What’s Wrong with the World

I know it sounds cool to drop little allusions to Nietzsche in, but at least pay the dude the respect of not making a straw man out of him.

I suggest everyone read this pdf, which is the actual statement produced by the Physician's College. Specifically, page 12 of the pdf - not the document/text page number. It deals with a situation in which the doctor feels that no minimal goal is reachable, and the patient/proxy insists on life sustaining treatment.

3. Implementation

· WHERE THE PHYSICIAN CONCLUDES THAT THE MINIMUM GOAL IS
REALISTICALLY ACHIEVABLE BUT THAT TREATMENT SHOULD BE
WITHHELD OR WITHDRAWN, that physician must consult with another physician.

1. Where the consultation supports the opposite conclusion, that treatment should not be withheld or withdrawn, the physician who sought the consultation must either provide the treatment or facilitate transfer of care to another physician who will provide the treatment.

2. Where the consultation supports the conclusion that treatment should be withheld or withdrawn:

a. The physician who sought the consultation must advise the patient/proxy/representative that the consultation supports the initial assessment that treatment should be withheld or withdrawn

b. If there is still a demand or request for treatment, the physician must attempt to
address the reasons directly and with a view to reaching consensus. The physician
should consider resolving the conflict by:
i. offering a time-limited trial of treatment with a clearly defined outcome;
and/or
ii. involving additional or alternative methods to facilitate a consensus,
including, but not limited to, available resources such as a patient advocate,
mediator or ethics or institutional review processes.

c. If consensus cannot be reached, the physician must give the
patient/proxy/representative a reasonable opportunity to identify another physician
who is willing to assume care of the patient and must facilitate the transfer of care
and provide all relevant medical information to that physician.

You know what? That's pretty thorough. It doesn't tell the doctor to whip out an axe and hack off the head of the patient - in the end, the doctor is required to transfer care to another patient.

Death isn't something to be hysterical about.

It does not follow that, because I used the words "will" and "power" in close connection, I was alluding to Nietzsche. Neither does it follow that, because I referred to self-creation, I was alluding to Nietzsche. People are quite capable of conjuring vulgar notions of that type without drawing upon or bowdlerizing Nietzsche.

"Pretty thorough" isn't the same thing as "right" or even "wise" or "a good idea." I could write up a "thorough" series of protocols that, say, I and the other bloggers at WWWtW have to go through before we can do some wrong to Joe, including trying to "address concerns" and "offering a time-limited trial" of _not_ doing that wrong to Joe, and none of this thoroughness nor any number of complicated-sounding steps would make any of it right. Procedure is no substitute for justice, when the procedure itself is based on an unjust premise in the first place--in this case, that any "treatment" at all (where "treatment" can include something as simple as a feeding tube) can be stopped against patient wishes and/or the wishes of the patient's family.

And no, before somebody starts telling me I'm being inconsistent, I _don't_ think doing these things and not doing them are on a par, and I am not elevating the "wishes of the family" to the one and only standard of what is right or wrong.

Procedure is no substitute for justice, when the procedure itself is based on an unjust premise...

The above from Lydia says it all; however, although I agree with all she's said here, to be fair, there are those who would contend that what defines something as 'unjust' is better left up to the liberal standard.

Procedure is no substitute for justice.

That's a fine little epigram, Lydia.

It does not follow that, because I used the words "will" and "power" in close connection, I was alluding to Nietzsche. Neither does it follow that, because I referred to self-creation, I was alluding to Nietzsche. People are quite capable of conjuring vulgar notions of that type without drawing upon or bowdlerizing Nietzsche.

Really? Really? Someone that has time and again insisted they have a knowledge of philosophy talking about will, power and self creation is not referring to Nietzsche? Ok. What's next, a discussion of dialectics that doesn't refer to Hegel or Marx?

Lydia, that analogy doesn't work at all. You're talking about a "sin of commission," while the most you can say about the withholding of treatment is that it is a "sin of omission." And the doctor is specifically required to transfer care of the patient to another doctor, so even that criticism doesn't work.

We all recognize that there are some circumstances under which life is not worth living. Being a vegetable is one of them.

Mike,

I would invite you to re-examine Maximos statement wherein he mentions "will" and "power":

It was in this manner:

"...who knows neither reason nor the Good, but only will and power."

Now, could you possibly entertain the slightest notion that perhaps he meant to use this combination of words not to invoke Nietsche but instead because of the words themselves?

