[The Daily 08-09-2006] The Road Continues

Kelly Hills
2006-08-09

It’s a hot afternoon in Washington, D.C. and a young boy buys a pickle from an ice cream and hot dog vendor, expecting cool relief from the sweet vegetable.

Instead, a flood of PCP and ecstasy floods his system, causing him to go into convulsions. By the time EMTs arrive, the boy has stopped respiration. While they are able to restore his breathing, and the hospital stabilizes him further, he does not wake up.

Two of the three neurologists to examine him are certain he is completely and totally brain dead. The third sees some electrical activity, and cannot say whether there is total brain death, but agrees that the child will never wake up.

Doctors wish to take the boy off life support; In their eyes, he is dead. He cannot survive without a ventilator and his heart needs assistance to beat. But the boy’s parents frantically demand doctors do everything possible to keep their son alive; they are Black Muslims, and believe that until Allah calls their son home, they must keep the child alive.

What’s a doctor to do?

If you have a clear idea, let me know. Robert Veatch, the ethicist, philosopher and professor asking my class this question, doesn’t have a comfortable answer, and neither do any of us.

The class, however, is not at the University of Washington. I have left the school, and even left the West coast — I’m now in Albany, New York, doing a slow boil in the high heat and humidity. They assure me the weather is not normal; I suspect they’re just trying to pull one on a Seattle girl.

I’ve spent the past six months using this space to rant and rave and think aloud, to provoke you (hello, pharmacy students!) into your own thoughts about ethics and medicine. I hope you’ve read what I’ve said and agreed, wanted to know more — or disagreed violently, and wanted to learn more.

I hope that at least a few readers decide to go down to the Health Sciences Center and take some of the medical history and ethics courses offered, maybe for a minor, maybe to join me along this road towards becoming a specialist in bioethics.

I’ve taken stands here that I don’t necessarily agree with, and I’ve worn my position on my sleeve. If you know me, you probably know which is which. For this last column, I’ll be obvious about having my heart and gratitude in the wide open.

I hear it’s tradition that your last column is a bit of reflection and goodbye. My time at The Daily has been one where I’ve had the chance, thanks to my dear friend Maureen Trantham, to explore some ideas about medicine, ethics and popular culture outside the formal academic setting. It’s been a wonderful opportunity and experience.

But as it may be evident, I’ve a lot to learn before I can comfortably call myself an expert. That’s why I’m on the other coast, three hours ahead, being steamed to death. I’ve joined a program run by the Alden March Bioethics Institute; I’ll be earning a master of science in bioethics from the Graduate College of Union University and Albany Medical Center, as well as a PhD in Philosophy from the State University of New York.

Hopefully, I’ll be following in the footsteps of those who’ve inspired me, the people you should seek out if you want to be so inspired: Phillip Thurtle, Denise Dudzinski, Sara Goering, Brian Reed, John Toews, Jess Olsen and all the great folks in CHID and MHE. Thanks … I’ll miss you all.

I don’t have the answer for the scenario I posed at the beginning of this article, but maybe I’ll come back in a few years and let you know what I’ve found out.

[The Daily 07-19-2006] Death Made Pretty

Kelly Hills
2006-07-19

Death by lethal injection was dealt a blow last month when a U.S. district judge ruled the process may cause extreme pain and suffering before death.

In the United States, death comes in a three-drug cocktail. First, a drug is administered to cause unconsciousness. Another causes paralysis and a third stops the heart.

The objection is that it’s possible for someone not to be fully unconscious after being given the first drug, and feel both the paralysis and the burn of potassium that will stop the heart, causing significant fear and pain.

The court ruled fatal drugs couldn’t be administered without certified medical personnel there to ensure the prisoner is first unconscious before administering further drugs.

Since no medical personnel can be found who are willing to violate the American Medical Association ruling that it would be unethical to participate in involuntary death, there have been no deaths by lethal injection since the ruling.

There is a second method that could be used to bring about death, and it’s one that requires no medical personnel to participate — administer a much larger dose of the drug that causes unconsciousness. The higher dose assures unconsciousness — so no awareness or pain — but it can also cause death by ceasing respiration.

So which matters more: The comfort of the to-be executed, or the comfort of the witnesses to the death? The first method takes only 10 minutes, and because of the paralysis, the prisoner appears calm and relaxed.

The second method becomes visually difficult for witnesses: the unconscious prisoner could jerk and spasm for upwards of 45 minutes before death.

I believe that too many people on death row are there falsely, due to the failings of science or the legal system. But I also believe there are people there who’ve admitted to their crimes, or for whom the evidence is more than overwhelming.

In general, these people are so heinous, reform appears impossible and it’s in society’s best interest if they were humanely euthanized.

