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He who pays the piper, Chapter #3,459,621

A Swiss canton has passed a regulation that all nursing homes in its jurisdiction that accept government funding must cooperate with assisted suicide. The nursing homes must set aside a death room where suicide assisters from the ghoulish organization Exit will kill people. If anyone from the home tries to stop these assisted suicides, the patient who wants to die can complain.

Here are the rigorous (!) regulations:

The law establishes some conditions for such procedures. The disease or condition must be serious and incurable and other end-of-life options must be discussed.

Notice, if this were relevant, that "serious and incurable" doesn't even mean "fatal," much less that the person is presently dying. Not that it would be right deliberately to kill the person if he were presently dying, either, but one just gets so tired of the dishonest claims of strict regulations and restrictions after a while.

Notice, too, that there is no mention of guarding people with dementia from "choosing" this option without full understanding or under pressure. Nor is this point merely theoretical. Suicide is not illegal for dementia patients in Switzerland.

Considering that all or nearly all nursing homes in the U.S. accept Medicare, it is difficult to counsel them all to stop accepting government funds. But this story is just another reminder of the strings that can be attached. People with consciences who want to help others need to be thinking about this point at all times. Rather than looking for further ways to get government funding, they need to be looking for further ways to do without government funding, because at this point the confirmation is overwhelming: It will always come back to haunt your institution later on.

This sort of thing will happen in the United States. Using funding as a means of control is a very old game in the U.S., so old that it is almost passe. It's an obvious thing for the "death with dignity" types to do, and they will probably start it on a state-by-state basis. An attempt to force facilities to cooperate with suicide was already made in California in 2007. The law would have required all nursing homes and hospices to allow assisted suicide on the premises. I have been unable to discover whether the bill passed or not. I think it did not pass. In the name of honesty I should add that the California law does not even appear to have used the excuse of targeting facilities that receive government funding. It simply imposed its requirement on healthcare facilities across the board.

But it would seem even more "logical," by some people's notion of what is logical, to impose this on facilities that receive government funding.

More and more disengagement from the government and more and more willingness to engage in civil disobedience are going to be required from healthcare workers and from those who run healthcare facilities. It is inevitable as our Western governments become more and more committed to enforcing the culture of death.

Comments (23)

The situation in Ireland is that those who cannot afford nursing home care receive means-tested state subventions to cover their costs. It is very foreseeable that these payments will eventually come with "strings attached".

Thanks, DeGaulle. I think that all over the world the government has gotten involved in paying for healthcare for the elderly. I'm not such a diehard libertarian as to say that this is intrinsically bad policy. But it does open up all sorts of problems when the "chattering classes" go to the bad and control government policies. This has implications for Christian institutions from a purely prudential point of view.

Lydia,
it may well have the deepest consequences for all who do not have the resources to afford their old age care, which, given the already astronomical costs and the dismal prospects for world economics, will be the vast majority. How do we protect ourselves? How do we defend our loved ones? We will need new religious doctrine to deal with these new situations. Is it a mortal sin to give in meekly to state pressure or must we resist? How do we resist? Because as surely as night follows day, once one costs the state too much to maintain, on will come the needle. And there won't be as much concern for procedural efficiencies as with the murderers on Death Row.

Well, obviously, one can't ethically set aside a death room in one's nursing home for the use of Exit. So there's one bright line right there.

I think increasingly people are going to prefer dying at home. This is relevant even to things like receiving nutrition and hydration. At least you can (in theory) be spoon fed at home. See my post here:

http://www.whatswrongwiththeworld.net/2012/12/a_case_for_throwing_patients_o.html

DeGaulle, in my opinion the state killing the aged is not much different from the Roman state killing the Christians, and a good Christian can submit to it in much the same way. That is, you can choose go quietly as a martyr, you can go testifying to the fact that murder is a grave evil in God's eyes, you can go loudly singing praises to God, and you can go physically fighting against evil knowing it won't do you any good. All of these are morally legitimate.

As for the people running a nursing home, their position is considerably harder: to what extent can they accommodate the "law" in order to be of service to the elderly rather than just throw up their hands and walk away from the whole business? Very difficult to say. I would suggest, very tentatively, that you could say to an elderly bent on suicide "what you do in your assigned room is your business, but I do not provide any services toward death." And then just not actively step in the way of anybody coming in to administer drugs or whatever. And say to the state officials that claim that you have to provide assistance to those who want help killing themselves, "my conscience forbids that I assist them, but I won't obstruct others carrying out their evil acts." And then take what comes, including fines or whatever.

I think the critical difference is active cooperation versus passive non-obstruction. It is your business to control your own behavior, not the behavior of others. So if the "law" says a doctor or a family member can kill one of your patients, in prudence you can choose to not obstruct it, but you cannot assist the event. (I say "law" with care, since no positive law that directly commands an action that is contrary to God's law is actually a real law, and it cannot bind the conscience, because all lower authority to legislate comes from God's authority, and it is impossible for a human legislator to have the authority to directly contravene higher law - or law would cease to be law at all and would simply be the will of the strong over the weak.)