Mind you, I am no proponent of Maximos, but merely an observer.

By your reasoning, if I were to say to you that I happen to like green eggs and ham for breakfast, you would think I was invoking Dr. Seuss.

Aristocles,

It may have something to do with this post:
http://whatswrongwiththeworld.net/2007/06/nietzsche_and_conservatism.html

Step2,

Thanks for providing the context.

"We all recognize that there are some circumstances under which life is not worth living. Being a vegetable is one of them."

No, we don't. And that second sentence is odious. No one is a vegetable. Talk about dehumanizing one's fellow man.

Mike, the doctor isn't required to continue providing the (so-called) "treatment" until transfer. That's the crucial point to see when understanding what really would happen here. If there is difficulty finding a transfer (as there might well be, once the system as a whole was set up), the patient could be dead long before a transfer facility was found. I've seen how this works in practice (by watching Texas cases from afar), and it amounts in practice--as it must, given no imperative to offer the life-saving measure until transfer--to an ultimatum from the doctor(s), period.

Leaving a helpless person under your care without fluids until death is not a "sin of omission" in the sense that, say, refusing to give your loose change to the guy ringing the bell for the Salvation Army is a sin of omission. If you have responsibility for the person's care, as his doctor does, then you are in virtue of that fact required to provide him with--or at least authorize him to be provided with--the basic necessities of life, like food and fluids, without which the healthiest person will inevitably die.

The man in the initial case also apparently requires a ventilator, but we are fools if we think that the doctors mean to limit their power to make all decisions to anything less than everything, especially given the unremitting insistence that everything, nutrition and hydration included, are equally "treatment." I have no doubt whatsoever that if this man breathed on his own after the ventilator was turned off and they had officially discontinued his ANH, they would just leave him that way until he dehydrated to death. No doubt in the slightest. It's all the same from their perspective.

No, we don't.

Yeah we do. Think of martyrs. They do not deny their cause because after such a denial, their life would lose its value. Martyrs choose to die -- if they are still executed after denying their cause, then they are dying as criminals, not martyrs to a cause.

And that second sentence is odious. No one is a vegetable. Talk about dehumanizing one's fellow man.

Sometimes the only way to preserve dignity is to make a well timed exit. As if keeping an unconscious person alive for 10 years is somehow a preservation of dignity and humanity? It would have more to do with a total lack of backbone on the part of the proxy.

Mike, the doctor isn't required to continue providing the (so-called) "treatment" until transfer.

I assume you're reading this into point (c)? I don't think this is a fair reading, especially since you seem to disparage the treatment. This guide only applies to patients that have already been reduced to life-sustaining treatment. I have no idea why you say (so-called) "treatment" - nothing more is medically possible.

Only a completely hostile interpretation would assume the doctor was not required to maintain treatment until transfer. Without such a requirement, the concept of transfer is largely pointless because as you say, the patient would die. Why not assume that the Manitoba College is not full of complete idiots who spend their time writing self-defeating documents? You can assume they are evil all you like, but idiocy is a whole other game.

I guess we're hardly going to reach a consensus here. So my last word: all things end. Spending 10 unconscious years hooked up to a machine is an infantile denial of that basic truth. The refusal to accept death simply turns life in the anemic spectacle of the last man.*

*Not a Nietzsche reference!

Mike, I assume this because this is how these things have worked in other jurisdictions. This is how it works throughout Texas. They give them a certain number of days to find a transfer, and after that, that's it. It's ranged from three days to ten days with a change in the law. Some states in the U.S. expressly require treat-until-transfer. When they don't, it is presumed that treat-until-transfer is not required, and there are plenty of examples of unilateral deadlines being given when treat-until-transfer is not required. I've actually researched this in some detail in the U.S. The whole pro-life community has been looking into this stuff in detail in connection with the Texas flap and the question of how or whether the laws should be revised there. So it is hardly attributing idiocy to anyone to attribute to the doctors in Manitoba the intent to give the patients an ultimatum, probably with a deadline. In fact, it cd. be argued that the protocols would lose their value for giving the physicians the final say if they were required to continue treatment until transfer, because if no transfer were found, they would then not get to stop treatment without the agreement of the family, and the whole point of the exercise and the argument is that it is unambiguously up to the medical professionals, not up to the family.

