I am not an expert on health care rationing and end-of-life questions. But I know how to find experts, and the leadership of LifeTree, a pro-life Christian educational ministry, certainly qualifies. Executive director Elizabeth Wickham, Ph.D. and her associate, Ione Whitlock, have dedicated their lives to these matters. LifeTree’s Medical Decisions at the End of Life brochure provides the following answers to frequently asked questions:
What is palliative care?
Traditional palliative care is symptom management at life’s end. Symptoms such as nausea, shortness of breath, and pain can usually be mitigated or "palliated." Unfortunately, some palliative care groups are now training physicians to introduce palliative care (comfort care rather than cure) very early in the diagnosis of a chronic condition or terminal illness. This trend blurs the distinction between ordinary pain control and end-of-life care (palliative care). Moreover, terminal sedation and withholding hydration (see below) are often part of the mix.
When should food and water be withheld?
Death by starvation and dehydration is painful and inhumane. Withholding food and hydration is imposed death, unless the food/water cannot be assimilated, as when death is imminent—when the patient is actively dying, and death is expected within 24–48 hours.
Nancy Valko, RN, notes: “When people are truly [actively] dying and the body's organs begin to shut down, we often see people lose their appetite and desire to drink much. This is a process that can protect a person from suffering from fluid overload at the end and the dying person remains comfortable. But this is very different from a deliberate decision to ‘fast’ to death.”
What is terminal sedation?
Not to be confused with control of physical pain, the goal of terminal sedation (TS, also known as “palliative sedation” or “total sedation”) is “to induce a state of decreased or absent awareness (unconsciousness) in order to relieve the burden of intractable suffering.” TS is controversial, and has been called a legal alternative to assisted suicide. Too often TS is used when a patient is not actively dying, and is combined with removal of food and fluids. Withholding food and water can only lead to death. To offer total irreversible sedation to a patient might convey the idea that he or she is a burden, or that his or her life is probably not worth living.
Should I be an organ donor?
Pope John Paul II’s 2001 address to the International Congress of the Transplantation Society insists there be moral certainty that death has occurred before the transplantation of any unpaired vital organ. Unfortunately, in medicine today determination of death (brain death and non-heart-beating death) set standards which are much less stringent than the Holy Father's guidelines. Examples of organs/tissues safe to donate after true death are corneas, heart valves (but not the entire heart), bones, skin, ligaments, and tendons.
How, and why, have medical ethics changed?
Several factors have contributed to changes over the years:
1) Bioethics: Hospitals and medical schools have appointed bioethicists as ethics experts. Bioethics, as currently practiced, focuses on quality of life. Bioethics expert Dianne Irving, Ph.D., explains that whereas “traditional medical ethics focuses on the physician's duty to the individual patient, whose life and welfare are always sacrosanct,” the “focus of bioethics is fundamentally utilitarian, centered, like other utilitarian disciplines, around maximizing total human happiness.” Too often, bioethics shifts the emphasis from improving quality of life, to assessing quality of life — weighing the benefits and burdens of life itself.
2) An entrenched right-to-die belief system:… From Supreme Court cases, to state living will laws, to physician education, the mission was to popularize the concept of forgoing life-sustaining measures. Partnership [for Caring—a right-to-die group] disbanded, but many of its members are now in policy-setting positions in hospice and palliative care organizations at the national level. Visit www.lifetree.org/timeline for more information.
In the rush toward a new, federally controlled health care system, there is a distinct possibility that in their hysteria, its supporters will leave many of these questions either dangling in thin air or completely ignored. It is my considered opinion that health care “reform” advocates will answer very few such questions factually, with evidence to support their claims.
Finally, many ask whether or not health care “reform” could lead to rationing of health care. This is not a crazy question. To find answers, I did some research.
Did you know that Ezekiel Emanuel, M.D., the brother of White House chief of staff Rahm Emanuel, has written on the question of health care rationing? In fact, he has a long history of being deeply involved in end-of-life care discussions, and his statements do not provide comfort.
Wesley J. Smith, who studies bioethical questions, has examined Dr. Emanuel’s views. He believes that in his January 31 Lancet article, Dr. Emanuel did not “explicitly” advocate rationing “now based on age.” However, Smith pointed out,
The same can’t be said of an article he wrote in the Hastings Center Report, in which he explicitly advocates rationing based on what appears to be a quality of life measurement. From the piece:
This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources. Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity-those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic.
Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.
A lot of people are frightened that someone who thinks like Emanuel is at the center of an administration seeking to remake the entire health care system. Having read these two articles, I think there is very real cause for concern.
Terri Schiavo’s brother, Bobby Schindler, who has been deeply involved in defending the vulnerable so that nothing like the horrors she died from will happen to others, likewise has words of warning about health care rationing:
Much has been written warning us about the dangers of Obamacare, but mostly in terms of what it would mean for the elderly and perhaps the chronically ill. Unfortunately, I have not seen any reports of what will happen to those like Terri—the cognitively disabled. However, from what I am reading and what is being proposed for health care reform, I think it is safe to say that those like Terri don’t stand a chance. Especially, if the proposed Independent Medicare Advisory Council (IMAC) is formed that will put bioethicists in charge of who can and cannot receive treatment.
We are in grave danger any time health care decisions are taken out of the hands of individual patients and their families and placed into the hands of government bureaucrats whose decisions are based on cutting costs rather than valuing the dignity and equal worth of every human life.
Finally, I defer to Zane F. Pollard, M.D., a pediatric ophthalmologist for Children's Healthcare of Atlanta (a nonprofit organization), who wrote the following regarding “Obamacare”:
I have taken care of Medicaid patients for 35 years while representing the only pediatric ophthalmology group left in Atlanta, Georgia that accepts Medicaid. For example, in the past 6 months I have cared for three young children on Medicaid who had corneal ulcers. This is a potentially blinding situation because if the cornea perforates from the infection, almost surely blindness will occur. In all three cases the antibiotic needed for the eradication of the infection was not on the approved Medicaid list.
Each time I was told to fax Medicaid for the approval forms, which I did. Within 48 hours the form came back to me which was sent in immediately via fax, and I was told that I would have my answer in 10 days. Of course by then each child would have been blind in the eye.
Each time the request came back denied. All three times I personally provided the antibiotic for each patient which was not on the Medicaid approved list. Get the point — rationing of care.
Over the past 35 years I have cared for over 1000 children born with congenital cataracts. In older children and in adults the vision is rehabilitated with an intraocular lens. In newborns we use contact lenses which are very expensive. It takes Medicaid over one year to approve a contact lens post cataract surgery. By that time a successful anatomical operation is wasted as the child will be close to blind from a lack of focusing for so long a period of time.
Again, extreme rationing. Solution: I have a foundation here in Atlanta supported 100% by private funds which supplies all of these contact lenses for my Medicaid and illegal immigrants children for free. Again, waiting for the government would be disastrous…
The bottom line is that I urge all of you to contact your congresswomen and congressmen and senators to defeat this bill. I promise you that you will not like rationing of your own health.