I would suggest, very tentatively, that you could say to an elderly bent on suicide "what you do in your assigned room is your business, but I do not provide any services toward death." And then just not actively step in the way of anybody coming in to administer drugs or whatever. And say to the state officials that claim that you have to provide assistance to those who want help killing themselves, "my conscience forbids that I assist them, but I won't obstruct others carrying out their evil acts." And then take what comes, including fines or whatever.

I have several problems with this suggestion, so I'm going to challenge it.

Problem 1: The nursing home is responsible for the well-being of its patients. This places positive duties on the nursing home. This is why the nursing home would always stop a patient from deliberately taking an OD of his medication *on his own*. We would think the medical and other caregivers criminally negligent if they just sat by and watched old Mr. Jones as he hoarded away a bunch of his sleeping pills and then swallowed them down with the full knowledge of the staff. The point can perhaps be seen more vividly if we imagine Mr. Jones doing something more "icky" like hanging himself from the something in his room or cutting his wrists and slowly bleeding to death in the bathtub of his room. If the staff don't stop him, they are not carrying out something that should be fundamental to their job. This is basic medical professionalism: You don't allow your patient to harm himself. This new policy is radically undermining that professionalism and is doing so by the insidious methods of using only "clean" and "less icky" methods of suicide and also by involving other people who are billed as "experts" to come in and "assist." But that is all just cosmetics. Essentially, it's standing by while your patient, under your care, in your nursing home, slits his wrists or hangs himself or blows his head off with a gun. If he has "experts" from an official organization to show him how to slit his wrists less painfully, that makes no difference to the criminal negligence involved. This isn't just some person killing himself who has nothing to do with you. The owners and staff of the nursing home have a relationship with and responsibility to the patient which should not permit them to allow him to harm himself. This is obvious in all sorts of small ways (if a patient were continually scratching or cutting himself, for example, the would be expected to stop him), but here we are being asked to blow a gaping hole in that relationship.

Problem 2: It is absolutely inevitable that people with dementia are involved and will be involved in these so-called "choices." Also people who are under pressure and coercion. And in the end, people who merely left instructions that they are to be killed later if they become incapacitated. Which means that if one takes a hands-off approach one is going to be refusing to interfere in _outright_ murder of the patient by third parties on one's own premises, within one's own facility. Again, if we imagine this as "messier" the evil becomes clearer: Old Mrs. Jones left instructions that she was to be killed if she became unable to recognize her children. Now she can't recognize her children. The facilitators walk into _your_ nursing home, and you, as the owner, tell all of your nurses, doctors, and all other staff, including those who dearly love Mrs. Jones, to stand back while the facilitators chop her head off in your nursing home. This is obviously wrong. She is _your_ responsibility as the nursing home owner and is the responsibility of the staff. To take responsibility for her as a resident and then allow her to be murdered is obviously outright wrong.

Notice, too, that the only way to make a cut between my Problem 1 and Problem 2 (if Problem 1 is not considered prohibitive in itself) is to involve oneself directly in overt and apparent approval of suicide. For one would then need to investigate in detail to make sure that the resident is _really_ killing himself rather than simply being killed by others. One would need to investigate his alleged "rationality," his present state of mind, his consent to what is about to happen, etc., and only then "back off" and allow him to kill himself. The approval of suicide involved there is quite obvious.

Problem 3: The incorporation of suicide into medical care is psychological abandonment. It sends a message to patients that this is an acceptable and even expected response to their physical and psychological problems and that it is a way of "not being a burden" to their children. For facilities to accept and allow this, even passively, on their premises is for them to participate in this abandonment and encouragement of future suicides by the elderly and disabled.

Essentially, it's standing by while your patient, under your care, in your nursing home, slits his wrists or hangs himself or blows his head off with a gun.

Lydia, I accept everything you say in problem 1, as a general characterization of what now holds. But what I am suggesting is that if and when we get to state-mandated "nursing homes must allow for patient-directed suicide" is that at the point where a patient (in spite of your consistent work caring for them and alleviating their causes for wanting to die to the extent possible) insists on having a doctor in to administer the drug and gets a friend to bring the doctor, then at that point both legally and morally that patient is no longer under your care. The state has, at that point, REMOVED from your care that patient, against your intention and against your best efforts. Just as we typically say that a pro-life sidewalk counselor has no moral authority to go into the abortion clinic and physically prevent the abortionist from performing the abortion - even though he knows it is about to happen - because the pernicious state laws preclude that (by legally protecting the murder), so also for the nursing home worker or owner. I admit that the nursing home owner and worker, because they have a positive definite relationship with the patient, have a greater moral responsibility to try to prevent that from happening up to the point where do everything they can to dissuade the patient from taking such steps. Yet their responsibility is limited by BOTH the patient's own actions in defiance of due regard for life and by state laws protecting people who will do the legal but immoral act of killing.