Martyrs do not deny their "cause" (like, God, for example), because to do so would be wrong and risk the loss of their eternal souls. Not because they should prefer to be dead if they did so. In fact, this would seem to imply that a person who denies Christ (for example) should commit suicide thereafter, because life would be no longer worth living, whereas in fact Christian teaching would call upon him to repent and be forgiven and _of course_ not to regard his life as "not worth living." St. Peter comes to mind as an example of someone who did quite a bit with his life after having three times denied his Lord.

But, Mike, since you obviously regard unconscious people as Lebensunwertes Leben, I pray you may never be the proxy for anyone unfortunate enough to be severely mentally disabled. Unless, that is, you lost what you regard as your "backbone."

One has to blame advances in medicine for such a state of affairs. In the old days cholera or heart trouble or kidney failure would get you before before you get too old. The men in white give, the men in white take away. Nothing comes for free.

Actually, what I had in mind while writing the phraseology Mike insists upon attributing to some vulgarization of Nietzsche was the infamous sweet-mystery-of-life passage from Planned Parenthood v Casey: "At the heart of liberty is the right to define one's own..." But who knew that Mike could read my mind?

The refusal to accept death simply turns life in the anemic spectacle of the last man.

The preservation of life is the denial of the reality of death?

Death isn't something to be hysterical about.

We only get hysterical about murder.

We all recognize that there are some circumstances under which life is not worth living. Being a vegetable is one of them.

Another one is the circumstance of being afflicted with a superiority complex in which one insanely imagines that he has the authority to call a fellow human a vegetable.

By your reasoning, if I were to say to you that I happen to like green eggs and ham for breakfast, you would think I was invoking Dr. Seuss.

The point there is that if you say "green eggs and ham" you will, inevitably, invoke Dr. Seuss. If you don't mean to refer to Dr. Seuss, you need to make that clear. Since the main target of scorn at this site is the "Autonomous Superman", any mention of "will" and "power" is, willy-nilly, going to invoke thoughts of Nietzsche. As it did. The responsibility for avoiding such a misconception (if that's what it was, in this case) rests with the author of the phrase.

but we are fools if we think that the doctors mean to limit their power to make all decisions to anything less than everything

Every physician harbors a secret inner Mengele.

To paraphrase an old anti-hippie bumpersticker:

The next time you're sick, call a conservative philosopher.

But who knew that Mike could read my mind?

Actually, Maximos, you assume Mike's ability to "read your mind" when you assume his ability to know that you weren't alluding to Nietzsche, after using the words "untermenschen" and "will" and "power" in close juxtaposition.

Another one is the circumstance of being afflicted with a superiority complex in which one insanely imagines that he has the authority to call a fellow human a vegetable.

Yeah! And that goes double for Aristotle and Thomas Aquinas for having the vulgarity to speak of the "vegetative soul." Oh, the hu-man-ity!

Another one is the circumstance of being afflicted with a superiority complex in which one insanely imagines that he has the authority to call a fellow human a vegetable.

Go, Bill. But I'd preserve Mike's life nonetheless. And he certainly _would_ do better off if he were disabled to have me as his proxy than one of these doctors in Manitoba. I say that without the slightest hesitation.

WHERE THE PHYSICIAN CONCLUDES THAT THE MINIMUM GOAL IS
REALISTICALLY ACHIEVABLE BUT THAT TREATMENT SHOULD BE
WITHHELD OR WITHDRAWN

I don't quite get this part - if the physician concludes the minimum goal is realistically achievable, then why would he even consider withholding or withdrawing treatment?

Obviously, because the "minimum goal" just ain't enough in their view. In the case in question (I can never remember how to spell the man's name and don't have time to look it up right now), his condition has actually improved since the doctors first started pushing all of this. But they are still pushing. It's pretty clear that the principle to them is to get it enshrined in precedent that *they make the call*.

"The right to die becomes the preference for death becomes the expectation of the affirmative choice for death becomes the duty to choose death becomes the mandate to die"

Maximos, do you think Cruzan was held incorrectly? i.e., people should not have the right to refuse medical treatment, even if it means they will die?

I think both that Cruzan was held incorrectly and that your precis of it is rather tendentious.

I can't imagine what Royale is talking about. The most "conservative" aspect of Cruzan is the fact that it permitted the states to require "clear and convincing evidence" that the person would thus have wanted ANH withdrawn. It doesn't even require states to do so, and the definition of "clear and convincing" is left open--e.g., whether it requires written evidence, for example. The justices in Cruzan merely refrained from striking down a state's "clear and convincing" standard. I suppose that's good from the pro-life side as far as it goes, but it doesn't even come close to saying that people "should not have the right to refuse treatment." It almost makes me wonder if Royale threw in an extra "not" accidentally.

