The Dying Society

More and more jurisdictions across North America are embracing the latest nihilistic trend in medical decision making - euthanasia.  Multiple states, led by Oregon, have legalized it under specific circumstances and last year the Canadian Supreme Court struck down the federal law prohibiting physician-assisted suicide after deciding that it violated the Canadian Charter of Rights and Freedoms.  

As the situation currently stands, the old law remains in place for another month or so.  The current government has asked the Court for an extension so it can craft a new law before the old one expires.  If the extension is not granted, or even if it is but the government can't pass a satisfactory new law, Canada will be without any law prohibiting physician-assisted suicide, much like it has lacked any law regulating abortion since the old one was struck down by the Supreme Court back in the 1980's.

The results of this development are either enlightening or frightening, depending on which side of the debate you sit.  For those who hold that God gives life and only He can take it away, this is a tragedy and another step towards civilized barbarism as Western society sinks into cultural decay.  For those who see nothing sacred in life this is a great step forward.  For decades we've been able to kill unborn babies without consequences (at least none that we're allowed to talk about).  Now we can proudly add the terminally ill to the list.

But will the list end there?  Already in Europe, the pioneering area in euthanasia, physician-assisted suicide has expanded to include children with disabilities, people with prolonged but not necessarily terminal illnesses and even the very depressed in some places.  In the absence of a law in Canada, will the initial "Only for the terminally ill and those with intractable pain" quickly expand to other indications?

Consider how the definition of death changed in Western society in the late 20th century and you'll see a reason to shudder.  The former definition was a strict one, quite close to one of the mainstream positions in Jewish law in requiring cessation of cardiorespiratory function.  Faced with a need for organ transplants and a lack of organs due to this definition, ethicists in the 1970's and 80's changed it to one requiring brain death only, not brain stem death or cessation of cardiac function.  This had the beneficial effect of allowing doctors to pronounce people dead even thought they would have previously been considered to be alive and thus increased the availability of organs for transplant.  

Currently Western society considers it a sign of mental illness to desire suicide.  We hospitalize people against their will when they try (and fail, of course).  Well, what happens when we change the definition?  Let me present the following one for your perusal: Suicide is wrong when attempted by a person with no physical or mental illness that might reasonably encourage him to want to kill himself.

Imagine that definition going into play.  It sounds nice in that it creates a category of people for whom suicide would be considered wrong but the minute someone tries to kill themselves it becomes evident that they have a mental illness that encourages them to want to kill themselves.  

Part of this drive takes place in the shadow of Western society's growing aversion to any kind of suffering.  We want to live without pain, without illness, without disability and see any of those three things as intolerable affronts to our pursuit of personal fulfillment.  A life not free of these things is not a life worth living, according to this popular way of thinking.

In typical decadent Western fashion, it won't be the patients ending their lives themselves.  No, they'll get their physicians to do it for them.  They don't want to suffer and they don't want to lift the syringe either.  They want to sit back and passively exit life without even taking the final responsibility for the moment it happens.  

And where are the red lines?  If people will end-stage cancer and ALS can request that their doctors kill them, why can't people with dementia, severe depression or just good old fashioned loneliness?  Any red lines would be arbitrary and ultimately moved to accommodate societal desires.

As an Orthodox physician I tremble at the thought of this coming to pass.  Engaged as we are in a low level culture war between religious and secular liberal forces, this will play out for me on a personal level.  Halacha is very clear on this issue: I am forbidden to participate in any way in physician-assisted suicide (even of socialists and communists, nebich).  That means that I cannot even refer a patient to  physician willing to kill them if I won't do it myself.  On the other hand, the political correct regulatory authority that issues my licence to practice medicine has, over vociferous protests and objections, announced that it expected physicians either to kill their patients on request or to make arranged to find a doctor who will.  Refusal to help kill patients would result in disciplinary action and possible loss of right to practice medicine.  What's a God fearing Jew to do?

Well the answer to that is evident, isn't it.  But it's the bigger picture here that should scare us all: a society that has no interest in living with adversity will eventually lose its will to live at all.

Let's Kill The Sick!

