It's Not About Conscience, It's About the Nature of the Healing Profession, by Stephanie Gray

With today’s news that the Canadian Medical Association has voted to reject a motion that would protect the conscience rights of physicians who refuse to refer patients to die by euthanasia, panic and fear is likely to set in with some pro-life physicians.*

“Well, if I’m forced to refer for euthanasia then I can no longer practice as a doctor,” some might say.

Not true.  We create a false dilemma by saying there are only two options: Either I refer for euthanasia or I don’t practice as a doctor.  No.  There is a third option: You practice as a physician and you do not refer for euthanasia.  Let me explain.

I have never been a fan of emphasizing “conscience” as one’s argument for doctors avoiding practices that simply aren’t good medicine.  I have written on this before regarding abortion and that can be viewed here.  Emphasizing conscience has the risk of marginalizing true, ethical physicians, putting them on the “fringe,” as though pro-life doctors are somehow different from the average doctor because they have a “conscience” that tells them something that is different from what “real” medicine would do.  That is not the case. 

Real medicine heals, not kills. 

Real medicine alleviates suffering without eliminating sufferers.

Real medicine addresses the underlying motivation for someone’s request to die (e.g., administering pain medicine, giving love and attention to the lonely), rather than responding at a surface level.

Real medicine believes we should “do no harm.”

Real medicine heeds the Canadian Medical Association’s Code of Ethics which says, “Practise the profession of medicine in a manner that treats the patient with dignity and as a person worthy of respect.  Provide for appropriate care for your patient, even when cure is no longer possible, including physical comfort and spiritual and psychosocial support.”

Real medicine remembers it was less than a century ago when physicians were lead killers during the Holocaust, killing not only Jews, but also the elderly and disabled, the individuals they categorized as “lives unworthy of life.”

Real medicine remembers the words of Holocaust-survivor Elie Wiesel whose essay, incidentally titled, “Without Conscience,” was published in 2005 in the New England Journal of Medicine and read by UBC medical students in which he writes, “[I]nstead of doing their job, instead of bringing assistance and comfort to the sick people who needed them most, instead of helping the mutilated and the handicapped to live, eat, and hope one more day, one more hour, doctors became their executioners…Why did some know how to bring honor to humankind, while others renounced humankind with hatred?  It is a question of choice.  A choice that even now belongs to us—to uniformed soldiers, but even more so to doctors.  The killers could have decided not to kill.”

Real medicine simply does not kill.

Instead of emphasizing conscience, we need to emphasize what the nature of the healing profession is all about.  We have to show it is simply not good medicine to kill a patient.  Instead of saying, “I do not refer for euthanasia because my conscience tells me not to,” a pro-life physician should declare, “I do not refer for euthanasia because it is not good medicine.  I do not refer for euthanasia because it goes against the nature of the healing profession.  I do not refer for euthanasia because as a physician I am called to do no harm and I would be violating that command.”  At this link I have developed an apologetic to help guide physicians to articulate why euthanasia is not the proper response, and what, in fact, is.

To my many dear, and some of my closest, friends who are physicians: Do not let this decision discourage you.  Let it empower you.  Let it embolden you.  Get ready to love your patients like you’ve never loved before, and get ready to fight your medical establishment like you’ve never fought before.

If the day will come when you no longer practice as a physician, may it be because your license was taken from you, not because you voluntarily walked away.  Do not walk away.  If the day will come when you no longer practice as a physician, may it be because you were literally dragged from doing so, not because you willingly left.  Do not willingly leave.  

If the day will come when any of this happens, our attitude must be to look at it, not as the end, but as a beginning, to get creative about how physicians can practice as doctors and do the right thing, regardless of the environment one is in--just as others in the past who have lived through human rights violations have done.   Never give up. 

Patients who are truly loved and cared for physically, emotionally, and spiritually are unlikely to request euthanasia.  So do your job and let the lawyers who exist to defend you (here  and here) do theirs.

