Monday, February 25, 2008

Lydia McGrew on Physician Professionalism and Dehydrating People to Death [Jay]

I like Lydia McGrew and I enjoy lurking at What’s Wrong With The World? I loved RightReason and many of those bloggers ended up over there including Francis Beckwith. I was recently monitoring a thread that covered the decision of The College of Physicians & Surgeons of Manitoba to instate protocols that govern the treatment of patients where the physicians judge that treatment is not worth continuing. Among the medical procedures that fall under the spectrum of “treatment” are feeding tubes, which would unnaturally prolong the life of a patient in a persistent vegetative state or other severely mentally impaired condition. I find many of the exchanges that grow out of these threads completely unproductive but I was struck with something as I watched the WWWTW regulars argue with the regular dissenters and I added my two cents to the end. Lydia responded and I am going to cut and paste a little of the exchange because I like her style and she makes an important point about the conflicting concepts of medical professionalism:


I think that in defending the thoroughness of the protocols some people are actually missing a larger point. This move creates a culture where doctors understand that they are allowed to choose not to treat certain conditions and the burden of the patient advocates is to find a physician that is willing to do what his/her ethical code says they are perfectly free not to do. Treatment of the severely mentally disabled is now a codified option.

It is not necessary to paint the doctors as moral monsters to recognize that it is a bad idea to develop a commonly understood procedural sensibility that certain patients do not matter. A doctor should offer his/her professional opinion on prognosis, treatment options, and other areas relevant to their field of study. Doctors are not qualified to determine when life ceases to matter. It simply is not part of their medical training. One of the most unsettling aspects about these conversations to me is that those who are arguing for human worth to be evaluated by utility can sound as if we are merely entertaining conflicting philosophical positions. The problem is that at the end of the day actual people are being unnecessarily dehydrated to death. The absolute confidence in an at best arguable position that ends with the deaths of other human beings is at once astonishing and troubling to me.


There is certainly a faulty assumption of special professional expertise on the part of the doctors to determine questions that don't in any special way fall within their field.

An interesting thing to see is how, even on the "liberal" side, standards of what is professional behavior vary. Yet the declaration "this is the only professional way to behave" or words to that effect is made solemnly as though with the weight of unquestionable authority behind it. Take the question of patient autonomy. Over on one of my recent threads, you can find a commentator (who may be a doctor himself, though this is a guess) arguing determinedly that the only way for a doctor to be a true professional w.r.t. ANH is to do whatever the patient has chosen when the patient was legally competent. He carries this even to the point of defending dehydrating someone to death who is asking for food and water after becoming legally incompetent where this is taken to conflict in some way with the person's wish given before while legally competent. This, he assures us, is the only true professionalism. But presumably this would mean giving me, for instance, a feeding tube, since I have declared both orally and in writing while legally competent that I want a feeding tube.

But there in Manitoba you can see a rather different notion of professionalism, and our friend Mike on this thread implies that a patient proxy would be negligent and lacking in "backbone" if he didn't order a patient's dehydration when "life was no longer worth living." And the doctors in Manitoba clearly do _not_ think that letting the patient's wishes (as represented by his family) be controlling is true professionalism.

So even if we had no moral intuitions of our own on this, why should we believe the medical experts when they tell us solemnly that they are bound to do this or not do that by the _true_ standards of their profession? After all, truth just is what it is. It's either "medically professional" to override a patient's and family's wishes and dehydrate him to death or it isn't. It can't be both.

As for moral monsterhood, well, people can do terrible things without being monsters, I guess. People decide that "this is the way it has to be" and steel themselves, telling themselves "it isn't as bad as it looks." I believe that this is what has happened w.r.t. dehydrating people to death. The descriptions of what happens to people as they are gradually dehydrated over a period of two weeks are hair-raising. The medical people have to have somehow convinced themselves that this is okay despite the obvious fact that it involves a shocking degree of neglect of the patient's basic needs.

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