On the "liberal" interpretation side, it's often pointed out that Cruzan appears to speak of ANH as a form of "treatment" and that this opened the door to its being withheld rather than being in the category of basic care. In other words, the more liberal interp. is that Cruzan held that people _should_ have the right to refuse ANH like any other "treatment." I've just been reading the decision recently, and from what I could see the talk in it about ANH as treatment comes in a long summary of other court rulings which perhaps are being neither endorsed nor attacked but merely recounted. That's left a little unclear. (There is one place where it begins a sentence with something like "we will grant for the sake of the argument that..." which only increases the unclarity, to my mind.) But the _effect_ has certainly been to _increase_ the number of withholdings of ANH rather than otherwise. The legislative advisor for my state Right to Life organization told me on the telephone a few years ago that the RTL organization will not even try to get our state legislature to write a law calling ANH basic care, because this has been ruled out by Cruzan. So right-to-die advocates are usually relatively positive about Cruzan rather than otherwise.

The court stated:

"for purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition" (497 US at 279)

I don't know what was so biased about my "precis" or how Lydia "can't imagine", but those are other issues.

I'm curious though, what about where a Jehovah's Witness refuses a blood transfusion citing his religion? Should the government have the power to force a blood transfusion?

"Maximos, do you think Cruzan was held incorrectly? i.e., people should not have the right to refuse medical treatment, even if it means they will die?"

Royale, I took your "i.e." to mean that what followed was in your view a summary of the court's conclusion in Cruzan. That is, I took it that you were saying that the court held that a person should not have a right, etc. That was what confused and surprised me. From your latest comment, I understand what follows the "i.e." to be a summary of what you're asking Maximos about--that is, you are asking him if this is _his_ position.

"for purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition" (497 US at 279)

Besides gluttony, are there any instances of nutrition and hydration that are non-lifesaving?

It's worth pointing out that, besides the "for the purposes of this case"--which is slightly odd--the statement refers only to competent persons. I could find no statement in the opinion (and in fact Wesley Smith insists that this is _not_ the purport of the opinion) that a non-competent person must be permitted to refuse the same thing by means of substituted judgement. Some courts have indeed ruled this, and my recollection is that their rulings are _mentioned_ in Cruzan, but as far as I could tell the Cruzan decision left it up in the air as to whether this is required by the federal court.

I am no fan of Cruzan. Like Justice Scalia, I feel that the quoted sentence should never have been included and is, in fact, false. But there is what I might call wiggle room in it which might, if the states would seize the opportunity and if some new "clarifying" interpretation were not then handed down by the Supreme Court, permit states to make it in practice impossible to dehydrate at least a non-competent person to death.

I mean, I think that it is false that the U.S. Constitution grants..., etc.

Of course, not a single member of the "Right to Die" crowd will defend the right to the opposite choice, which implies that they are being dishonest when they present the issue as one of respecting people's choices.

They ought to have the same slogan as Henry Ford: "You can have it any color you like, as long as it's black".

Of course, not a single member of the "Right to Die" crowd will defend the right to the opposite choice, which implies that they are being dishonest when they present the issue as one of respecting people's choices.

That is false. I basically defended the opposite choice in the Texas case. The only caveat I made back then would not even apply to this case, because they have universal health insurance. They also live in a different country, which is why I don't consider it any of my business to opine about it.

And that goes double for Aristotle and Thomas Aquinas for having the vulgarity to speak of the "vegetative soul."

All this demonstrates is that you have no idea what Aquinas meant by the use of that term.

Besides gluttony, are there any instances of nutrition and hydration that are non-lifesaving?

I like it, brendon.

I think that in defending the thoroughness of the protocols some people are actually missing a larger point. This move creates a culture where doctors understand that they are allowed to choose not to treat certain conditions and the burden of the patient advocates is to find a physician that is willing to do what his/her ethical code says they are perfectly free not to do. Treatment of the severely mentally disabled is now a codified option.

