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Attacks on life and medical conscience and the importance of the states

The bad guys are always up to more badness in the world of bioethics. Several weeks ago Wesley J. Smith highlighted some of the worst points in a "consensus statement" by a group of bioethicists. The topic was forcing doctors to participate in abortions and euthanasia. (I say "the topic," though neither of these is named in the statement. However, the statement is filed on the blog under "abortion," and in the social context this is clearly what the participants have in mind. The comments are somewhat interesting. One commentator points out that the much-maligned "reparative therapy" would have fallen within the ambit of the "services" that doctors can be punished for not referring for or providing, right up until the time that it was disavowed by the medical profession.) The statement was published by Oxford University and is available en toto here. It represented conclusions drawn by participants in a bioethics conference in Geneva in June of this year.

Some highlights:

In the event of a conflict between practitioners’ conscience and a patient’s desire for a legal, professionally sanctioned medical service, healthcare practitioners should always ensure that patients receive timely medical care.

The assumption is that any "legal, professionally sanctioned medical service" is a form of necessary "medical care" that the patient must receive.

Policy makers should ensure that in any geographical region there is a sufficient number of non-conscientious objectors for patients to obtain the medical services they need in a timely manner even if some healthcare practitioners conscientiously object to providing that service. This implies that regional authorities, in order to be able to provide medical services in a timely manner, should be allowed to make hiring decisions on the basis of whether possible employees are willing to perform medical procedures to which other healthcare practitioners have a conscientious objection.

Blatant discrimination against pro-lifers in order to insure that there are "enough" killer doctors in a given region.

Healthcare practitioners who are exempted from performing certain medical procedures on conscientious grounds should be required to compensate society and the health system for their failure to fulfil their professional obligations by providing public-benefitting services.

If you conscientiously object to something these people think you shouldn't conscientiously object to, you should be punished by being forced to provide community service to "compensate society" for the alleged "cost" of your conscience.

Medical students should not be exempted from learning how to perform basic medical procedures they consider to be morally wrong. Even if they become conscientious objectors, they will still be required to perform the procedure to which they object in emergency situations or when referral is not possible or poses too great a burden on patients or on the healthcare system.

This means everybody has to, e.g., perform abortions at some point, if only in the course of medical training. In order to learn how. Because they may be forced to do so later anyway.

Healthcare practitioners should also be educated to reflect on the influence of cognitive bias in their objections.

If you try to get an exemption to performing these "services," we'll put you through bullying, non-optional re-education to try to get you to change your mind.

Now, these are a bunch of philosophers saying what they want. But this sort of thing is by no means purely theoretical. The State of Illinois isn't doing the forced re-education and community service punishment yet, but it's made it a crime to refuse to provide conscientiously objectionable "services" or refer for them. This is directly contrary to federal law, but the federal law is not being enforced.

So this is a real, practical matter. The ideas floated by these bioethicists are coming into the real world.

Moreover, the list of objectionable activities is always expanding. For example, activists want to include euthanasia in the "services" that doctors must be forced to participate in when euthanasia is legal in a particular venue.

The New York Times is continuing the push for starving and dehydrating patients to death even when they can be spoon fed. This moves beyond the previous starvation regime in the U.S. which applies chiefly to patients who need (or are perceived to need) tube feeding, since tube feeding is considered "medical treatment" in the U.S. But spoon feeding is considered basic care. I recently blogged about a woman in Oregon whose life was saved from death by dehydration, which her husband insisted she "would want," because she was accepting spoon feeding. The new push is to remove even this and, moreover, to permit patients to say by an advance directive that they don't want to be spoon fed and for this advance directive to be enforceable.

The New York Times puts this in faux neutral terms:

The question grows much murkier for patients with dementia or mental illness who have specified VSED under certain circumstances through advance directives. Several states, including Wisconsin and New York, forbid health care surrogates to stop food and fluids. (Oregon legislators, on the other hand, are considering drafting a bill to allow surrogates to withhold nutrition.)

The question intrigues bioethicists. Can your current competent self cut off nutrition and hydration for your future demented self? In a handful of court decisions, judges have declined to enforce such directives.

Very "intriguing." Also, I wonder why they say specifically that Oregon legislators are considering such legislation. No link is provided for that assertion. Does it relate to the case I have discussed? At that time readers will recall that I emphasized how everyone involved in the case spoke as if it was terribly regrettable that state law would not permit them to withhold spoon feeding.

The article mentions a man named Alan Alberts who was diagnosed with Alzheimer's and who died by stopping eating and drinking with the "support" of his wife, doctor, and two caregivers. Exactly what this "support" consisted in and whether Alberts had any second thoughts during the process, we aren't told.

This obviously is relevant to medical conscience, since doctors and caregivers could potentially be required to participate in starving and dehydrating a conscious patient able to accept food by mouth. This would include giving drugs to prevent the patient from being in pain or from distressing others by requesting food and water. The NYT article refers explicitly to "aggressive pain medication" for thirst.

None of this is merely alarmist. It is all quite plausible and indeed has already been happening for a long time in the case of patients deemed to "need" tube feeding. This would just expand the base of patients to which it would apply. And if the Oxford group gets their way, it would make it harder, or impossible, for nurses and doctors to save the patient, since "helping" patients to be starved to death could be deemed a "service" that must be provided.

The usual moral I draw from this for individuals is to make it quite clear in writing that you do want food and water, so that at least there is no excuse for pretending that you would have wanted otherwise.