Dr. Donald Low, a Toronto physician who was a main player in the fight against SARS a decade ago recently passed away.  He was a real hero whose level-headed leadership during the crisis was decisive in local public health's containment of and successful struggle again the virus.  Beyond that he was am indefatigable teacher, prolific researcher and clinical, an inspiration to a generation of students.
Unfortunately life was not kind to him after that.  He suffered from cancer and after a courageous battle with his brain tumour he recently succumbed at the young age of 68.
But in his final days he also had a dark side.  Like too many unfortunate people who must struggle with painful illnesses at the end of their days it seems he seems to have decided that he should have had the right to end his life when the prognosis became hopeless and the suffering intolerable.  To that end an interview from the final days of his life shows him expressing the view that assisted suicide should become a legal option for people in Canada. In the interview he noted that he was frustrated that the system couldn't accommodate him like it would have had he lived elsewhere like certain European countries.  He lamented that the debate in Canada was so difficult to have on a "mature" level and opined that people who opposed him should have to live 24 hours in his body to see what real suffering is like.  And naturally the liberal crowd which supports his position chimed in to support him.
Without meaning any disrespect to the dead, could Dr. Low have been any more condescending?
Consider how he set up the discussion.  He implied that if you opposed him you didn't understand him.  He came out and stated that mature discussion was difficult which means if you oppose him you're not capable of having that mature discussion.  He felt that the last days of his life should have been enjoyable, something that all people wish for but so few get to have.
It is really not surprising that a significant number of folks in the Western world and especially in Canada are in favour of assisted suicide.  We live in a culture where unborn foetuses live under constant threat of being aborted for such deep reasons as "Oops, I forgot to take my pill like I was supposed to".  If the lives of the unborn are worthless and unprotected it is not a huge step to extend that kind of the thinking to the old and palliative.  It seems it's all about convenience.  We are used to unwanted babies.  Now we have unwanted sick people, so unwanted that they are undesired even by themselves!
I do not wish to minimize or dismiss the suffering Dr. Low and others suffering like him went and are going through.  As a physician I well know how much pain, nausea, confusion, sweating, shortness of breath and other disturbing symptoms the dying patient can go through.  I have seen people degenerate into unmanageable Alzheimer's states causing a horrible burden on themselves and their caregivers.  I have watched people linger away from chronic heart failure and lung disease.  People too often outlive their minds or bodies.  These are fates I would only wish on my worst enemy and I certainly want not even a taste of them in my life, chas v'shalom.
Finally one must keep in mind that a position endorsing assisted suicide is a sure sign of a godless secular society where life is no more valuable that those shoes you bought last week.  Great to have around while comfy, easy to throw away when worn out.
And don't think that I'm exaggerating.  Only a few years ago The National Post carried the story of an elderly woman who was lobbying for assisted suicide for herself.  She was in perfect health but was recently widowed and in her grieving state couldn't stand the idea of going on without her husband.  It seemed perfectly reasonable for her to demand the right to commit suicide rather than go on alone.  For those who think that assisted suicide would be restricted to the very ill or elderly I would ask: how would you justify to this woman that she doesn't qualify?  How about someone who has just been diagnosed with an incurable illness?  If he says that he'd rather end things now way before he begins to feel any serious decline, will he be told he first has to suffer a little before being allowed to kill himself legally?
And that's why I have to state my opposition to Dr. Low.  For one thing, there is the bias he presents by being a member of the group he supports.  Yes, I cannot truly appreciate the suffering he endured but his enduring that suffering is exactly why he should not have been opining about the role of assisted suicide in Canada.  The decision should not be up to people who have already made the decision because fate has dealt them a lousy hand and they see killing themselves as the only acceptable option.  What's more, the decision should be in the hands of people who see some value in life.  Not lip service "Well of course life is important" folks but those, religious or secular, who truly see life as something more than just another commodity we're stuck with, who see being alive as bigger than them.
I'm sorry if Dr. Low thought that disagreeing with him means I'm immature.  I'd rather be immature and value life than be mature and live a meaningless existence with the thought of ending it the minute I couldn't have my self-perceived entitlement of a suffering-free life anymore.