It is not necessary to paint the doctors as moral monsters to recognize that it is a bad idea to develop a commonly understood procedural sensibility that certain patients do not matter. A doctor should offer his/her professional opinion on prognosis, treatment options, and other areas relevant to their field of study. Doctors are not qualified to determine when life ceases to matter. It simply is not part of their medical training. One of the most unsettling aspects about these conversations to me is that those who are arguing for human worth to be evaluated by utility can sound as if we are just entertaining conflicting philosophical positions. The problem is that at the end of the day actual people are being unnecessarily dehydrated to death. The absolute confidence in an at best arguable position that ends with the deaths of other human beings is at once astonishing and troubling to me.

There is certainly a faulty assumption of special professional expertise on the part of the doctors to determine questions that don't in any special way fall within their field.

An interesting thing to see is how even on the "liberal" side standards of what is professional behavior vary. Yet the declaration "this is the only professional way to behave" or words to that effect is made solemnly as though with the weight of unquestionable authority behind it. Take the question of patient autonomy. Over on one of my recent threads, you can find a commentator (who may be a doctor himself, though this is a guess) arguing determinedly that the only way for a doctor to be a true professional w.r.t. ANH is to do whatever the patient has chosen when the patient was legally competent. He carries this even to the point of defending dehydrating someone to death who is asking for food and water after becoming legally incompetent where this is taken to conflict in some way with the person's wish given before while legally competent. This, he assures us, is the only true professionalism. But presumably this would mean giving me, for instance, a feeding tube, since I have declared both orally and in writing while legally competent that I want a feeding tube.

But there in Manitoba you can see a rather different notion of professionalism, and our friend Mike on this thread implies that a patient proxy would be negligent and lacking in "backbone" if he didn't order a patient's dehydration when "life was no longer worth living." And the doctors in Manitoba clearly do _not_ think that letting the patient's wishes (as represented by his family) be controlling is true professionalism.

So even if we had no moral intuitions of our own on this, why should we believe the medical experts when they tell us solemnly that they are bound to do this or not do that by the _true_ standards of their profession? After all, truth just is what it is. It's either "medically professional" to override a patient's and family's wishes and dehydrate him to death or it isn't. It can't be both.

As for moral monsterhood, well, people can do terrible things without being monsters, I guess. People decide that "this is the way it has to be" and steel themselves, telling themselves "it isn't as bad as it looks." I believe that this is what has happened w.r.t. dehydrating people to death. The descriptions of what happens to people as they are gradually dehydrated over a period of two weeks are hair-raising. The medical people have to have somehow convinced themselves that this is okay despite the obvious fact that it involves a shocking degree of neglect of the patient's basic needs.

I've been meaning to add that my statement that we are fools if we think doctors will draw the line at a ventilator (to which Rodak took exception) is easily supported. In the other thread our medical professional commentator actually quotes from a U.S. medical manual that states in so many words that ANH is a treatment just like any other treatment. And that opinion is fundamental to liberals on this subject. They have, in fact, worked as hard as they can to get that opinion enshrined in U.S. case law, and in the Canada case the feeding tube and ventilator are _clearly_ both being considered "treatment" and on a par with each other as forms of "life support." This is standard liberal fare, not some sort of invidious implication on my part.

"As for moral monsterhood, well, people can do terrible things without being monsters, I guess. People decide that "this is the way it has to be" and steel themselves, telling themselves "it isn't as bad as it looks." I believe that this is what has happened w.r.t. dehydrating people to death. The descriptions of what happens to people as they are gradually dehydrated over a period of two weeks are hair-raising. The medical people have to have somehow convinced themselves that this is okay despite the obvious fact that it involves a shocking degree of neglect of the patient's basic needs."

I think you see this proven over and over again with art in our culture. I remember talking to people about Million Dollar Baby that saw the ending as a man having the "courage" to do the "right thing" even when it was uncomfortable. In another film, Extreme Measures, Gene Hackman portrys a doctor that sees eperimenting on the homeless to cure spinal injuries for us all as heroic. Every week on Fox, House uses wildly exprimental, unethical,and occasionally tortuous methods of treating people in order to "solve the riddle" of the illness while cavalierly dismissing the value of the patients themselves. It sometimes appears that people are "steeling themselves" to fight through the obviously grim consequences in some misappropriation of the ideas of courage and heroism. They are strong enough to make the hard decisions that people do not want to make. We are increasingly losing site of the basic fact that some of these "decisions" are not properly decisions at all. We are not at liberty to use medicine to choose who deserves to live or has value. Human beings simply matter more than that.