But I want to draw a different moral here in addition: With the abdication of the U.S. federal government in enforcing federal conscience protections for healthcare workers, state law becomes crucial. For right now, these matters are going to be fought out at the state level. It is easy for voters in the U.S. to get fixated on the federal government and to forget how much is still left to the states. Euthanasia/assisted suicide law varies widely across the states. Laws concerning how advance directives work also vary. With the Illinois defiance of federal law, I predict that we will see increased variation concerning conscience protection for doctors and nurses. I also predict that, with the push for starving patients who can receive spoon feeding, we will see pushes for change in state laws on this matter, and our state lawmakers will need to be alert to stop them.

So whatever happens at the federal level, there remains a lot of both good and bad that legislators can do at the state level, either to attack life or to protect it, either to drive good doctors out of the profession or to keep them. In your civic activities, don't neglect your state.

Comments (7)

Whether this undeniable specter of direct repression of men and women of conscience, will ever rouse our dear liberals from their soma haze, remains to be determined.

Only to cheer it on, I fear.

What I find rather offensive about it (because it's an insult to intelligence) is the pretense in the "consensus document" that this is based on some neutral metaprinciple concerning medical duties and legal treatments. Rubbish. As the astute commentator implied (without quite saying it), it's quite clear that these philosophers mean this only to apply to *some* legal treatments. They would never really intend that psychiatrists in California *before* reparative therapy for minors with SSA was outlawed would have to be punished by community service if they refused to do reparative therapy. If a Catholic woman wants counseling in natural family planning but her ob-gyn thinks it's all hogwash, none of these philosopher kings is going to lobby to force the ob-gyn to undergo re-education camp in order to examine his "cognitive biases" against NFP. Yet such a consultation certainly falls under the heading of legal, professionally sanctioned medical services.

And in contemplating a different historical era, they would no doubt think someone a far-sighted hero for refusing to engage in electroshock therapy or lobotomy, even though those were legal and professionally sanctioned at one time.

There is no value-neutral principle here. In principle there *can* be no value-neutral principle, because the medical community and the legal community can be *wrong*, both morally and empirically. And the individual doctor may realize that. Moreover, doctors are *constantly* making decisions to offer or not offer a particular "legal medical service" on the basis of what they specialize in and what they actually think is best for the patient. Anything else would be irresponsible. But they are in favor of certain *particular* "medical services" that happen at this moment to be legal and professionally sanctioned but to which some doctors and nurses (whom they despise) conscientiously object. So they want to play the totalitarian and force medical professionals to cooperate with *those* "medical services." Yet they write up their cutesy little pseudo-intellectual "consensus document" in pseudo-general terms with no mention of what they actually have in mind anywhere in the text and then coyly file it on their Oxford blog under "abortion."

As a philosopher, I find that rather disgusting. Whom do they think they're fooling?

The miasma of clinical and consensual blandness serves the purpose with quite a few people: it gives them the cover to look away. Nothing to see here, folks.

"Exactly what this "support" consisted in and whether Alberts had any second thoughts during the process, we aren't told."


While not my first choice (hemlock is plentiful on the property), I really can't see a problem in the Alberts case.

You wouldn't.

I gave strict instructions to the caregivers that I was the only person who could talk with Alan if he asked for food or water. On the fifth day, he asked me twice. Both times I reminded him why he wasn’t eating or drinking. I explained that drinking water would prolong the process. Then I said to him, “Would you like me to give you a glass of water, or would it be okay if I spray mists of water into your mouth until you are satisfied?” Both times he said the mists of water was okay. After I had explained to Alan why he wasn’t eating and drinking, if he had still asked for water, I would have, of course, given it to him.

So this man, who had already been diagnosed with dementia, was put entirely into the hands of his wife, who *talked him out of* receiving any significant amount of water on occasions when he *actually asked for it*, while he was dying of thirst. Sweet. She satisfies her conscience by saying that she would have given him water if he'd _persisted_ in asking for it after she'd given him her little lecture, reminding the guy that he was trying to die by not eating and drinking.

But of course Al still won't be able to "see a problem."

The Times article describes another case:

an 81-year-old attempting VSED with inadequate pain medication, crying out to his wife at night, “I’m dying of thirst.”

Says the advocate,

“And of course, he was, but slowly,” Dr. Schwarz said. “This was a horror show.”

Well. I guess the solution was just to give the 81-year-old more pain meds so he wouldn't be crying out while he died of thirst.

Thanks for the thoughtful commentary. This "philosophy" has plenty of potential to evolve into reality in today's culture. Prop 106 in Colorado is seeking to give mentally capable people end of life options. The seed of this is not pure evil. We all have a fear of death and even more fear of a difficult death(particularly for those around us). Unfortunately, the slipperiness of this slope is beyond a Nickelodeon double dare slip and slide. In the hands of politicians that are like-minded to the above philosophers, this thing could easily evolve into "mandatory" services of licensed healthcare providers. It is a power too great to wield. I personally believe suicide is a sin anyhow, but also sinful would be to force a doctor to give life-stopping pills or to force with-holding life sustaining nutrients. Scary thoughts these philosophers propose. Interesting how easy it is to propose this onus on doctors. It reminds me of death penalty advocates that have never fathomed whether they would pull the lever. These philosophers seem so disconnected from boots on the ground healthcare that their conjectures come out as something from a dystopian horror novel. Oh wait, prop 106 is a reality in Colorado. Yikes. The implications along the abortion topic here give me a sick feeling in my stomach. Keep up the good work Lydia. This doctor hears you and will vote to keep our conscience alive.

The question of assisted suicide drugs and conscience is very live for pharmacists

See here


And here


It looks like WA state may have backed down, but I haven't been able to come up with clear information on the state of conscience protections for pharmacists in general in states with physician-assisted suicide.

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