In The Culture Of Death

The most precious thing any of us have is our lives.  Just being alive and sentient is an amazing gift from the Creator of the Universe.  It also seems to be the one gift from Him that we take most for granted and often resent that we don't have ultimate control over it.  After all, we don't choose when we are to be born or die. The processes of conception and death occur independently of us and sometimes despite our best efforts and wishes.
Is it any wonder, then, that as society moves away from an awareness of God and sanctity towards a hedonistic, self-centered form of civilization in which personal pleasure is the highest personal goal, that we start to introduce voluntary death into our daily lives.
Abortion, for example, is already commonplace in society, so much so that we don't even think of it in terms of snuffing out a life but rather as a medical procedure done much of the time for convenience.  A human being, DNA and all, is destroyed and we argue instead over "right to choose".
It should therefore not be a shock to anyone that once we've established that a foetus can be killed with impunity that society would then turn its sights on someone else.  As a result we now have the efforts of some to declare that a person with a terminal, painful illness now has a right to demand someone help him die so as to end his suffering.
Recently the province of Quebec moved towards making euthanasia legal there when an "expert" panel recommended allowing mercy killing in certain limited cases.  Of course, they don't call it mercy killing but rather death with dignity, just like we don't call abortion foetus killing.  That doesn't change what it really is though.
Quebec is an interesting place in any case.  Originally a very religious population tightly controlled by the Catholic church, the mainstream went secular decades ago and has defined itself by being anti-religious.  If God says "X" then you can be sure Quebec opinion will be "We hate 'X'".  As a result the province has one of the highest abortion rates in Canada.  Interestingly enough it also tops the list for suicides.  No surprise then that mercy killing is something the population wants.
Now I do not want to gloss over the suffering some with terminal illnesses endure.  I've met patients with Lou  Gehrig's disease who are prisoners in their own bodies.  I've attended to patients racked with the pain of cancer eating into their bones and organs.  I know that there are some horrible diseases out there that don't take life quickly but slowly and painfully over months to years.  I do not claim that this suffering is tolerable or at all desirable.  Even with the best medical care people can still undergo significant difficulties on their final journey.
Years ago as a resident I took part in a discussion on mercy killing and was asked what the Jewish position was.  I pointed out that in Jewish tradition every instant of life has immeasurable value.  In addition life is a gift from God and only He is in a position to take it.  As a result any measures that specifically aim to shorten the lifespan of a person, no matter how much they are in pain, is forbidden and those measures would be considered murder.
Indeed the Talmud and Shulchan Aruch deal with the idea of terminal suffering and how to alleviate or shorten it without violating that rule.  This is a complex subject, not one that can be discussed standing on one foot.
Naturally my statement was met with a rolling of the eyes.  In the view of the secular culture where moral relativism is king anyone saying that they have a non-negotiable red line in their beliefs is automatically an unreasonable fanatic.  But really, without the red line what do we have?
For example, most physicians facing a patient with end-stage cancer who is going to die shortly anyway and is screaming with unbearable pain would not have much of a problem administering just a little too much morphine which would lead to respiratory arrest and death.  But what about a scenario in which the patient's pain is currently controlled but expected to spiral in the next day or two?  The patient knows he will be in agony and doesn't want to suffer.  He wants that injection of morphine now because it's too late.  Is that still okay?  If not, why not?  If the whole point is to minimize suffering then why does the guy rolling on the bed get the shot but not the guy who's going to be?
Heck, why is physical and not psychological pain the main criteria?  A person might, chalilah, receive a diagnosis of inoperable cancer and simply not want to deal with it.  The idea of waking up every day and knowing there is a dark force slowly eating away at his insides is intolerable to him.  Why can't he have the shot to relieve that burden?
To take it to the extreme a few years ago the local paper told the story of an elderly widow who wanted to have an assisted suicide.  She was in great health but was very lonely following the death of her husband and wanted to be with him.  She felt she was quite the candidate based on that.  Even the most dedicated proponents of mercy killing weren't in favour of this but if a competent woman like her reached such a decision why should she be denied the opportunity?
We live in a society in which "dirt" is not allowed.  We don't want to suffer.  We don't want to feel pain.  We don't want to wait more than 5 minutes for that burger we ordered.  We want what we want and we want it now.  The idea of being in pain is justifiably frightening but it is also part of life.  To treat one's existence like one's cell phone, as something that's fine for now but to be disposed of when no longer convenient, speaks to a shocking devaluation of the great gift.
Imagine a society in which mercy killings are as commonplace as foetus killings, where lobby groups fight to prevent anti-euthanasia groups from protesting, where the idea of even questioning the morality of mercy killing leads to screams of outrage.  Once upon a time abortion was a procedure undertaken with great care and caution.  Now it's a form of birth control.  Today we are told that mercy killing would only happen under exceptional circumstances.  Does anyone really believe that as time goes by it won't become easier and easier to get?