What the great Dr. Martin Luther King, Jr., once said, in his Letter from Birmingham Jail, about the early church is as a relevant to the civil rights activists of his day as it is relevant to the pro-life physicians of our day:

“There was a time when the church was very powerful -- in the time when the early Christians rejoiced at being deemed worthy to suffer for what they believed. In those days the church was not merely a thermometer that recorded the ideas and principles of popular opinion; it was a thermostat that transformed the mores of society. Whenever the early Christians entered a town, the people in power became disturbed and immediately sought to convict the Christians for being ‘disturbers of the peace’ and ‘outside agitators.’ But the Christians pressed on, in the conviction that they were ‘a colony of heaven,’ called to obey Gad rather than man. Small in number, they were big in commitment. They were too God-intoxicated to be ‘astronomically intimidated.’ By their effort and example they brought an end to such ancient evils as infanticide and gladiatorial contests.”

If we are going to bring an end to the present-day evil of killing the weak and vulnerable, we will not only have to capture the sacrificial and courageous spirit of the early Church, but we will need to be prepared for an epic battle.  That is what happens when the Culture of Life clashes with the Culture of Death.  But we need not be afraid, because we are people of hope.  And as the late Fr. Richard John Neuhaus once said,

“Hope is a virtue of having looked unblinkingly into all the reasons for despair, into all of the reasons that would seem to falsify hope, and to say, 'Nonetheless Christ is Lord. Nonetheless this is the story of the world. Nonetheless this is a story to which I will surrender myself day by day.' Not simply on one altar call, but as the entirety of one's life, in which every day is a laying of your life on the altar of the Lord Jesus Christ being offered up in perfect sacrifice to the Father.

“And will we overcome? Will we prevail? We have overcome and have prevailed ultimately because He has overcome and He has prevailed. There are days in which you and I get discouraged. On those days I tell myself — I suppose almost every day I tell myself, sometimes several times a day — those marvelous lines from T. S. Eliot's 'East Coker,' where Eliot says, 'For us there is only the trying. The rest is not our business.'

“For us there is only the trying. The rest is not our business. Some people read those lines as lines of resignation, kind of shrugging your shoulders and saying, 'What can you do?' But I read them as lines of vibrant hope. The rest is not our business. The rest is God's business.

“Thank God, we are not God. Thank God, God is God.”

So try, try with all your might, and watch God work mighty wonders through you.

---

*It should be noted that there were several votes by the CMA on this topic. Although the CMA reported that “Conscientious objection was a contentious issue, with 79% of delegates voting against a motion to support conscientious objectors who refuse to refer patients for medical aid in dying”  the CMA also reported that “According to results of a CMA member survey [of 1407 responses] presented at the meeting, many doctors remain opposed to assisting in a patient's suicide. Only 29% of those surveyed said they would consider providing medical aid in dying if requested by a patient, 63% would refuse outright and 8% were undecided.”   The CMA also reported, “‘No physician should be forced to participate against their conscience,’ said Dr. Jeff Blackmer, vice president of medical professionalism at CMA. ‘But there's disagreement about what this means.’”  

This isn’t the end of the story as the CMA is looking at all these votes and motions and considering guidelines moving forward; therefore, it is still possible the guidelines to come will respect a physician’s conscience.  Time will tell, which is why, at minimum, protecting conscience rights can still be lobbied for, but, more importantly, a solid pro-life apologetic on euthanasia must be articulated, not only at a national level with the CMA, but also to the provincial governing medical bodies as well as to our elected representatives on a provincial and federal level.

Do You See What I See? by Stephanie Gray

Glass half empty or glass half full?  It’s a question that shows how the same thing can be viewed two entirely different ways—the negative or the positive.  How we see something determines everything.  It’s all about perspective.

If you walk into an assisted living home for the elderly, you might see this:

•    An empty piano alongside a blaring TV with a row of wheelchairs in front of the latter, with the occupants of said chairs ranging from sleeping to zoned-out watching.
•    A drooling old man, wearing an oversized bib, sitting alone, slumped against a table.
•    A crippled, toothless person sitting alone in a room staring out the door to an empty hallway.
•    An elderly lady who refuses to leave her dark room for breakfast.

And if you see that, you might just support euthanasia. 