Which means that if one takes a hands-off approach one is going to be refusing to interfere in _outright_ murder of the patient by third parties on one's own premises, within one's own facility.

You are absolutely right that dementia (or any mentally disabling condition) is going to make the difference between passive "not interfering" and active cooperating a messy business. But I think the principle is still valid even if difficult to discern. The underlying moral reality is still there: you have a moral obligation to do everything you can to prevent the circumstances coming around to the point of a state-directed murder, but you have no moral obligation to physically obstruct OTHER agents from legally protected acts of murder - especially when doing so will get you thrown i prison and the state will go about the murder anyway. The only "hands off" I am saying is that physical "hands off" of not physically preventing others from _their_ actions. Which is different, for example, from the hands off of no longer feeding Mrs. Jones when the state tells you to. In that latter case, I would say the owner can tell the state "this nursing home has an absolute rigid rule about feeding patients, you can either abide by these rules or take the patient away against my intentions."

I would submit that Problem 3 is a problem at the societal level at least as much as at the nursing home level. Yes, you need to run the nursing home as a beacon of love for life until natural death. That includes re-iterating a message of love for every person no matter their condition. No, that does not obligate you to illegally physically obstruct a 'legal' act of suicide - even if that "sends a message" to other patients. That unintended message is contrary to your actions of trying to do everything short of illegal obstruction in supporting life. That's the best message you can send in the given circumstances. The fact that circumstances are not better is due to the larger society, not due to negligence on your part running the nursing home.

And you can make a nursing home explicit policy "we completely disregard patient instructions toward causing death if they become incompacitated, including so-called medical directives which direct us to take non-medical immoral acts. As a consequence, by accepting our care you hereby alter your prior directives toward killing you. And any medical directive signed after you enter is subject to our consent to the conditions. Sign here..." Sure, you will get grief from the state. But the state's options will mostly be limited to either accepting the result or shutting down your facility - which AGAIN is removing patients from your care. They can try fines, but frankly if you can get the case before a jury, at least at the moment not one jury in 4 will agree to significant fines for a policy you stated up front before you accepted the patient and the patient signed. And if the state declares your consent form is invalid, you write a NEW one that gives plausible coverage for your not taking action to kill people - if necessary one that explicitly cites the state's attempt to declare your prior consent form invalid and why you think the new one is different, and get the patient to sign THAT so they know the legal shenanigans and still consent - including a hold-harmless clause that also requires the patient to pay any of your legal fees and fines if they become due because you followed your conscience. Goodness, lawyers know how to write fine print - be creative.

Sure, eventually the state will put you out of business if they are adamant on persecuting people who just want to take care of old and sick people. But once you are out of business you are no longer responsible for those patients.

Thank you both for your replies. You have certainly got to the gist of the matter. I would suspect any nursing home owners who stand by their patients or make any efforts to prolong their lives against the wishes of the State will very quickly lose their licences. It is apparent in other issues how quickly and zealously the culture of Moloch takes situations to their conclusion. I fear that, like children with Down's Syndrome and other "distasteful" conditions, people with dementia will become rare as hens' teeth. These people can stand no reminders of their own mortality.

then at that point both legally and morally that patient is no longer under your care. The state has, at that point, REMOVED from your care that patient, against your intention and against your best efforts.

Well, no, if they are killing the patient under your facility's roof, then I can't agree with this characterization. Note that as long as the person is vacillating, the person is obviously still your patient. The patient is only taken out of your care if literally taken out of your care--i.e., removed from the facility. I suppose that _could_ be forcibly done, but that is different from killing the person _in_ your facility. Notice here the arbitrariness: If Mr. Jones just randomly decides to cut his arm with a knife, you are _obligated_ as a professional who is responsible for him to stop him. If Mr. Jones decides to take an overdose and the members of Exit come in to assist him, then you aren't obligated to stop them and in fact can morally just step aside and let him harm himself in his room in your nursing facility. I maintain that this is arbitrary. There is not really any act by which he is removed from your care *except the act of killing itself*.

Just as we typically say that a pro-life sidewalk counselor has no moral authority to go into the abortion clinic and physically prevent the abortionist from performing the abortion - even though he knows it is about to happen - because the pernicious state laws preclude that (by legally protecting the murder), so also for the nursing home worker or owner.

Well, no, I don't agree with this analogy, because of the relationship with the patient. That causes you to have a _specific_ relationship with and responsibility for _that_ patient, which includes protection. You aren't justified in deliberately, knowingly standing back while some Exit members kill Mrs. Jones, your patient, any more than you would be justified in standing back deliberately and "not interfering" while some random murderer wandered through the halls and killed Mrs. Jones, your patient.