The Living Dead

The problem with death is that it's so hard to define nowadays.
Once upon a time this wasn't so.  You dropped, you died.  Done.  With the advent of invasive monitoring and CPR however the definition of death has become much more variable, leading predictably to lots of problem including in halacha.
The problem with using the Talmud to determine the exact definition of death is that the cases discussed by the Sages all occured in the absence of an ability to monitor or accurate assess the internal workings of the bodies being examined.  The Sages had no way of measuring blood pressure, never mind brain waves or the electrical activity of the heart.  Thus the classic case that is always reference, from Yoma, discusses the cessation of respiration as the criteria for death.  How the Sages would have paskened today with the more advanced understanding of anatomy and physiology is what leads to the divergent opinions between the poskim.  Some still see cessation of respiration as the gold standard and now that we understand that respiration is controlled by the brain stem this means that brainstem death is the criteria for true death.  Others hold that the Sages were looking at circulation and therefore cardiac activity is the gold standard.  And of course, this being a halahic dispute there is much rancor and bitternes on both sides.  After all, if the respiration definition of death is correct then the circulation folks are indirectly killing patients who require transplants and if the cardiac definition is correct then the people relying on brainsteam death are murdering patients for their organs.
What is not helpful is when terms get mixed up.  It is important to remember that "brain death" and "brain steam death" are very separate things.  According to both the respiratory and circulatory positions, destruction of the cerebral cortex with a residual functioning brain stem is not a true death.  This is important to remember when the subject comes up and often gets blurred with the term "brain death" acting as an inappropriate catch all.  This is also important because in the secular world there are those for whom properly defined "brain death" is a form of death leading to a person becoming an organ donor.
Thus Rav Natan Slifkin's critique of a recent Wall Street Journal article both emphasizes but also aggravates the discussion.
In my opinion the comparison with the lizard tail is what is irrelevant.  A severed tail is only part of an organism, non-essential to the life of the creature.  The brain is not like that at all and whether it is considered physiologically severed is of crucial importance.  I'm surprised that Rav Slifkin did not bring the mishnah in Oholos which specifically discussed decaptitation as a form of death despite signs of life from the body.  That is what Rav Moshe Feinstein, zt"l,  used as his definition in a later teshuvah and would have fit more in the discussion of brain and brain stem death.

The article writes about how brain-dead people have "more in common biologically with a living person than with a person whose heart has stopped. Your vital organs will function, you'll maintain your body temperature, and your wounds will continue to heal. You can still get bedsores, have heart attacks and get fever from infections." It talks about how they "react to the scalpel like inadequately anesthetized live patients, exhibiting high blood pressure and sometimes soaring heart rates."

This is all entirely true. It is also entirely irrelevant.
Physiological processes do not always denote life, and reactions are not the same as feelings. The detached tail of a gecko can move around with complicated motion and respond to an external stimulus, but clearly the gecko does not feel anything. Even a properly anesthetized patient can respond to the surgeon's scalpel and have their blood pressure go up, but that does not mean that they are feeling anything.

Another point to recognize is that the whole pain argument is out of place.  Pain is a conscious reaction to a physical insult like a scalpel cutting into the body.  In the absence of pain a person can still have an automatic response to such an insult resulting in measurable physiological responses but that doesn't mean he feels the pain, especially if his higher cerebral centres have been destroyed.  Yes his heart rate will go up but there is no consciousness that feels the pain.
The Wall Street Journal article therefore does not prove its point but both it and the rejoinder seem to miss a bit by not clearly describing the difference between brain death and brain steam death.

A Word on Influenza

Although it's a departure from the main theme of the blog, I would like to inform folks of what to worry about and what NOT to worry about regarding the current outbreak of H1N1 influence virus.