The innocence issue aside, it takes entirely too long to move from sentencing to execution. We change so much in 20 years that we’re quite literally not the same person — our cells have died and been reborn and died again almost three times over. Multiple biological changes have occurred, and that’s not even beginning to consider the mental and emotional ones.

Secondly, there’s the objection of pain and suffering. Yes, the person is being executed — but I don’t think that means we should cause pain in the process. The supposedly “humane” death by injection is fraught with problems and pain, but a serene death for the prisoner is disturbing to witness.

Of course, we opt to comfort the witness and not the person being executed. It makes me wonder a bit at our attitude toward death: It’s OK, so long as it’s pretty and serene … ?

Is this just a manifestation of our general desire to have death be neat and tidy, a further extension of our attempt to sanitize dying? In our desire for neat appearances to comfort the vision we have of our own deaths, do we take the fast and cruel approach because it’s prettier?

I think most likely, yes.

[The Daily] – The Right to Life

The Right to Life
2006-07-05

So here’s a question for you to mull over: When were you old enough to make your own decisions?

Chances are you were pretty young when you figured out you didn’t like the taste of broccoli. And you probably weren’t old enough the first time getting drunk sounded like a good idea.

Now ask yourself this: At what age were you old enough to make your own medical decisions?

You were probably old enough to know what you wanted or didn’t want, medically speaking, before you turned 18. Probably even before 16 or 14, although it gets murkier the younger you go. Some kids are a lot more capable of that sort of thinking than others.

I doubt anyone thinks they were young children when they were able to make their own medical decisions. Since the concept requires speech, infants are ruled out.

This means in the case of infants and anyone else who hasn’t reached that nebulous age of “old enough,” someone else — a parent or legal guardian — is making their medical decisions.

This is how it should be, right?

Or is it?

Consider that by the time someone is in his or her teens, doctors will start asking for assent, if not consent, from the teenager. That is, they’re asking to sound out the patient’s feelings on treatment, aside from the feelings of the parent.

While legally the patient cannot give consent (unless, as in some states, it’s for issues related to sexual health), the patient can assent to treatment. Or they can disagree, in which case the doctor has to decide how to navigate the suddenly rough waters.

While you’d think doctors would want to avoid situations that could place them between patient and parent, the reason they do ask for assent is because — as I’m sure we’ve all experienced firsthand — children do not always follow parents in belief.

For most of us, we deviate from our parents’ beliefs in simple ways. PC vs. Mac, Democrat or Republican, science fiction or not.

But sometimes the apple falls pretty far from the tree, and children end up disagreeing with their parents about more serious, weighty things, like religion.

Religion has typically been the reason you would find a parent in court, arguing that he/she had the right to determine a child’s medical treatment. Parents who believe only in prayer, or who refuse blood or other life-saving treatments for any number of reasons, typically justify their decisions through religion.

That changed in Seattle last week when a 9-month-old baby was smuggled from Children’s Hospital by his mother, who wanted to pursue naturopathic treatments instead of allowing the surgical implantation of a shunt that would allow him to receive dialysis for his failing kidneys.

One Amber Alert and two days later, the mother was in jail and the child back at Children’s. Friday morning, a judge granted Child Protective Services custody, and permission for the surgery the mother so strongly opposed.

Not surprisingly, this case has privacy advocates up in arms, insisting that the government has overstepped its authority, and that parental rights are what matter.

In this case, the legal logic is similar to that used in religious cases, and it’s one I have a hard time finding any ethical fault with.

A child should be allowed to live to the point of making their own choice on whether or not to receive medical treatment, and until that age, you default to the assumption of doing whatever it takes to live.

[The Daily] – Biological Incubators

Biological Incubators
2006-06-21

Susan Anne Catherine Torres and Cristina Doe were born 10 months apart, in August 2005 and June 2006, respectively.

Sadly, Susan Torres passed away six weeks after birth. Yet these two girls are connected to one another through a very unusual circumstance: Both babies were born to braindead women.

According to Dr. Winston Campbell of the University of Connecticut Health Center, there are approximately a dozen cases of braindead women completing gestation to the point of delivering a viable fetus in the medical literature.

Further research in the journal of Obstetrical and Gynecological Survey shows another 15 cases of pregnant women in persistent vegetative states remaining on life support to deliver.

While there are few cases in the literature, this is largely because technology has only recently advanced to the point of making this a possible practice.

The idea of leaving a woman on life support to gestate a fetus is a highly contentious issue. There are those who believe all pregnant women should be kept on life support until delivery is possible. There are those who believe it’s up to individual families to make the decision. Then there are those who see a slippery slope of forced pregnancy and believe if a woman is dead she should be allowed to die, regardless of pregnancy.