I admit that the nursing home owner and worker, because they have a positive definite relationship with the patient, have a greater moral responsibility to try to prevent that from happening up to the point where do everything they can to dissuade the patient from taking such steps. Yet their responsibility is limited by BOTH the patient's own actions in defiance of due regard for life and by state laws protecting people who will do the legal but immoral act of killing.

We would never agree that this responsibility is limited in this way were it not for the artificial distinction that "killing oneself with the help of this group is different." For example, we would never say that you are responsible merely to _dissuade_ the patient from routinely maiming himself with a knife every few days. Since he's your patient, you're responsible to _stop_ him. By treating tidy death as different, one cooperates in this kind of schizophrenia--I'm responsible to care for and protect this patient, except when he decides to kill himself under such-and-such circumstances, and then it's fine for me to stand back and allow that to happen *in my own facility*.

Consider: If the nursing home accedes to the state's demands, this will have to be a matter of _policy_ concerning what is done and not done on-site. For example, if one of your doctors or some compassionate nurse's aid tries physically to stop the death-mongers from murdering Mrs. Jones, you will have to discipline that person. It will have to be your policy that "We allow this to happen on our premises. no one may interfere." That makes it clear that you aren't really free of the responsibility of the patient, because there are going to be all these people literally walking around the halls, seeing the murderers coming in, perhaps even literally witnessing Mrs. Jones murdered, and being told, by the Christian nursing home owner, that they must stand back in their own professional domain and allow it to happen.

In the proposed CA bill, by the way, the facilities were required to continue to keep on staff actual employees of their own who killed patients. So you'd in that case be paying the salary of a doctor, nurse, or other employee who was murdering people as part of their job, on-site in your facility.

I think myself that we need to start thinking outside the box altogether. For example: A Christian network of registered nurses, physicians assistants, doctors, and also non-medical caregivers, all committed to house calls, joining together to form a home health care coalition. Through donations, the organization could means-test prospective clients and offer greatly reduced rates or free in-home care for those who cannot afford to pay. There would still be a doctor-patient relationship, but no institutional relationship to the patient. It would still be _possible_ for the patient to commit suicide, but not while the actual Christian home-care workers are present (the Christian home-care organization would not fire them for trying to intervene, even physically, under those circumstances). And home health care workers would make every effort to report attempts at murder as elder abuse--be a gadfly and a nuisance to the authorities.

In general, though, the organization would probably be sought only by those who were not suicidally minded and even wanted to be protected from suicide, because it would bill itself in that way.

Whatever else happened, the organization itself would not be literally funding the space amounting in practice to a murder-clinic in which the killings were taking place.

Also, if the intent of these laws were literally to take the patient out of the care of the nursing home with a conscientious objection, then the laws would allow objecting homes to refuse and require that the patient discharge himself and transfer to another facility. They don't allow that because that isn't the intent. They aren't taking the patient out of the care of the objecting facility. They are requiring the facility to subsidize the murder by allowing it to take place *on their premises*, in the space for which they pay lease or property taxes, heat, electricity, etc., in their rooms, in their facility's beds, and so forth. So I think it is just untenable to say that the institution's relationship to the patient is severed because the government insists on killing that patient or the patient insists on killing himself.

Well, no, if they are killing the patient under your facility's roof, then I can't agree with this characterization. Note that as long as the person is vacillating, the person is obviously still your patient.

I thought I took the case where the patient himself is insisting on suicide (or administered death). No vacillating anymore.

I agree that it occurs "under your roof", and this normally implies a degree of responsibility to stop this grievous evil act. But additional factors are in play in addition to it occurring under 'your' roof (i.e. your facility which is not your personal home - or 'castle' - either really or legally). We recognize that state law can alter or modify your responsibilities toward persons within your care: if state law is silent you can educate your kid any way you see fit and not notify anyone. But if state law says "put her in X schools or else notify us how you are schooling her" then you have an obligation to choose one of the two and let the state know: state law altered the limits of your right and responsibility. Your obligations to stop your minor child from doing something immoral (and/or illegal) in your house - including physically holding him down if necessary - are slightly different from your obligation to stop the same child when he is 24 and visiting your house. Their just being under your roof doesn't complete the story of what obligations you have.

Nursing home business standards and laws make it so that limits on your control over patients and their behavior are NOT like your control over the behavior of your minor child or your visitor to your home - it is a different category with different limits: you cannot spank an adult who misbehaves, and you cannot tell them to leave today if they violate a minor rule. Normally you cannot refuse to allow family and friends to visit patients, etc. So the sets of constraints on what you can and cannot control significantly alter your responsibility over them. If state law demands you allow access of a patient-selected (independent) doctor, and the patient demands that doctor give him killing drugs, and state law protects the doctor's actions, then you would have to take on the action of ASSAULT (as the law defines it) to stop the murder, and that's not your responsibility to the patient in that circumstance.