1) You can call it swine flu. However, it is traditional to name influenza outbreaks after the country of origin, hence the Spanish flu of 1918. As a result, the WHO is currently working to rename the outbreak as Mexican flu. This is not due to any chareidi attempts to control the WHO. They already control the banks.
2) Mexican/swine flu is simply a genetic variant of the common influenza virus. Because of this genetic variance, human immune systems have no initial defence against it, nor will the influenza vaccines injected last autumn/winter offer any protection. However, unlike the 1918 and 1968 outbreaks, this virus lacks the super-virulence genes that cause millions of deaths. It is unlikely (at this point) that we will see any further deaths except in people who are already quite ill and can't handle the strain of the infection.
3) The best way to prevent transmission of the virus is to practice meticulous handwashing, avoiding coughing in someone's face, and don't share drinks and food. In other words, the same as preventing the transmission of the common cold.
4) If someone has been to Mexico, they are not automatically plague infested. If they have been back a week and don't have any symptoms, they do not have the virus. Simple as that. Therefore, if your friend or neighbour just got back from Guadalajara and shook your hand on Shabbos, don't panic and run to your doctor for Tamiflu. It wastes your time and annoys the doctor.
5) Don't call your doctor and ask him for a prescription for Tamiflu "just in case". You won't get the 'script and the doctor will think you're a paranoid nut. If you have symptoms of the flu, then go see the doctor and he will decide if you need the medication.
6) Finally, in the unexpected event of the virus undergoing a genetic shift and becoming dangerously virulent, then I will delete this post, deny its existence, and run for the hills.

Things I'd Like To Say

Working in a small country ER can be fun and challenging.
It can be fun since, without the extra staff around any given crisis requires one to do thngs which would be referred to specialists in a bigger centre. Casting, stitching, clot-busting, we do it all out here.
It can be challenging because some patients, despite our best efforts, seem incapable of following instructions or answering the simplest questions in a straight-forward manner.
So, in order to relieve some of my stress, here are some lines I'd like to use but can't:
1) What made you think this was an emergency?
2) You've had this for two years, haven't called your family doctor and it's now 2 am on a Saturday night. Why aren't you asleep in bed like you should be?
3) So you've tried absolutely nothing and it hasn't worked?
4) "A while" is not an answer to "how long have you had this".
5) It's a "yes or no" question. Do you have chest pain.
6) No, I don't care about what you told your friend yesterday. I asked you if you have shortness of breath.
7) So you drank 12 beers and then jumped into a firepit. And you now want me to be empathetic?
8) You should wear loafers. Tying your shoes is clearly a challenge.
9) If you don't know why you're here today, how do expect me to know?

A Push for Experience

There's something to be said about society's lack of respect for age, experience and knowledge. One feature of modern secular liberalism has been an emphasis on equality to the exclusion of all else. To the popular mind, the opinion of an uneducated illiterate is equal to that of someone with a PhD in astrophysics. Because, according to this creed, all people are automatically of the same worth, their opinions are too.

I see this in my profession on a regular basis. Back in the late 1980's and early 1990's, a new form of learning and practising medicine came into vogue. Called Evidence-Based Medicine, it demanded that decisions by doctors no longer be made through experience, trial and error, or gut instinct, but through the use of the medical literature and its findings. Systems were designed to analyze medical trials and determine their worthiness of being used to analyze patient problems. Medical research began to change their standards to produce more trials that would meet the new rigorous standards.

So far, this all sounds fine. Who could object to a doctor finding importance in knowing the very latest in medical knowledge and using it to help his patients? The problem with this system, as with all systems, is that the fanatics pushing it went too far with their agendas. When I was interviewing at one school, for example, I was given a paper to read which stated that "with evidence-based medicine, a first year intern is just as competent a clinician as a consultant who has been practising for 30 years because both have equal access to the literature and use the same skills to analyze it."

Right. Thirty years of experience, of trying therapies out, of interviewing patients and developing a feel for the art of medicine, all meant nothing. The only thing a doctor really needed to do was consult Medline, the all-knowing database of medical literature. Left unanswered were some very basic questions.

Why do we need doctors then? Nurses can check Medline just as effectively to give answers to patients. What happens if their no evidence? Do we just wave our hands helplessly and refuse to treat our sick patients? How exactly does one interpret the evidence? If the trial included males 46-58 years old, do I tell my 45 year old patient that I can't use its conclusions to assist him?

In the end, medicine is both an art and a science. Science can be learned, facts can be memorized. But art? You don't teach art from a textbook. You teach it through example, through encounters, and through the passing of experience from seasoned clinicians to new recruits. There are some things for which there will never be evidence, patient problems that will only be solved by consulting one's instincts. It must be remembered that there is inestimable value to that.