cross-checking, and not because one is merely upset.

Two examples from my ridiculously melodramatic Life Story :

Throughout 1979, I was in and out of an Oncology Ward (ward C3 West at Royal Prince Alfred in Sydney). Basically a tumour would block a blood vessel or pinch a nerve, I'd have severe pain, then the spasms would tear things apart and I'd feel better in a few days, until the next time.

One man, Mr T. was there. A welder by trade, he'd had a dozen operations, each time more of his digestive tract taken out. Each time, they hoped it was curative.
He'd had enough. He told me as soon as he got out, he'd get some cyanide (used in cleaning surfaces before welding) and end it all.
I tried to pursuade him to give it one more go. But he was adamant.
I convinced myself that if he truly wanted to do it, he wouldn't have told me, so I blabbed to a visiting religious councellor. Very useful people those at the time, few of us were expected to survive more than a year.

Anyway, over the next 12 months, as I was in and out, I saw what the cancer did to his body. It was obscene, nightmarish, at the end he looked more like the Elephant man.
My fault. But even now, I'd have to do the same, if I thought there was a reasonable chance of a cure.

If there was no chance though, he'd had enough. Time to go and end the torture.

The second episode - well, I had 15 seconds of suicidal ideation once. It scared the heck out of me. I'm afraid to say the actions of a psychiatrist were causal, he hadn't understood the clinical notes. He shouted at me, telling me the awful effect my actions were having on my son. The trouble is, he wanted me to stop being silly and taking black market hormones, and I wasn't doing that : the changes were all natural, I wasn't on HRT then.

For maybe 15 seconds I thought that in order to stop dreadful harm to my son, I would be better off dead.

I wasn't thinking straight, I was terribly emotionally upset (being screamed at by somebody trained in pushing emotional buttons will do that), but from my days in the Cancer Ward, I knew how to do the deed. I won't go into details, but the first step was to use a particular medication that would destroy the liver if no antidote was given in 24-48 hours. A slow, agonising, undignified death within 2 weeks, but 100% sure, which other techniques weren't.

It would also give me a full 24 hours to think about what I was doing, and make sure I wasn't being irrational.

Most of my thoughts were on trying to figure out how to minimise upset to those finding my body. I was rational, but my logic was based on irrational premises.

After 15 seconds I realised two things.

The first was that no matter how much damage having a freak, a man-in-a-dress as a father would do, having a father who suicided would be worse.

The second was that this eminent and widely respected psychiatrist (I'd picked him very carefully) was totally wrong. I wasn't taking hormones, yet he was convinced I was, and doing so not in a fugue state, but deliberately to gain attention.

Now I could have believed that I was nuts, amnesiac, taking hormones and forgetting it, it would have explained a lot that was otherwise inexplicable. But I knew I wasn't doing it consciously.

Now if he was so completely 100% wrong in his diagnosis, maybe he was wrong in other areas too.

I've not seen him since that appointment. He was good enough to send an apology to me, after he read the endocrinologists report confirming my claims.

Anyway, the point is, I can easily imagine situations where in order to spare others harm, and in order to escape a hopeless and worsening situation, suicide is a moral act.

It therefore follows that any
physician aware of the facts, and giving advice in ways and means to accomplish it as surely and painlessly as possible, is also acting morally.

Gerbil said...

On another note, Clink, what's up with this new riot and lockdown?

ClinkShrink said...

Gerbil: I love the word 'snark'. I can't explain it, it's just a great word.

MWAK: I tend to lean toward the personal autonomy and privacy end of the spectrum, so I'm with you on the issue of deciding to waive appeals.

Kantian Realist: I'm glad you're still with us. I'd hate to think we could have missed out on the chance to have your very articulate and insightful input. That thought is just too sad. I agree with you about the need for careful cross-checking and peer review in states where it is legal. I struggle with knowing how much review is enough. How many psychiatrists should certify competence? Or should it be one psychiatrist and one somatic doc (to verify expected lifespan)? Or maybe more than one psychiatrist? Then you run into the issue of having to manage split decisions---Shrink Rap is proof that three psychiatrists won't always simultaneously agree on any particular issue. As far as actually giving the means of death, that would be pretty much out of the question for me---in spite of what one might read into the cat picture.

Midwife with a Knife said...

As a resident, when I was on my medicine rotations, I participated in a couple of cases of "terminal sedation" which isn't that different from physician assisted suicide. For these people, their symptoms from their terminal disease (the one I remember was a young man with Huntington's disease) essentially could only be controlled through such high doses of meds that they would sleep and not wake up often enough to do things like eat or drink enough to keep themselves hydrated. So.... after a few days of this, they would die. I think it was a humane way to deal with these people's symptoms, but... it kind of had a heavy burden on the caretakers, you know?

Then, on gyn-oncology, we also did a lot of palliative care for people who were dying from various gyn cancers. What I learned from this is that it is possible to get people's pain controlled, even in terrible end of life circumstances. With good pain control (up to and including terminal sedation as above), there should be no need for physician assisted suicide as such.