But I’d like to tell you what I see:

•    I see people to give the gift of music to, entertaining them by a person playing the piano.
•    I see an elderly lady who can be given an opportunity to come alive with music, giving her a chance to joyfully reminisce about her days when she attended musicals.  I see that lady not just standing, but dancing to the beat, swinging her arms, and singing along.
•    I see an opportunity to wipe the face of someone who, decades before, wiped the faces of many other souls.
•    I see a chance to slide open curtains and share the sunshine with a lady who didn’t know it was there.
•    I see someone with ears to speak to.
•    I see lips to be provoked into a smile.
•    I see sweet ladies to listen to and laugh with.
•    I see a fragile, soft hand to hold and give the gift of touch to.
•    I see people in wheelchairs to push into the brilliance and beauty of the outdoors.

And if you see that, you might just thank these people for being.  You might just realize their existence is enough to warrant our attention.  You might just realize

we have something to give,

something to learn,

and most importantly, someone to love.

Indeed, how we see something—especially someone—determines everything.

End of Life Decision-Making: The Details, by Stephanie Gray

A couple years ago, a friend of mine, who is a young husband and father, was diagnosed with a brain tumor.  His wife contacted me for counsel on handling end-of-life decision-making should things move in that direction, and she wrote me the following:

 “We are in the midst of writing up our Power of Attorneys and part of that includes the following statement: ‘If the situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by cardiopulmonary resuscitation, mechanical respiration, artificial nutrition, or other artificial means.’

I am just wondering what your thoughts are on the ethics of withholding feeding tube in an 'end of life' situation.  Do you consider it an artificial means of preserving life the same as keeping someone on a ventilator?  I somehow feel it is quite different and shouldn't lumped into one statement.  Is there discussion around this topic?”

In light of Canada’s recent Supreme Court Decision, I thought it would be beneficial to publish my response to her as a resource for others who may find themselves in similar situations.  So here it is:

My heart goes out to you having to think of this right now. I do have some thoughts on end of life issues and interventions and wording guidelines that I'd be more than happy to share with you.  On matters of end of life, the morality of what to do is often difficult to wade through because in order to determine the ethical we have to really understand the medical, and these days the medical can be quite complicated and varies according to each person’s unique condition and situation.  Knowing what to do can be determined, but it takes a bit more digging. 

I would therefore caution against any type of general statement like you have because I think it allows for too much interpretation and if you don’t have a pro-life physician, the doctor’s determination of “extreme” physical or mental disability could be problematic.   This article here further explains why one should be cautious about general statements.

I should note that that link and others below all go to documents written by Catholics.  Because that is my background and I am very familiar with the National Catholic Bioethics Center (from which almost all my links are drawn) I nonetheless provide them to you, knowing your different background, because I’ve never found anything more extensive and consistent with natural law principles than these.  It’s not that other good documents aren’t out there, but it’s that these are what I know and I think very logical and grounded in principles that, at their core, cross denominational boundaries.  Let me know if that's okay or not.

Anyhoos, when I took my certification in health care ethics, one of the things we were taught is to distinguish things which are proportionate versus those which are disproportionate (instead of things like concern for general disability, as that can lead people to make decisions based on “quality of life” which is very subjective).  I’ve attached the reading for it I was given, but in brief, the main things to focus on would be whether a particular intervention hasa hope of benefit or not and would it be excessively burdensome or not.  This article draws on that principle when it comes to DNRs (“Do Not Recuscitate”) and I think it says it better than I could so if you don’t mind I’ll just point you to it.

Regarding nutrition and hydration, I would classify that as care, rather than treatment, even when requiring some artificial assistance to get the process going, as food and water are basic necessities for our survival.  Therefore, rather than a general statement to withhold these, I think that has to be determined from the perspective of whether administering them would be excessively burdensome (again, back to that proportionate/disproportionate standard).  For example, when someone is in their dying stages, administering food and water could possibly cause more pain and little to no benefit, so it could ethically be withheld, not to speed the dying process, but to avoid causing pain to someone who is already in the dying process.  But that has to be determined on a case-by-case basis to know what the administration, in a specific scenario, would actually do.  This document provides some helpful insights on nutrition and hydration, although a good chunk of it relates more to those in a “vegetative” state.

