To cure sometimes, to relieve often, to comfort always.
– Ambroise Paré, French surgeon, 1510-1590
I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give a woman an instrument to produce abortion.
– Hippocrates, Physicians’ Oath, c. 400 B.C.
I just read the April 11 issue of the New England Journal of Medicine. Regrettably, the leading medical journal in America continues to push its agenda of assisted suicide.
Previously the journal made its case for euthanasia. I wrote a brief letter to the editor, noting the absence of any reference to the Hippocratic Oath or other sources of medical ethics. The letter was rejected with the condescending comment that the journal accepted only “reasoned argument” and not “appeals to authority.”
This policy should apply to scientific articles. But where do we get ethical principles? Not from science. Dr. Josef Mengele, the Nazi doctor infamous for experimenting on live inmates at the Auschwitz concentration camp, had both an M.D. and a Ph.D. from the University of Heidelberg, one of the top universities in the world at the time.
The Nazi scientists who tortured human beings were as well-trained as the British scientists who, at the same time, were developing penicillin. The difference lay not in their scientific training, but in their ethical foundations – which led them toward different goals. But this obvious truth escaped the editor of the New England Journal.
“Reasoned argument”? The Christians who, at the risk of their lives, saved Jews during the Holocaust were acting unreasonably – but morally. “Appeal to authority”? The editor didn’t realize that in rejecting the Hippocratic Oath and 2400 years of medical ethics, the editor became the self-appointed authority.
With this depressing introduction, we turn to the current article. The authors discuss the assisted-suicide programs in Washington and Oregon, which – no surprise – they approve. But what is surprising is not what is in the article, but what isn’t.
● There is no mention of verifying the diagnosis except by “reviewing the chart.” Reviewing the chart gives us a good idea of the chart, but not of the patient. I spent 25 years in medical oncology at a university medical center. For every patient, we reviewed the biopsy slides with our pathologists. Usually the referring diagnosis was correct. But sometimes it wasn’t.
The most glaring example I saw was a woman referred with a diagnosis of breast cancer. The microscopic slides indeed showed cancer, but it was not connected to the normal breast tissue. The pathologist suspected it was a “floater” – that is, that someone else’s cancer tissue floated off her slide in the preparation process, and floated onto our patient’s slide. He was correct. Our patient didn’t have cancer. The other patient biopsied that morning, who had been told she was okay, in fact did have cancer.
If it were not for a second pathologist reviewing the slides, we would have treated the healthy woman unnecessarily, while the woman with cancer would have been left untreated – perhaps until cure was no longer possible. “Reviewing the chart” would have caused us to perpetuate the error.
Similarly, patients with neurologic disease should be evaluated by an independent neurologist, patients with heart disease should be evaluated by an independent cardiologist, and patients with intractable pain should be evaluated by an independent specialist in pain management. None of this was done.
● There was no requirement that the patient be seen by an independent psychiatrist or psychologist to rule out depression. True, anyone contemplating suicide is by definition depressed. The question is whether the physical disease or the depression is the chief reason for the suicidal thoughts. Patients were evaluated by patient advocates and social workers. If depression was suspected, patients were referred to psychiatrists or psychologists who were part of the unit. I am not impugning their objectivity. But I am saying that they should have been independent to avoid suspicion, and should have evaluated all the patients.
My point is that treatment for depression includes psychotherapy, antidepressants, and family support – but not death. Suicide is not a treatment for depression. Suicide is the result of failure of treatment for depression.
On the other hand, availability of a “way out” may help some sufferers to endure their problems. Some patients expressed gratitude, even when they decided not to commit suicide. Honesty requires that we recognize this fact.
Advocates for assisted suicide or euthanasia often talk about respecting the patient’s “autonomy.” To me, this word means that I decide whether or not to end my life. And if my answer is yes, I take responsibility for ending it my way, and not ask others to do it for me. “Autonomy” should mean what it says.
Suggesting suicide to a patient should not be called “respecting autonomy.” A more honest term would be “cost containment.”
● There is no comment on possible errors – that is, facilitating the deaths of patients who were not “terminal.”
“Terminal” used to mean “in the actual process of dying.” For example, a chart might state, “Blood pressure falling, pulse weak, appears terminal.” But now, “terminal” means “expected to die in six months.” Such predictions are often inaccurate.
The most glaring example I saw was a young man with rapidly growing tumors. We expected him to die in days. Nevertheless, high-dose chemotherapy was begun. The tumors shrank and eventually disappeared. The biopsy was reviewed to be sure it was cancer. It was. The young man went on to finish college, get married, and father a normal child. But if we had caused his death, we never would have discovered our error – and therefore we would have repeated the error again and again.
● Perhaps most telling, the study offered no feedback to the referring doctors. Of the patients who entered the study, 30 did not actually take the lethal medication – either because the decided not to, or because they died before they could. But of these 30, 11 lived longer than the expected six months, in one case 97 months – that is, eight years after he or she was expected to die. So much for prognostic accuracy.
But wait, it gets worse. Of the 11, nine took the lethal dose after the six-month period. That is, only two patients were allowed to live out their natural life spans. So except for these two patients, the doctors running the study had no way of knowing how long these “terminal” patients would actually live if their deaths hadn’t been hastened. The experimenters usually had no way to detect the most serious side effect of their “treatment” – helping to kill a patient who might have lived for a significant time.
And it gets still worse. The doctors running the study did not inform the referring doctors when the “terminal” patients lived longer than the expected six months. Their rationale was that they didn’t want the referring doctors to learn of their errors, and therefore to wait “too long” before telling patients their grim prognosis. But the experimenters had no fear that the referring doctors would do so too soon. No, that possibility didn’t worry them at all.
Perpetuation of error is the opposite of science. Failing to learn from mistakes is the opposite of education. Concealing mistakes is the opposite of honesty. Have a nice day.
● Finally, also absent from the article is the fact that under the Oregon and Washington laws, the doctor makes out the death certificate to indicate the underlying disease as the cause of death, but the doctor omits assisted suicide. The cases are supposed to be reported to a central authority, but may not be. The most reliable – though not completely reliable – source for a cause of death is the death certificate. However, an ordinary physician cannot list “suicide” on a death certificate. Only a coroner or medical examiner can do so. This provides an excuse for omitting suicide from the certificate.
Accurate data on physician-assisted suicide may be hard to come by. The New England Journal article lists 255 as the number of patients who have participated in this program. Like all pertinent facts in a scientific article, this number is referenced with an endnote. I assumed this would refer to official Oregon or Washington records. I was wrong. The authors’ reference for verifying their statement, which the editors accepted for publication, is an article in the New York Times.
So much for scientific documentation. So much for scientific objectivity. You have to read an article not only for what is there, but also for what isn’t.
The bias of physicians from the time of Hippocrates, 24 centuries ago, until only a few years ago, was for the continuation of life. The bias is now shifting. Unless we do something, soon the bias will be for the cessation of life as soon as it becomes inconvenient to others. In an era of “cost containment,” this thought should trouble all of us.
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