I suspect this might not be related. Sorry 'bout that!

Zoe Brain said...

Thanks Clinkshrink for the welcoming words. Thanks also for forgiving my overly-long comments.

And yes, I still feel guilty about Mr T (but that was screamingly obvious). As I said though, I'd still do the same again.

Hence my admiration for those in the medical profession. I think I have the smarts for medicine (I have a very high opinion of myself, even if no-one else does (chuckle)), but I know I don't have the strength.

Anonymous said...

The question is, "Do any of you have cancer? An incurable cancer?" My husband does. So do many other people. The issue, as MDAnderson clinic Dr.s will tell you, is quality of life, or QOL. I know all the well meaning opinions from health food to "wait it out for a cure." We are highly educated people and have done our homework. When is enough enough? I am happy to say that our life is full of happiness and wonder. But, the nature of this beast is that it for sure will you keep repeating chemo over and over again? How about immunoglobulins that are so low that you contract every infection that comes your way? Or the fatigue that is so inherent in this cancer that to get to the bathroom is an unbelievable chore? Or the sweats and the weight loss and the bone pain and the depression...."Kill Me Now" becomes a viable option. Hospice does it all the time at end stage cancer. ALL THE's called Morphine Overdose. They just tell the family how to administer the morphine over 24 hours to end life. Hospice Nurses will not do it themselves, but they are right there with they go to jail? No. Assisted Suicides are done all the time in the World.

As for the inmate and volunteering his/her execution.....why would competency be a factor? If they are on death row for murder we already know that they are not competent. A sane person does not murder unless in self defense. That's my story and I'm sticking to it.

Zoe Brain said...

Parked - Can I hope your husband has a Spontaneous Remission? Miracles are rare, but they happen.

In the meantime, I hope your lives are as fulfilled as possible. Then again, that goes for everyone, doesn't it? The only difference is the time we have.

I hope you have a wonderful life together for whatever time is left, months, years, or decades.

Hugs too.

DrivingMissMolly said...


For the record, I think you're awesome. I'd rather have a great conversation with "a freak, a man-in-a-dress," as you described yourself (hopefully you felt that way just at that time but not now), than with a run-of-the-mill bland "regular" person. You're intelligence, insight and openness are assets to this blog!

If you were speaking of acetaminophen, eating charcoal and having constant blood tests to have your liver function checked isn't a fun way to spend an evening. For the record, charcoal is a whole lot worse coming out that getting in : ) MESSY!

I'm glad that you only thought about suicide for 15 minutes. I have been tormented by those thoughts for about 20 years. It seems that the respite from taking lithium has worn off and thoughts are back.

Anyway, um, what's this post about?? ; )


Anonymous said...

Zoe Brain-
Thank you for your caring support. This is not a subject that I will dwell on here, but I do want to say that this is a different situation than, "we are all going to die someday." This disease has given my husband and myself the beautiful gift of getting to say goodbyes, I love you's and just sit in awe together watching a pink lemonade sunrise. This Cancer has given us time to do things that maybe we would have put off until too late. Our son's will benefit from their Father's words and wisdom. They will know he loves them. But the main gift is that no one in our family will end up saying, "I wish I'd told him how much he meant to me."

Hugs back--you are quite a remarkable, strong, interesting person. Rock on...let's make this life as fun as possible.

Sarebear said...

Parked, my thoughts are with you and he.

Lily, yeah I tried that too. I didn't mind the charcoal; it was the er docs and stuff getting all annoyed w/me for gagging my way into throwing up (not on purpose) as they were shoving a tube down my throat.

Uh, how does one stop an automatic reflex, anyway? Quit shoving that thing down my throat and I'll quit gagging, thank you very much. Not an option, I know, but it was like they were holding a match to my hand and getting mad at me for pulling away and saying ouch.

Anyway. Actually, it just occured to me, kind of funny actually, that my throwing up may have at least partly solved the problem they were trying to solve w/the tube.

It's ironically funny now, 11 years later, in hindsight.

anynonymous, funny pun. Bang-up joke, there.

Zoe Brain said...

Thanks everyone for the compliments - keep 'em coming!

As regards the "Man in a dress" bit, this blogpost shows what happened, pictorially. I'm just very glad it went that way, and not the reverse. That would have been... difficult... to live with. Though it would have meant that I would have had a normal girlhood, young womanhood, motherhood, so even that has its upside.
Being a teenage Geek Girl in the 70's wasn't socially cool though, so who knows?

Lily, I'm glad you're still here.

And Sarebear, you cam contact me via my blog. If you ever need anyone to vent to, I do a good line in absorbent shoulders.

Sarebear said...

Lily, I'm glad you're still here too; I hope my not mentioning that didn't hurt you! I just had a brain full of stuff I was typing.

Thanks, Zoe! What'dja do, load 'em up with Always? (that's a brand of feminine hygiene product in the States)

kazza26 said...

right i kind of scan read this because its late in UK and my brains turning itself off.
are you asking whether people should be allowed to have assisted suicide.i think yes they should provided that they have an illness that they will never recover from and just get worse,such illness include