There’s also helpful information related to that topic, along with respiration, which not only distinguishes artificial hydration and nutrition from ventilators, but also makes the point that determining whether one should maintain the use of a ventilator or not should still be run through the “proportionate versus disproportionate” test.  You can read about this here and here. 

Another perspective to bear in mind is that when someone dies, to determine the ethics of our commissions or omissions surrounding their death, we should ask, “If I act or do not act, and the person dies, what will be their cause of death?”  Will it be their underlying disease/condition, or will it be our act or omission?  If it’s the latter, there’s a problem.  If it’s the former, that is tragically a part of life.

Admittedly, sometimes when we do one thing (e.g., administer pain medication), it can have two kinds of effects—a good effect (pain goes away) and a bad effect (the medication hastens death).  If the act is consistent with the Principle of Double Effect, it can be justified.

All this to say, I think the wisest choice in end-of-life issues is what is described at the end of the first article I linked to:

“There is a better choice available to Christians than a living will. We can choose a surrogate, a living person, who will make health care decisions in real time on our behalf if we are rendered unable to do so. The proposed surrogate (also called a "health care proxy") is someone who cares deeply about us, who loves us, and is reasonably able to make decisions in accord with our known wishes and with our best medical and spiritual interests in mind. Filling out a form to designate our health care proxy is something that each of us should do as a sensible way to prepare for difficult end-of-life situations that may arise. Preparing such a document can also prompt us to begin discussing these important topics more effectively with our families and loved ones.”

This way, the specific circumstances of each scenario that arises in the future will be dealt with, and ethically analyzed, in the present moment, rather than hypothesizing about the future.  In fact, the NCBC organization I draw my information from, has a 24-hour ethical consult line that anyone, not just Catholics, can call to get an ethical analysis based on specific medical situations that arise.

I hope this helps.  Again, please let me know if you’d like to discuss any of it, and please be assured of my continued prayers for you and your family.

Peace be with you, Stephanie

Note: My friend responded, “This is so very helpful.  Thank you so much.  I had not found as much clarity or peace in speaking to other people to this point.”  Most encouraging is that almost two years since our exchange, her husband has had two brain surgeries to remove the tumor and is doing very, very well!  Please keep them in your prayers.

On Assisted Suicide and Perspective: A Practical Response, by Stephanie Gray

Image source: Wikimedia Commons, Adam Jones

Last Friday as I flew to Texas to speak at a mother-daughter event, I stared out the airplane window at the majesty of the setting sun which had painted the sky red, yellow, orange, and blue in a breathtaking scene of beauty, and my mind wandered to a stark contrast: the turmoil going on back in my own country.  February 6 was a dark day for Canada, for it was the day our Supreme Court overturned the law prohibiting assisted suicide.

In between flights that day, I saw my newsfeed and e-mail fill with messages of deep sadness, fear, and dread.  These were, and are, healthy reactions to a horrifying decision that attacks the dignity of the person.

Now that the news has settled over the weekend, it is good to take a moment to reflect on the importance of perspective.  Holocaust-survivor Viktor Frankl, in his book Man’s Search for Meaning, reminds us of a truth we must cling to during these dark days: “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances.”

The bad news is that the sick and vulnerable are in danger in Canada.  The good news is that we are in control of our response to this horrible set of circumstances.  No judge or government or individual can take away how we respond.  So a question each one of us must ask is this: Are the sick and vulnerable, in my circle of influence, in danger?  Each of us determines the answer to that question.

Consider Lord of the Rings, a story revolving around a young hobbit, Frodo, who inherits the Ring of Power and who is charged with the grave responsibility of transporting it to a volcano to destroy it.  At one point, Frodo laments, “I wish the ring had never come to me.  I wish none of this had happened.”  And the wizard Gandalf, replies, “So do all who live to see such times.  But that is not for them to decide.  All we have to decide is what to do with the time that is given to us.”

