AMA 2016 Code of Ethics

amaThe AMA is in the process of updating its Code of Ethics.  The preliminary documents are available online, including Chapter 5: Opinions on Caring for Patients at the End of Life.

Based on this preliminary document, it looks as if the AMA will continue to stand against physician-assisted suicide and euthanasia. In both cases, the document states that “permitting physicians to engage” in either of them “would ultimately cause more harm than good.”  Both are “fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”

Although the AMA remains against active killing, it very much encourages passive dying. Of eight sections, three are dedicated to insisting that patients be left to die, sometimes even when they don’t want to.

The first two sections are about Advance Care Planning and Advance Directives.  These are new concepts that medicine has not needed before the era of cost containment because the assumption has always been that if a person comes to a medical professional, it is because he or she wants care.  Now we must ask patients again and again if they are sure they want treatment because certainly some, even many, will refuse.

We know most patients refuse certain treatments before they even need them out of fear and pride–the “I would rather die than live like that” effect.  (See Rubin EB, Buehler AE, Halpern SD. States Worse Than Death Among Hospitalized Patients With Serious Illnesses. JAMA Intern Med. Published online August 01, 2016.)  When actually confronted with these conditions, patients willingly to adapt to them and go on living.

states-worse-than-death

The next three sections are all scenarios in which the AMA insists that doctors let patients die.

5.3 Withholding or Withdrawing Life-Sustaining Treatment: “When an intervention no longer helps to achieve the patient’s goal for care or desired quality of life, it is ethically appropriate for physicans to withdraw it.”  This opinion does contain hope, however.  I advise patients not to refuse any treatment in an advance directive before they are faced with that choice because even after starting a treatment it always can be stopped if it is not effective.  In other words, don’t make a decision before you actually have to make it.

5.4 Orders Not to Attempt Resuscitation: “Whether a patient declines or accepts medically appropriate resuscitative interventions, physicians should not permit their personal value judgements to obstruct implementation of the patient’s decision.”  Compare this statement to what is found in the next section.

5.5 Medically Ineffective Interventions: “At times patients (or their surrogates) request interventions that the physician judges not to be medically appropriate.”  It goes on to say, “Respecting patient autonomy does not mean that patients should receive specific interventions simply because they (or their surrogates) request them.”

So physicians should not let their “personal value judgements” get in the way of treating someone but must insist on their judgements regarding what is “futile”?  The section states, “The meaning of the term ‘futile’ depends on the values and goals of a particular patient in specific clinical circumstances.”  While patient autonomy is the overruling factor in refusing treatment, it can be ignored when a doctor’s opinion is that something is futile.  And how often will physicians deem a treatment futile not based on the merit of the treatment, but on the arbitrary value they place on someone’s life becasue of a patient’s age or condition?

 

 

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Jerome Lejeune and End-of-Life Care

In 1969, Jerome Lejeune became the 5th recipient of the William Allan Award of the American Society of Human Genetics, the highest honor a scientist can receive in the field of genetics.  He earned this honor for discovering Trisomy 21, the cause of Down Syndrome.

His discovery, rather than leading to a greater insight and acceptance of Down Syndrome, instead led to prenatal detection and subsequent abortion of those with Trisomy 21. This consequence greatly troubled Dr. Lejeune, a devout Catholic.  He had already become very active in pro-life causes by 1969.  Like any martyr urged to denounce Christ in order to spare his or her life, Lejeune was advised to just stick to scientific information in the speech he gave to the ASHG; instead he carefully decided to use it to reflect his deeply-held beliefs.

In his eight-page, hard-hitting lecture he wrote:

Nevertheless we human geneticists have to face everyday reality: disabled children and distressed parents exist…I believe our response must be guided by two sentiments only-humility and  compassion.  Hu­mility because we must recognize we have no ready-made answers, because geneticists have not broken the secret of the human condition, and because scientific arguments are of little help in ethical issues; compassion because even the most disinherited belongs to our kin, because these victims are poorer than the poorest, and because the sorrow of the parents cannot be consoled by science. But should we capitulate in the face of our own ignorance and propose to eliminate those we cannot help?

After his speech he wrote to his wife, “Today, I lost my Nobel Prize in Medicine.”

The medical and scientific communities severely punished Dr. Lejeune for his beliefs. The video demonstrates the hatred he and his family endured from the public for his views, some even calling for his death.  As grants were denied and colleagues shunned him, he no longer could work in genetics.  That was in the 1970’s.

Today, abortion as a result of prenatal screening is commonplace and abortion itself–for any reason and at any stage of development–has claimed the lives of millions.  Just as we are turning the tide in public opinion regarding the moral acceptability abortion, now at only 43%, we are seeing the rise in the acceptability of doctor-assisted suicide, now at 53% according to the a May 2016 Gallup poll.

The same medical establishment that martyred Dr. Lejeune professionally, one which has steadily grown in its acceptance not only of abortion but also of expensive technology to manipulate embryos, now wants to minimize our end-of-life care through physician-assisted suicide and physician orders for life-sustaining treatments (POLST). Society is aging, they claim, and it is too expensive to continue giving “futile” care.

POLST forms require patients to make decisions on the spot that go into effect immediately about treatment options for any future condition they may face (crystal ball not included.) They vary significantly from state to state and cover a wide array of treatments on only one page.  Accompanying instructions for clinicians filling out the form are extensive, and when actually put in practice these forms are commonly misinterpreted in a manner leading to even less care than the form specifies.

Had the medical establishment heeded Dr. Lejeune, we would not have aborted millions of lives; the percentage of the population considered elderly would be much lower and we would have many more people paying into Medicare than depending on it. Now that we have killed so many grandchildren we seek to hasten the deaths of grandparents.

Dr. Lejeune concluded his lecture with the following:

For millennia, medicine has striven to fight for life and health and against disease and death. Any reversal of the order of these terms of reference would entirely change medicine itself. It happens that nature does condemn. Our duty has always been not to inflict the sentence but to try to commute the pain. In any foreseeable genetical trial I do not know enough to judge, but I feel enough to advocate.

Replace genetic trial with decline in health and those words call out still more loudly today.