domingo, 24 de enero de 2016

BioEdge: JAMA debates assisted suicide

BioEdge: JAMA debates assisted suicide

JAMA debates assisted suicide

The latest issue of JAMA showcases the views of leading American doctors and lawyers on physician-assisted suicide (PAS). The theme is captured by the headline above one of the articles: “Physician-Assisted Dying: Turning Point?” After California legalised it last year, other US states could follow. Nothing novel emerges from the discussion, other than a sense of impending change.

One article by a leading advocate of PAS, Timothy Quill, of the University of Rochester argues that “Patients with serious illness wish to have control over their own bodies, their own lives, and concern about future physical and psychosocial distress. Some view potential access to physician-assisted death as the best option to address these concerns.”

Dr Quill et al also insist that the terminology must change:

“Physician-assisted ‘suicide’ connotes mental illness, and suggests a self-destructive aspect of such decisions that many find offensive. Even the term physician-assisted death, although better than physician-assisted suicide, puts more emphasis on the physicians’ role than may be warranted. This issue is driven by patients and reflects fundamental concerns of patients living with serious illnesses who feel that they are being destroyed by their illness; they are seeking what they regard as a small measure of self-preservation. The term ‘hastening death’ is less judgmental and respects the profound search for preservation of the self that many patients seek, even at the last moments of their lives.”
Dr Tony Yang, of George Mason University, and Dr Farr Curlin, of Duke University, go to more fundamental issues. They question whether doctors ought to support the desire of a few patients for unlimited autonomy. They fear that this will eventually destroy trust patients’ trust in their physicians.

"If the medical profession accepts physician-assisted suicide, it will be declaring decisively that “physicians” are mere providers of services, to be guided only by the desires of the individual patient, the will of the state or other third parties, and what the law allows. The idea of medicine as a profession, which embodies a shared commitment to care for persons who are sick and debilitated so as to restore their health, will quickly fade into memory. Those made vulnerable by sickness and debility, to whom physicians owe their solidarity as physicians, will have much less reason to entrust themselves to physicians’ care."
Patients like 29-year-old Brittany Maynard, whose YouTube video about her impending suicide in Oregon sparked the passage of California’s legislation, insist that they want to die on their own terms. But Yang and Curlin argue that: “Patients already have the right to refuse life-sustaining treatment. They have the right to proportionate palliation, even if death is hastened as a side effect. They also have the liberty to end their lives by all manner of methods that do not involve physicians.”

Like their opponents they also complain about terminology,  not because it is patronising, but because it lacks realism: “With respect to physician-assisted suicide, the ‘right to die’ is a euphemism for the putative ‘right to have a physician help me kill myself.’”

At the heart of their essay is the belief that doctors must maintain solidarity with those who suffer, not abandon them:

“Insofar as physicians enjoy societal trust, it is because since Hippocrates, physicians have maintained solidarity with those who are sick and disabled, seeking only to heal and refusing to use their skills and powers to do harm. That is why Doctors Without Borders treats injured Taliban soldiers. It is why physicians have refused to participate in capital punishment, or to be active combatants, or to cooperate with torture. It is why physicians have refused to help patients commit suicide. Many patients with terminal illness fear unbearable pain or other symptoms. The physicians’ role is to care for them in their illness so as to relieve pain or otherwise help them bear up under the symptoms they endure. Many patients loath the prospect of abject debility. The physician’s role is to maintain solidarity with those whose health is diminished, not to imply that debility renders a patient’s life not worth living.”
Palliative care expert Harvey Max Chochinov chaired a panel which reported to the Canadian government about community attitudes toward euthanasia. He also found difficulties with terminology.

“The terminology used seems to depend almost entirely on an individual’s philosophical vantage point. Descriptors from those appearing before the panel ran the gamut, from ‘killing’ to ‘an act of love’. Some took exception to the term physician-assisted dying, claiming that for those who look after patients with terminal illness, this describes the essence of their work. Others warned that the terms euthanasia and assisted suicide might be construed as judgmental, abrasive, or even punitive by patients contemplating death-hastening decisions. Many seem confused by the terminology…  A 2015 study indicated that only 40% of 271 Quebec health care professionals realized that medical aid in dying would allow them to administer lethal medication at the patient's request.”
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The Atlantic recently published a feature about the early days of artificial reproductive technology. The headline was: “The First Artificial Insemination Was an Ethical Nightmare: The 19th-century procedure involved lies, a secrecy pledge, and sperm from a surprise donor”.
It turns out that the first pregnancy with artificial insemination (at least in the US) was in 1855 in New York but it ended in a miscarriage. The first successful pregnancy with the same method took place in Philadelphia in 1884.
The patient was a married woman whose husband was infertile because of venereal disease. Without seeking the consent of either husband or wife, the doctor anaesthetised her and inseminated her with the sperm of one of his medical students. The women never discovered the truth and the students were sworn to secrecy.
However, when her baby was a 25-year-old businessman one of the students published his recollections of the event (after contacting the child). As far as he was concerned, artificial insemination was a eugenic boon, “a race-uplifting procedure”, which would produce children of “wonderful mental endowments” instead of “half-witted, evil-inclined, disease-disposed offspring”.
The author of the article in The Atlantic was amused by the old-fashioned lies, secrecy and donor anonymity. But has any of that changed? Most children born from contemporary reproductive technologies are “genetic orphans”. Most parents shop for donors who will confer “wonderful mental endowments” upon their offspring. Plus ça change, plus c'est la même chose.

Michael Cook



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