Friday, September 2, 2011

Ethics class

We have an interprofessional ethics course. This is a continuation of the same course that hosted the AMA president emeritus and a few other lecturers earlier this year. The course has changed a bit, and it's a little more like TAC (yippee!). (Even the grading is like TAC. My classmates are all nervy about it, but I sit grinning from ear to ear. At last! It feels like going home.)

A group of eight students (mostly medical students, but one or two nursing students also) and one moderator meet and discuss an ethically-challenging case study. There is a rubric full of questions and issues to cover. If appropriate, I will share these cases with you. This way, I can think through what was discussed in class, you can see what medical students are seeing and thinking, and the discussion can continue here.

The first case was that of Dax Cowart. This man suffered 60% burns and was treated at Parkland's burn unit in the 1970s (narcotics were not well-understood) beyond his wishes. He made a video called "Please Let Me Die," which we were assigned to watch before the discussion. My thoughts:
  1. Mr. Cowart's case and video remind me of the patients I've visited in nursing homes. They're alone so's heartbreaking. Who can live without love? I wish there had been someone with Mr. Cowart during all those sufferings.
  2. It isn't right to hand someone a gun so that they may kill themselves; however, it is right to allow a patient to decline reconstructive surgery. Somewhere in the middle, there is a line--where is it? What is heroic and what is not?
  3. I used to be pretty anti-autonomy, because I thought that "autonomy" only meant the patient coming to the doctor with demands (I need this prescription, I want this procedure...), which seems anti-medicine. But "autonomy" can actually means that the patient has the final choice about what is done to them. That's not so bad.*
That's about all I've got. There's a lot that I'm not very good at articulating right now--a lot about the Cross and suffering and Christ and love. I'd love to have that pour out of my mouth eloquently, but I never feel as though I have the ethos to start it.

What are your thoughts on Dax Cowart and autonomy?

* Our culture is more allergic than other cultures have been to the beneficent, paternalistic doctor. Reading Aristotle in isolation (which I have spent some time doing) makes it seem like the Greeks thought a patient should fling himself into the hands of the good doctor! The doctor was, after all, the Art personified.


  1. I hold a significantly different opinion than you on both autonomy and the right to die and, ultimately, I think that is most strongly attributed to the differences in our background and beliefs (you seem to be devoutly religious and also seem to benefit greatly from that; I, on the other hand, left all religion quite some time ago and have only felt healthier for it). Unlike you, I not only support the ideas of patient autonomy*; but also support the right to refuse treatment and physician-assisted suicide. To each their own, of course.

    I am interested, however, in your reasons for believing that physician-assisted suicide is morally wrong. Most strongly religious people I have discussed this with cite the fact that it is, in many ways, "playing God" - that assisting someone in ending their life is interfering and overriding His greater plan (ie, when he is ready to call someone home, he will). Yet, if one were to take this reasoning to the logical end, then all preventive, life saving, life-sustaining or life-improving treatment would be unethical and against God's will. If ending someone's life is altering His greater plan, logically, saving someone would be, as well (you are preventing someone from returning to God). To this, I have heard the response that God has placed medical professionals and treatments on Earth to help do his will; but, once again, one could say the same - that he also gave us the ability to end our lives or assist someone else in ending theirs. None of us can truly know God's will; however, that common argument against physician-assisted suicide is both hypocritical (as seeing most who argue it receive medical treatment) and assuming to know God's will. If one uses it as an argument, to me, it seems they must also argue that one should not seek out any medical treatment at all - and, indeed, many fringe sects of Christians do not.

    *I do not support patient demands; however, I do support patient's having the right to decide what is done to their own bodies. Conversely, as long as the situation is not one of Emergency, I feel a physician has the right to refuse to give a certain treatment if she/he feels that it is not appropriate. The patient can then decide to go with the doctor's recommendation or seek out a second opinion.

  2. Akire, it was a pleasure to read such a well-written and respectful comment.

    We see eye-to-eye about patient demands, and we might share more about patients' sovereignty over their bodies than you think. I know it is wrong to override the free will of others without their permission.

    In your second paragraph, you asked me about physician-assisted suicide (PAS). You asked why I think PAS is morally wrong. Do you mean:
    1. Why is PAS wrong for the patient? (Why is any suicide morally wrong?)
    2. Why is helping a patient commit suicide wrong? (Why is assisting in suicide wrong for anybody?)
    3. Why is assisting in PAS wrong for the doctor? (Is there something about being a doctor that's somehow incompatible? He's supposed to relieve suffering.)

    I hope to hear from you soon!

  3. Thank you for responding so quickly.

    We likely do share more in common on autonomy than I initially thought. I believe I was more thrown off by your original language - ex, "that's not so bad" - that seemed to paint it differently. Ultimately, I believe that a physician's role is to guide and to treat and, in that sense, he/she has every right to state what he/she feels is the best approach to a patient's particular illness (as long as other options and risk/benefit are openly discussed) or injury and also has the right to refuse to engage in a treatment that he/she does not feel is appropriate. Just as I believe that doctors should not control their patients, I believe that patients should not control their doctors.