These positions are all very self-explanatory, and a few years back, this columnist would have been firmly in the camp of “she’s dead — let her die.”

The idea of a woman being kept alive as a fleshy incubator horrified me — it was like a dystopic nightmare come to life. Women die, but their bodies are kept alive to gestate. What’s next — taking that dead woman, hooking her up to life support and then impregnating her?

In the meantime, I’ve realized that this is a non causa pro causa fallacy, the slippery slope at its worst. It’s saying that if A happens, by a gradual and continual process, B, C, D and eventually Z will happen. Z of course is a horribly bad thing, and since it should not happen, A shouldn’t either.

In reality, there is a strong line drawn between the A of keeping a pregnant woman alive a handful of months to deliver a desired fetus, and the dystopic possibilities inherent in Z.

That strong line is biology. It seems the body can maintain a pregnancy while it is braindead for somewhere around 3-4 months. While it’s long enough to attempt to bring a fetus to viability, it’s not long enough to create a pregnancy from scratch.

These days, I fall in the middle ground: I believe it’s a decision that should be made between family, doctors, friends and religious figures — the important people in the individual woman’s life.

That it be a personal decision, not a political or legislated one, is key. There is currently legislation in 27 states that allow doctors, lawyers and hospitals to override the wishes of the pregnant woman or her family. These pregnancy clauses mandate that every attempt should be made to save the life of a fetus, including keeping the woman alive on life support beyond the wishes of her family and friends.

This is where our concerns should be. It shouldn’t be with people who opt to keep their loved ones alive in order to have a piece of them continue to live in the form of a child.

Nor should it be with the people who believe that heroic measures should not be attempted, and mother and fetus should be allowed to die as nature dictated.

Our concern should be with the people who are taking these decisions out of the hands of those immediately affected and placing them in the clinical hands of the disinterested and uninvolved.

This decision, whether or not to attempt a medical miracle to bring a life into the world, is a private one, not a matter of public policy.

[The Daily] – Medicine or Miracle?

Medicine or Miracle?
2006-05-30

A recent episode of the television show House titled “House vs. God” dealt with the idea of faith healing, something that comes up a lot these days in medical journals.

What is the power of prayer? Does faith healing work? Can miracles happen?

As many are aware, there have been multiple studies that attempt to look at these subjects, the strongest being that of the effect prayer has on people.

Unfortunately, even the people running these studies will tell you they are not well designed, and potentially flawed.

This came to light recently when one of the most comprehensive studies on the power of prayer showed that prayer for post-operative cardiac patients actually appeared to have a slightly detrimental effect on the patient.

Perhaps this is a reflection of my interdisciplinary training, but I think the much more interesting questions to ask are why miracles can’t happen and prayer can’t heal.

Some would say that it’s because there is no higher power, deity or God, but do we need such a being to exist for prayers and miracles to work?

After all, couldn’t you argue that a miracle is just that which we don’t understand?

You could quite often say the same thing about our medicine. The typical example is a cell phone in the rain forest, although I’d argue there’s an awful lot of technology and medicine that might as well be (and probably is) “magic” based on how well we understand it.

There is simply the belief, the faith that it will work, because someone is being told it will work.

How is that so different than hearing a faith healer tell you the same?

Of course, we of the rational, medical type say we have medicine. We can take the time to understand how technology works. We can figure it out and we can do the math.

But we cannot and do not fully understand how the body works; we keep finding new things.Miracles keep being rationalized and understood, filed away into things to learn and knowledge to distill.

If we have learned one thing, it’s that the body is an amazing thing.

In the episode of House I refer to, the patient — a young teenage boy — hears the voice of God, and believes God wants him to be a faith healer. Dr. House takes the case on after the boy collapses in the middle of a church meeting, and eventually discovers the boy has a tumor in a certain part of his brain, the result being that he experiences hallucinations — hallucinations he believes to be the voice of God.

Who is to say that the power of the placebo effect isn’t enough to help some people?

After all, we know scientifically and medically that positive thinking does positively affect our health, including helping us recover from illness.

Does it even have to be a placebo? We understand so little of how the brain works, is it so genuinely inconceivable that there are still processes left we don’t understand?

We don’t want to entertain the notion that something can be both real and invisible, quantifiable yet mystical, so it gets filed away as faith-healing fakery and fraud.

But in 10 years, perhaps it will have a Latin name and a textbook, diagnosis and belief, some way to reconcile disbelief and faith (or evidence).

That’s the way knowledge goes: a part of life for both miracle and medicine.

Why should we limit our view of the world to that science we already understand, instead of enjoying the magic and mystery behind those things we don’t?