Saturday Essay
Medical Ethics Under Siege
by Paul A. Byrne, M.D.
Softer than butter is his speech, but war is in his heart; his words are smoother than oil, but they are drawn
swords. (Ps. 54:2)
He who defines the terms of engagement has already won the war. As the "quality-of-life" camp presses its
assault on the sanctity of life ethic that once served as the firm foundation for medicine, the cancerous confusion that ensues,
when the definitions of words and what they convey are revised to serve new ends, imperils patients and physicians alike.
On May 10, the Academy of Medicine of Toledo and Lucas County, the Toledo Bar Association, and Riverside and
Toledo hospitals sponsored a program in Toledo that featured Dr. Timothy Quill, an internal medicine doctor. Dr. Quill plays
an active role in a hospice in Rochester, NY. In articles in the New England Journal of Medicine and the Journal
of the American Medical Association, Dr. Quill has detailed without shame prescribing a lethal dose of medication for
a patient.
As does Jack Kevorkian, Dr. Quill portrays himself as a physician who assists patients in dying, claiming
many doctors have been doing it for years behind a curtain of silence.
Yet Dr. Quill debunks Dr. Kevorkian as "a wild card" and mocks those who have fallen prey to his ministrations.
He vividly evokes the pathetic desperation of those lost souls whose last journey is in a rusty VW van.
He notes that were any of these poor souls to change their minds-and God alone knows how many may have, Mr.
Kevorkian would not be competent to help them. Dr. Quill boasts that, to the contrary, he has never abandoned a patient and
would be there to help should one change his mind.
Dr. Quill criticizes the medical profession, citing inadequate training in caring for dying patients. He charges
that comfort care is offered when it is too late. He asserts that doctors' worries over addiction, overdose, and investigations
that may lead to criminal prosecution create a climate of fear intimidating their more liberal use of narcotics. He declares
that hospice should be the "standard of care," praising it as "a valuable substitute for suicide."
Dr. Sigmund Freud was euthanized, according to Dr. Quill, who adds that it would have been beneath Dr. Freud's
dignity to have anyone help him with his feeding and toileting.
At the academy conference, Dr. Quill described how a patient can be sedated into unconsciousness-the condition
in which they die. In defense of such deeds, Dr. Quill invoked the principle of "double effect."
He maintains the principle applies when a patient is given medication with one effect of treating pain and
another of causing death. Dr. Quill's application grossly violates the traditional understanding of the double-effect principle
and distorts it beyond recognition and ethical utility.
For the principle of the double effect to be applied properly to an act which has both a good and evil affect,
the original operational concept holds:
- The act itself must be morally good or at least indifferent.
- The good effect is directly intended, while the evil effect is foreseen but unintended.
- The good effect must not be produced by means of the evil effect.
- The good effect must be proportionate to the evil effect.
- There must be a grave reason for permitting the evil effect.
Unlike congressional legislation, the clauses in the principle of double effect cannot be severed, i.e., all
five conditions must be met fully for the principle to be applied properly.
Since the good effect of pain relief results from the evil effect of the patient's death, medicating patients
until they die cannot be justified by the principle of double effect.
Talk of "active" and "passive" euthanasia permeated the conference. The consensus was that there is no real
difference between the two, inasmuch as both result in premature death.
The conventional wisdom at the conference was that active euthanasia consists in taking an action that kills
the patient, whereas passive euthanasia involves failing to act in order that the patient might die. In the past, some proponents
of passive euthanasia defined it as the withholding or withdrawing of extraordinary means of treatment. With the shift in
definitions and standards, it is evident that such ambiguous terms should be retired from the medical lexicon and ordinary
speech.
The same deconstruction plagued the way the construct of "ordinary" and "extraordinary" means was used or abused
at the conference. As ten colleagues and I cautioned in the
Linacre Quarterly:
In the religious context in which "ordinary" and "extraordinary" means originated, they are limited to particular
criteria that may (not must) be employed by the patient himself to ascertain his moral duty to utilize specific medical treatments.
In secular and legal parlance, however, they have come to provide a pretext for persuasion to accept the imposition of yet
another euthanasia subterfuge i.e., "passive" euthanasia and failing that for it's involuntary application.
The cancer of confusion continues.
"I would never want to be a vegetable [sic] like Karen Quinlan," someone intoned at the conference. Was the speaker referring
to a squash, a string bean, or, possibly, a pumpkin?
As recently reported in the New England Journal of Medicine, the autopsy of Karen Ann Quinlan revealed that her
cerebral cortex was relatively intact. She lived ten years without the aid of a ventilator despite the prognosis of every
physician testifying before the court that she would not survive a year without such assistance in breathing.
Questions remain: Did she receive antibiotics to combat opportunistic infections during the decade she lived in coma, in
particular, immediately prior to her death? Why was the examination of Karen Ann's brain not undertaken until three years
after her death? Why did six more years pass before the autopsy report was made public? And, finally, shouldn't those seeking
to exploit the tragedy of Miss Quinlan in 1995 at least take into account the facts available in 1995?
Do we not have physicians and attorneys here in Toledo ready and able to defend the ideals of their noble professions joined
in a common commitment to the defense of innocent life, in particular, the vulnerable lives deemed "devoid of value" by the
Kevorkians, the Quills, and their ilk?
And if such local champions of their professions were denied a platform by program organizers--even one shared with our
adversaries--what does this tell us about the intentions of the programs' sponsors?
A Toledo pediatrician and neonatologist who for many years has studied and written on the medical,
moral, and legal issues surrounding death and dying. Dr. Byrne serves as President of the Catholic Medical Association.
Toledo Blade, July 8, 1995