That can apply to employees as well: If you are a nurse, you can (morally) work IN a hospital that does abortions and even work around other nurses and doctors who perform abortions, without actually helping those abortionists. The fact that the hospital does abortions doesn't give you the moral responsibility to stop those heinous acts that occur on their premises with your knowledge. The fact that the hospital administrators pay abortionists to perform them means those administrators are at fault, but not you as a nurse for not jumping into the operating room and taking away the surgical supplies. Your employee status and knowledge of the act doesn't make you responsible - though your employee status and knowledge of the fact WOULD make you responsible if you knew someone was suffocating a 6-year old boy with a broken leg in the next room. Likewise, if you are a doctor and work in a hospital that takes state money to assist old people insisting on suicide, you are not obliged to physically step in and try to stop the acts merely because you are an employee there.

because there are going to be all these people literally walking around the halls, seeing the murderers coming in, perhaps even literally witnessing Mrs. Jones murdered, and being told, by the Christian nursing home owner, that they must stand back in their own professional domain and allow it to happen.

This is exactly what we do tell people who work in large hospitals (especially teaching hospitals) where other doctors do abortions and tubal ligations as contraceptives: that in order to learn their profession they have to try to ignore (or at least permit) these other evils to occur even though they do not in any way participate in them.

Admittedly, you may wish to get out of working at such a hospital at earliest possible moment, and work elsewhere. This is a prudential matter admitting of more than one moral solution.

That causes you to have a _specific_ relationship with and responsibility for _that_ patient, which includes protection.

Until it becomes illegal and contrary to the patient's own demand to provide that protection. (Both conditions important.) There is a big difference between protecting your minor child from harming himself and protecting a full grown adult from harming himself. And yes, you have a responsibility to protect even the adult if he is out of his mind, but it's still a qualified responsibility: you don't have to protect him when he is out of his mind due to choosing to drink a 5th of vodka and trying to stop him is going to put YOU in grave danger.

For example, we would never say that you are responsible merely to _dissuade_ the patient from routinely maiming himself with a knife every few days. Since he's your patient, you're responsible to _stop_ him.

Sure. Because (a) he cannot be in his right mind if he is trying maim himself, and (b) state law doesn't preclude you from treating such behavior as a form of insanity or otherwise lack of intent.

In the proposed CA bill, by the way, the facilities were required to continue to keep on staff actual employees of their own who killed patients.

See, in that case I would simply defy the state and then make them jump through the legal hoops of putting me out of business. There is an enormous difference between 'allowing' non-employee doctors to come in and perform a 'legal' murder by not physically assaulting them when they try to do something the law says they may do, and actually paying doctors and nurses to do it (even if the state tells you to). The difference is that between formal cooperation with evil and material cooperation. There is no way of paying people to kill other people other than by formally cooperating in the killings. Formal cooperation is inherently disordered, whereas material cooperation has a different character and is sometimes permissible.

If you are a nurse, you can (morally) work IN a hospital that does abortions and even work around other nurses and doctors who perform abortions, without actually helping those abortionists. The fact that the hospital does abortions doesn't give you the moral responsibility to stop those heinous acts that occur on their premises with your knowledge.

Well, yes and no. This issue and the limits of this principle have come up recently when hospitals have attempted to coerce nurses into taking on pregnant women *as patients* who are having abortions. The hospital argued that it should not be considered a violation of the nurse's conscience "merely" to require her to do intake and prep. work for the abortion and clean up after the abortion (disposing of the baby's body, etc.) as long as the nurses were not literally constrained to be present while the abortion was taking place and to assist _directly_ with that procedure.

The nurses, rightly in my view, objected to this. Their objection involved the idea that, by taking on the abortion-minded women as their patients at the time of the abortion, they were taking on a professional-patient relationship while being required to use that relationship to facilitate the abortion by doing the check-in procedures (in a "non-judgemental" way, of course). Also that they were being unwarrantedly traumatized by being forced to clean up fetal remains from abortions that they opposed.

Now, what we're envisaging in the nursing home situation is that many of the staff may have Mrs. Jones as their *own* patient. For example, you could be coming in and taking Mrs. Jones's blood pressure and chatting with her and so forth on the very morning of her death, acting *as* her nurse or *as* her doctor. Her doctor might even be having to have conversations with her in which he gives her a prognosis while she tells him it's irrelevant because she will be killed this afternoon, and he has to work his professional work around this as well as not interfering *as her very own doctor* when the death dealers show up.

This gets even more vivid if Mrs. Jones obviously suffers from dementia and doesn't even know she's going to be killed that afternoon; then the murderers walk into the facility. As I understand your position, you are even saying that in *that* case her very own doctors, nurses, and other caregivers are right to step back from their very own patient and allow her to be murdered when they have been taking care of her lovingly up until that moment. And, moreover, that it is legitimate for their Christian employer (the owner of the nursing home) to order them so to do and penalize them if they try physically to protect her.