    As for my questions on PAS, I think that my question is most aligned with 3; however, 2 and 1 are also quite relevant to the discussion. I ask because, as I stated, in discussions with those coming from a background of faith, the answer as to why it is unethical for a doctor to assist in the suicide of a patient who wishes it due to severe, debilitating and possibly terminal illness (as long as said patient is competent and ruled to be sane) has often been the same and unsatisfactory. I described this response (that it is "playing God" or interfering with God's will) in my original comment and the reasons that I found it to be unsatisfactory.

    Hope to hear more from you soon, as well.


  4. (I am sorry about my language. When I said "that's not so bad," I was being a little tongue-in-cheek, which is usually foolish on the internet, where the nuances of communication are lost. I will endeavor to be more clear! Also, because this is a written debate, there is potential for questions to get lost in long responses written out by either side. Let's feel free to pause the conversation and ask questions about any particular part of each others' posts.)

    I am glad your question most resembles 3. This is the most focused question and the most relevant to the blog post. 1 and 2 are important, but 3 can be settled without settling 1 and 2.

    In your first comment, you reconstructed the typical debate about PAS nicely. As you say, the religious argument is often "we should not interfere with God's plan, but we can participate in it," and the response is, "your division between 'interfering' and 'participating' is arbitrary."

    However, though I draw much of my character from religion, I can explain my opinion on 3 without appeal to supernatural forces. (Basically, I think I'm right not on religious grounds, but on logical grounds.)

    I take up two principles:

    (1) Physicians exist because people get sick.
    (2) A healthy body naturally heals itself.

    What do you think of these? (We have an opportunity to pause and discuss here!)

    From (1) and (2), I draw out the duties of the physician (very similar to those you mentioned, probably identical): to help the body heal itself, to supervise the healthy body, and to relieve whatever pain possible when the body cannot heal no matter what help is given (palliative care). In general, the doctor acts as a support to the body's natural urge to be healthy.

    I do not include: to relieve pain by helping the person stop their body, because to cause death is opposed to his duty (support the body). In short: the doctor is a support to the body, and it is contrary to that occupation to aid in PAS.

    So, while participation in suicide (question 2) is not closed, it is clear to me that a someone who assists in suicide is not a doctor.

    (In the above, "doctor" and "physician" are synonyms.) Tell me what you think of any part of this.

  5. I just wanted to inform you that I have read this and plan on responding. You have certainly given me a lot to think about - a good think! - and I want to ensure that my response is equally well thought out.

  6. Apologies for taking so long to respond. Things have been a bit hectic around these parts and it was hard to find an extra moment or two to respond.

    (First, there is no need to apologize for your choice of words - often, our intent can become lost in translation when writing on the web; it happens to all of us).

    In response to your first principal, I have no disagreement - if people never fell ill, medicine, as a profession, would have no use. It is because people do become ill that attempts to treat it began in the first place.

    Your second principal I agree with; but only to an extent. If given the opportunity, a body that is, on the whole, healthy and able will be able to recover from most basic illness. There are many times, however, if left alone, it would not have such an opportunity; the disease overtakes before the body has the chance to respond and fight back or, perhaps, it is too strong to fight back by itself. This, of course, is where much of modern medicine steps in and, to that, I agree that the role of the physician and his tools is to support and assist the body so that it may heal.

    Unfortunately, and this is where the complexity comes in, a body is not always healthy and/or able to heal. Either this be because of a condition that has long become chronic or terminal, because of medicine's limitations or due to a combination, it occurs and, often, it brings a great deal of pain. At this point, there is no healing that will come and the doctor can do nothing to support such healing. There is just waiting.

    A moment ago, I mentioned medicine's limitations and, I think, its limitations especially come into play when discussing PAS. We have a come a long way in our ability to reduce pain and improve quality of life; however, we certainly have a long way we could potentially go. Even when given the best medicines available, there are numerous cases when a patient is still left in a great deal of pain. This suffering may be physical (very often), it may be emotional (it would, in most cases, come with the first; however, the suffering may only be emotional) or it may be both. Either way, the patient is suffering and there is little to nothing the physician can do. Is PAS still unethical, or wrong, in these cases?

    I mentioned that I believed a doctor's role is to treat, guide and advise. I do not believe that assisting in a suicide is inherently contrary to this. In the above described situation, the physician would discuss with the patient his or her options moving forward. There is no further treatment that can be done - in states where PAS is legal, the options are palliative care and assisted suicide. This doctor would present the options, give his recommendation and, ultimately, the doctor and patient would have to see if they agree with each other's plan. If not, the doctor could refuse and the patient could seek further opinion.



  7. I'm glad we're focusing on principles--that's the heart of every debate, and so often people fail to discuss principles and therefore fail to understand each other.

    I'd like to talk about the first principle first, because I think it bears on a lot of your response. We agreed on the words I typed, but I'm not sure we are thinking on the same page. Here are two ways of understanding this principle:

    1. Medicine came about because people get/got uhealthy.
    2. The purpose of medicine is to alleviate/prevent unhealth.

    (I coined "unhealthy" rather than say "sick" or "ill" because we both know physicians are involved even when no curable sickness is to blame for the patient's suffering.)

    Summary: the principle I laid out above was ambiguous! There are (at least two) meanings of the word "because." In (1) here, "because" means "as a consequence of" and in (2) it means "for the sake of."

    I meant my first principle more like (2). Did you read it more like (1) or (2)?