That is perspective.  And that is what we must continue to come back to in light of the Supreme Court’s decision.  While it is understandable that we lament, “I wish the court had never decided this.  I wish euthanasia didn’t happen in Canada,” we should focus more on how we have the power to decide what to do with the time that is given to us, how we can choose our attitude in this present circumstance.

So what are we going to do with the time that is given to us?

I heartily recommend supporting worthy causes like The Euthanasia Prevention Coalition.  Then, when it comes to a practical level, I think our primary response to Friday’s decision should be to love more deeply, and influence more positively, the people around us.  If no one asks for assisted suicide, and if strong people protect weak people from medical personnel who would be tempted to kill the vulnerable, assisted suicide and euthanasia won’t happen.  So what does that mean?  Each of us, in our particular circle of influence, should seek out those around us who we can 1) be a friend to and 2) be an advocate for.

Be a Friend

Many years ago, pro-life speaker Camille Pauley spoke about how she visited an elderly, unresponsive man in a hospital.  She spent time visiting him not for herself, but for him.  It didn’t matter that he couldn’t hold a conversation with her, because what mattered was that she communicated, by her time and presence and love, that he was valuable, that he was unrepeatable and irreplaceable, and that he had dignity by his very existence, not by anything he could do.  By simply “Being With” (the name of the program she developed for this very outreach), she affirmed his worth.  If someone is not made to feel like they are a burden, but instead made to feel that they are worthy of our time, they are unlikely to ask for assisted suicide.

Practically speaking, I think we all could do an inventory of our family and friends and think about one or two in our circle who most need special attention, and then be intentional about spending more time with them.  We could also seek out one or two people we don’t yet know that we will make time for.  I recently sent this message to my pastor and encourage others to copy and paste the same:

In light of the Supreme Court's decision to overturn Canada's prohibition on assisted suicide, I believe one of the best ways we can respond to this horrible ruling is for everyone to make sure that the people in their circles of influence don't ever ask for assisted suicide--to make sure that everyone in our circles of influence feels loved and supported and cared for. 

So in asking, “What can I do?” it occurred to me that there could be someone at our church who is an elderly or disabled person who is shut in with no family or friends who could use some visits and help.  So I was wondering if you know of a parishioner like this who could be blessed by someone forming a friendship to spend time with them?  If so, could you please connect me to them?

Alternatively, signing up to visit at a local elderly home is another practical way to be present and loving to the vulnerable.

Be an Advocate

Besides being a friend, we also need to be an advocate.  The dictionary defines this as “a person who speaks or writes in support or defense of a person.”  If one of your family or friends is hospitalized, are you equipped to ask the right questions and seek out the right information to ensure their medical treatment is handled in an ethical fashion?  Several years ago I took a certification course in health care ethics through the National Catholic Bioethics Center (NCBC) in Philadelphia.  Thanks to the NCBC’s resources, when my friend with a brain tumor was facing possible end-of-life issues, I was able to share their advice for ethical decision-making with his wife. 

Whether you know how to ethically handle end-of-life care (e.g., how does one determine whether an intervention is proportionate versus disproportionate?), or whether you know where to look for what is the right course of action, another important point for consideration is this: do you have the legal power to ensure the right thing is done for your loved ones?  Last night I confirmed that I have Power of Attorney for my parents should they ever be incapable of making medical decisions on their behalf.  This was a legal document I signed several years ago and you can bet, should it ever need to be enforced, that I will make decisions on their behalf that respect their dignity.  You can bet I will ensure doctors respond by alleviating suffering, not eliminating the sufferer.

If you are a health care professional, you can advocate for your patients by practicing ethically and not allowing the Supreme Court’s decision to cause you to do anything different except that it motivate you to be more loving, attentive, and compassionate, someone who exemplifies what it means to be a part of a healing profession.

When we are tempted to be overwhelmed by the gravity and far-reaching consequences of the Supreme Court’s decision, let us remember that we are in control of our response.  Rather than despairing or being overwhelmed, let us remember the words of Bishop Untener of Michigan who said, “We cannot do everything, and there is a sense of liberation in realizing that.  This enables us to do something, and to do it very well.”

Be a friend.  Be an advocate.  Let us each do that very well.