Something has _got_ to be wrong there, and the analogy with happening to work in a hospital where abortions are performed just doesn't hold. It would be more like being a pediatrician in a hospital that performs murders of six-year-olds and being told by your (ostensibly Christian) employer that you can't attempt to protect your own six-year-old patient, whom you were treating just this morning, when Dr. Mengele shows up, while you're around, to kill him.

It seems obvious to me that the employer is doing something wrong there and also giving an order that the doctor should ignore.

Because (a) he cannot be in his right mind if he is trying maim himself, and (b) state law doesn't preclude you from treating such behavior as a form of insanity or otherwise lack of intent.

Point a here is true as a general rule but the very same logic could be applied to suicide. There are things that we can choose to _define_ as meaning that a patient isn't in his right mind. Suicide would seem to be #1 on the list! If, on the other hand, we state that suicide can't be defined that way and that someone can commit suicide in his right mind, then I don't see why the same couldn't be applied to self-maiming. In fact, you could find people defending self-maiming as a rational approach to body identity integrity disorder (yes, that's supposed to be a real thing)in an attempt to create sepsis to force doctors to cooperate in removing one's limb which one "feels disassociated from." Either one regards that as manifestly a result of mental illness (I certainly do) or not, but the point is that all the same arguments can be applied to the firm intention to commit suicide.

As far as b, an unjust law must be disobeyed. If one has taken on a position of responsibility for the welfare of person X, and if person X has not *actually* been removed from one's charge, then one should disregard a law that says you have to let X be killed, even by his own wish, if you wouldn't otherwise let him kill himself.

I've argued above that it doesn't *actually* remove the person from one's charge simply for him to *decide* to commit suicide and for the state to have a law in place saying you have to allow him to commit suicide. If it did, then you would be able to demand that he discharge himself and go elsewhere if he no longer wants you to take care of him--where taking care of him *necessarily* involves not letting him be killed.

The hospital argued that it should not be considered a violation of the nurse's conscience "merely" to require her to do intake and prep. work for the abortion and clean up after the abortion (disposing of the baby's body, etc.) as long as the nurses were not literally constrained to be present while the abortion was taking place and to assist _directly_ with that procedure.

The nurses, rightly in my view, objected to this. Their objection involved the idea that, by taking on the abortion-minded women as their patients at the time of the abortion, they were taking on a professional-patient relationship while being required to use that relationship to facilitate the abortion by doing the check-in procedures (in a "non-judgemental" way, of course). Also that they were being unwarrantedly traumatized by being forced to clean up fetal remains from abortions that they opposed.

Exactly. You can't do the "prep-work" of setting a Mafia snitch's feet in a bucket of concrete and pretend you are not a proximate cooperator just because you aren't there when he's dumped into the East River.

Amazing.

The greatest usurpation of power in the whole history of America has just taken place, with the gravest possible implications for the future, & nobody who's left here can even be bothered to take notice.

Once upon a time, this blog was seriously concerned about immigration issues.

Not any more, it seems.

Point a here is true as a general rule but the very same logic could be applied to suicide. There are things that we can choose to _define_ as meaning that a patient isn't in his right mind.

You know, it's a funny thing, but they are not equally ripe for the conclusion "he must not be in his right mind. Not quite. We are usually quite ready to suppose that if someone killed himself, he may have been insane. But we also realize that there are a few people who have truly forsaken rightness, have embraced evil, for whom suicide is somehow the understandable and normal outflowing of their own decisions to embrace evil - and for whom the evil is a grave sickness, but the sickness is in the will, not the intellect. Those in society who have blinded themselves to the existence of true moral evil would like to say that even these truly evil people are insane, but the rest of us know better: their disorder is not that of the intellect, it is of the will.

Yet even such people do not typically maim themselves - except on the way to killing themselves, that is. I really don't think that there is anyone who tries repeatedly to maim himself in a serious way (not tattoos) and not as a form of suicide, whom we think is not nutso. But even if there are a few, the cases are NOT equivalent. We do tend to see self-maiming as almost always crazy, somewhat unlike suicide.

There are things that we can choose to _define_ as meaning that a patient isn't in his right mind. Suicide would seem to be #1 on the list!

Not really. There are people for whom suicide is plausibly sane given that they have denied the afterlife, and you cannot define mental illness in terms of failure to believe in something so difficult or elusive of demonstrative proof as that. Sure, it is always gravely wrong and spiritually disastrous unless they are insane, but you cannot define an act as insane because it is gravely wrong and so completely contrary to their spiritual well-being or we would have to re-define everyone on death row as insane.

As far as b, an unjust law must be disobeyed. If one has taken on a position of responsibility for the welfare of person X, and if person X has not *actually* been removed from one's charge,

You are just ignoring the scope of my argument here: being in charge of a nursing home means you have taken on a position of responsibility for the welfare of person X - with respect to some matters and not with respect to others. Part of those limits are written by law, others by common sense. You would not be responsible for baptizing someone in their sleep who had told you explicitly and clearly they didn't want baptism. Your responsibility for feeding them can be limited by their choice to eat: you cannot force-feed a sane person who goes on a hunger strike for the sake of the persecuted Christians in Iraq. So also their choices about causing their own death: normally you have a responsibility to prevent them committing suicide - except that this normal responsibility is modified by additional conditions like a law which makes it legal. Even so you continue to have a moral responsibility to try to prevent the death within certain bounds, but those bounds do not extend to physically assaulting someone else who the law protects in carrying out the patient's demands.

As far as b, an unjust law must be disobeyed.

That's just not true: an unjust law is not of itself binding. But being "not binding" of its own self doesn't make it, by that mere fact, something that you MUST DISOBEY. Otherwise you would be OBLIGED to stop abortionists that you know about. And you would be obliged to stop your neighbors, who are an unmarried couple, from fornicating. And you would be obliged to prevent judges from handing down no-fault divorce decrees. No, there are layers layers of goods in tension, and nuances of working them out, as we all actually realize in carrying out daily life: there can be laws that must not be tolerated and must be disobeyed, but there are other laws that must be tolerated even though they are evil, and bad laws that can be tolerated even if you are not obliged to, and there are laws for which disobedience to them would cause damage to others that is graver than the evil which you receive by tolerating it. Sometimes we tolerate bad laws because we can't effectively overcome them, sometimes we tolerate bad laws because the effort to overcome them would result in worse evils, and sometimes we tolerate bad laws in part because we are busy overcoming them slowly through other means and it is more effective to overcome them that way than simply outright defiance. There are a whole host of intermediate positions between fully and completely obeying a bad law and full, total direct defiance to it.

It would have been true if you had posed it as "you must disobey a law that explicitly demands of you an intrinsically evil act". Certainly, and I as much as anyone agree with that. If the law says "when Mrs. Jones requests death you must prepare a lethal injection and give it to her" then yes, I will disobey that law and be perfectly happy agreeing with you on that. But laws that tell me I "must not interfere" with someone else's harming my patient, when the patient himself demands it, is a different kettle of fish. Take this: you are harboring a Jew in your basement from the Nazi's. Along come the soldiers knocking on your door, and the Jew decides to turn himself in to them because he is tired of running, or because he wants to preach to those in the prison camps, or for any of 30 other reasons. And so you are faced either with tying him down and gagging him so he doesn't turn himself in, or letting him do it. Your normal obligation of protection to someone "under your care" because you have taken him under your roof is altered by his own choices and his own actions. According to your position, you retain a responsibility for his safety as long as he is under your roof - regardless of how difficult he makes that. Common sense says that cannot be true.

and if person X has not *actually* been removed from one's charge, then one should disregard a law that says you have to let X be killed,

You are not in charge of everything about him. That's a given. We are arguing about whether your charge of care can be qualified by a state law that protects a the patient or some third party to carry out the killing. All you seem to have said so far is "No, that state law is a bad law so it can't modify your responsibility to protect him." But you have ignored that there is a further condition: the patient's own choice. When BOTH the law AND the patient's choice (which is sane at least for these purposes) work together, YES, I think that can indeed change how far you remain in charge of him. You can rightly (i.e. according to the moral law) and legally prevent a person from seriously harming himself when he is not in control of himself, but that obligation toward him works out differently when he is in control of himself and when he is choosing something that is legal. You have a right to provide the right kind of diet for Mrs. Jones's health, but you cannot force her to not eat something that isn't good for her just because it isn't good for her. Your obligations to prevent Mr. Smith from being taken in by scam artists, but you cannot stand in his way when he decides (when he is sane) to spend $1 M on a piece of art that is disgusting and evil. That's not your place. Your obligations are constrained by other factors, including law and the patient's own choices made sanely.

Yes, it is a bad law, but bad laws sometimes have to be tolerated by not actively defying them, when they do not demand of you something that is intrinsically evil. It is not intrinsically evil for you to not physically assault the visiting physician who came at Mrs. Jones' demand - or it would be required of EVERY person who knows of it, not just you. And it would be required of every person who knows what the abortionists is going to do. (For, if we know that someone is about to kill X, we have a duty to take action EVEN IF we are not in a position of care over X. Even an innocent bystander is obligated to take action. But: the action we are required to take, normally, if there is time, includes calling the police and get the state involved, for the state has the right to use force to stop a killer. And if the state has a law not to stop certain killers...that changes the innocent bystander's obligation. As it changes the obligations of the father of the baby, and the mother of the girl about to get the abortion [where otherwise it would be the mother's obligation to stop the murder]. The state's use of force, and it's determined, stated, promulgated decision to use it on YOU instead of on the killer, alters your obligations.)

you cannot force-feed a sane person who goes on a hunger strike for the sake of the persecuted Christians in Iraq.

An interesting point. I would say that if the sane person is choosing to live in your nursing home, you can tell him he has to leave and cannot carry out a hunger strike while he is your resident patient. And I would say that you should say just precisely that. Same for active suicide.

Living in a nursing home isn't even like renting an apartment in an apartment building. (And I would argue that it makes perfect sense to kick out a renter of an apartment building under these conditions, too. But the situation is _much_ stronger and more specific for a hospital, hospice, or nursing home.) It involves putting oneself in a position of dependence on the staff and giving the staff certain responsibilities to the patient. A patient doesn't have the right to take advantage of that while demanding that a room of *that facility* be the place in which he kills himself, either by omission or commission.

It would have been true if you had posed it as "you must disobey a law that explicitly demands of you an intrinsically evil act".

I would argue that you must also disobey a law that explicitly demands of you that, while running a facility allegedly for the care of vulnerable people, you permit (and require your employees to permit) that facility's premises to be used for killing those very people of whom you have taken charge. I argue this on much the same grounds on which I would argue that you must disobey a law that tells you that you have to stand by and do nothing while your child is murdered. And order all your employees to stand by as well. No, the relationship isn't _as_ strong, but it's strong enough, in my opinion, to support this conclusion. Some omissions are also gravely evil, and the omission of protecting people to whom you stand in this sort of relationship is, in my opinion, evil.

You have a right to provide the right kind of diet for Mrs. Jones's health, but you cannot force her to not eat something that isn't good for her just because it isn't good for her.

If it's antifreeze, actually, you can. You can even pump her stomach afterwards. The implications for suicide should be clear.

And in fact, a nursing home _certainly_ can restrict a resident's diet. And should. Preventing a diabetic from gorging himself on candy, for example. Preventing a person with high blood pressure from eating a bag of Doritos. It's the kind of thing that happens all the time. That's part of what it means to be checked into a medical or quasi-medical facility! You lose some freedoms you have when living independently.

A fortiori for committing suicide.

If this person is so completely sane, so much in control of his own actions and decisions, then he can jolly well check himself out again and go with his creepy Hemlock friends and let them kill him somewhere else.

Why is that not being given as an option in the law in Switzerland? I'll tell you why: Because the powers that be _want_ to co-opt the nursing homes, _want_ to force the nursing home owners to pay the bills for their killing centers, _want_ to use them as servants of the evil being done, _want_ to infiltrate every nook and cranny of society. And that is _why_ they must be resisted. Also, because they want to murder people on-site who _aren't_ so fully compos mentis as to be able to coolly check themselves out and go elsewhere. And that is also why they must be resisted.

Steve Burton, you know nothing, at this moment, about any of us, about any of our other commitments, what else is going on in the rest of our lives, or what thoughts we do or do not have about Obama's recent diktat.

You now apparently specialize in drive-by, thread-jacking snark.

There is no reason why it should be tolerated, so further comments that are not on-topic for this post will be deleted.

I would say that if the sane person is choosing to live in your nursing home, you can tell him he has to leave and cannot carry out a hunger strike while he is your resident patient...[snip] If this person is so completely sane, so much in control of his own actions and decisions, then he can jolly well check himself out again and go with his creepy Hemlock friends and let them kill him somewhere else.

Fine, then we are in 99% agreement. But _until_ they have removed themselves from the nursing home, you don't have an obligation to force feed him. And your options until he has left are to PHYSICALLY force feed him, or PHYSICALLY assault him to get him out of the home...or to tolerate his behavior. The fact that the state has some sort of monopoly on physical force (otherwise than in an emergency) limits your resorting to force under the circumstances.

I would argue that you must also disobey a law that explicitly demands of you that, while running a facility allegedly for the care of vulnerable people, you permit (and require your employees to permit) that facility's premises to be used for killing those very people of whom you have taken charge.

Would you argue that you have a responsibility to force a patient to stop accessing porn on their cell phone while on your premises? And everything else that is legal but immoral?


Would you argue that you have a responsibility to force a patient to stop accessing porn on their cell phone while on your premises? And everything else that is legal but immoral?

Not everything. Each thing has to be considered on its own merits. You can certainly block porn from any on-line network you have.

But what you have to understand is that this isn't just about stopping your patient from doing things that are immoral. The point is that he is your _patient_. Therefore, what you have responsibility for is *at a minimum* his physically being alive (!) and his physical health and well-being. In those areas he cedes a certain amount of freedom by becoming a full-time resident at your facility and you, in turn, take on responsibility for his physical care.

I was quite serious about diet. You try being a nursing home patient and eating sweets as a diabetic! Being a nursing home patient just isn't like being a free adult living any-old-where. The aspects of one's life relating to physical health are controlled far more tightly. It's sheer moral and legal insanity and incoherence that the facility can be sued for negligence if they allow a patient to eat what he shouldn't as long as he wants to live (and they can) but _have to_ step aside if he wants to eat poison (an overdose of pills, for example) and die.

I stand by it that you should not cooperate in any such incoherence.

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