| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
CURRENT CONTROVERSIES IN CRITICAL CARE |
Dying has become a standard topic of debate in many social, political, and policy contexts. Certainly proper care of patients at the end of life continues to stimulate discussion in critical care settings. In some sections of the public and among certain healthcare providers, the discourse surrounding end-of-life care seems in some ways to presume the goodness of assisted suicide and, in certain prescribed circumstances, euthanasia. In this view, some means of directly hastening death either ought to be allowed and supported by medicine right now or, if not now, then once certain regulatory policies and guidelines are in place. To intervene to hasten death is seen as the most humane approach to care at the end of life when suffering is unavoidable or intractable.
Those in favor of hastening death draw on utilitarian and principle-based analyses in which hastening death is proposed as the best and most right course of action. I want to take a different stand in relation to end-of-life care by arguing against hastening death by medical means. I offer this argument because I am committed to the ideas it espouses. But I also argue in the interest of preventing the entrenchment of hastening death as the most reasonable choice at the end of life. I want to raise questions about the use of logical and analytic approaches to answer questions about dying and about the role of nurses and physicians who attend dying patients, particularly in critical care settings, in order to highlight the uncertainty involved in this work and the unknowable nature of dying and death.
The Application of Logic to the Question: Pascal’s Gamble
There is much to recommend medical intervention in the interest of hastening death in people for whom dying involves a great deal of pain and suffering. Many healthcare providers have aligned with the public outcry demanding assistance with dying that has become a polemic against medical paternalism on the one hand and what is characterized as the callousness of medicine on the other. Within this framework, the common understanding is that healthcare providers who oppose directly hastening death lack respect for autonomy, lack empathy with the dying, and stand between the average citizen and a peaceful death orchestrated by medical means.
But what if something really important happens in the process of dying? If we hasten dying, we circumvent what might be an important process and risk a diminishment of the good attached. This is something it is impossible to know, which makes it difficult to decide the best action. Blaise Pascal, a 17th-century Catholic monk and mathematician, developed a decision-making scheme that can be useful in such circumstances of uncertainty. Pascal’s most well-known application of his theory was his argument in favor of faith in the existence of the god described in the Judeo-Christian tradition. If God does not exist, he reasoned, having faith or no faith is of no consequence. On the other hand, if God does exist, having faith and living accordingly will be greatly rewarding whereas having no faith will be catastrophic. Therefore, based on the risk associated with lack of faith and on the comparatively small burden associated with having faith, it is best to cultivate faith in God and live according to God’s laws.1
Pascal’s risk analysis can be applied to the question of whether or not to hasten death. If there is no good attached and nothing important is associated with the process of dying, hastening the process is of no concern. However, if something important does happen in the process of dying, hastening death deprives us of this experience irretrievably. Given we cannot know what happens during dying, it seems best to leave open the possibility of access to this potentially important experience. Thus, hastening death should be avoided.
The extension of Pascal’s argument to the case of hastening death is complicated by the possibility that the process of dying often is accompanied by pain and suffering. Given this added dimension, if the process of dying is not important and has no good attached to it, opting not to hasten death imposes a meaningless burden on the dying person and on the friends and family who witness the death. If we could be certain the dying process is meaningless, we should in all cases act to hasten death when dying entails suffering. Even if dying is an important experience in some way, hastening the process in order to avoid pain seems like the most reasonable choice.
One danger of any stance in favor of hastening death is in the certainty with which proponents are committed to the idea that the process of dying should be controlled and should not involve suffering. This is a powerful image for many people, including those who fear the unknown and those who strive for control in all circumstances. But even when death is certain as the outcome, what happens to us in the process of dying remains unknowable and unpredictable. This is why a logical framework like Pascal’s is not adequate to address the choices involved in dying. We can never know if hastening death in order to avoid suffering is worth the trade-off of also avoiding the natural dying process, which may have turned out to be greatly important.
So, the problem remains that, even with the logic of Pascal, there is no certainty. There is no certainty that dying is an important experience. But neither is there certainty that dying, or witnessing the dying of a loved one, is not the most profoundly important experience of life, worth all the pain and suffering it might entail. If healthcare providers admit to this uncertainty instead of taking a firm stance for or against hastening death, the question of the best thing to do for the dying person and his or her family and friends once again becomes central.
The Introduction of Humility: Palliative Care
It is at this point of uncertainty where palliative care hopes to create common ground on which those on each side of the hastening death debate can stand together. Palliative care specialists argue against hastening death as a solution to suffering at the end of life. Unlike simply acting to end life as a means of relieving pain, the best palliative care provider takes into account both relief of suffering and the importance of letting the dying process unfold as naturally as possible. This requires a balance be struck in which suffering is relieved in part by medical intervention but without intentionally shortening the dying patient’s life.
It is this restrained intent to relieve suffering without inducing premature death that demonstrates the humility and respect for the dying process embedded in the palliative care approach. Because we cannot know what the process is really about, we should not presume to know that speeding it along will be an improvement. But we also cannot presume that allowing the full force of pain and suffering without any intervention to mediate the experience is in the best interest of the patient and family. The palliative care model thus falls between allowing a completely natural death without medical intervention and the medical control and management of death offered by the assisted suicide and euthanasia models.
Further Debate: The Power of Autonomy
Proponents of hastening death respond that palliative and comfort care interventions will never be adequate in all circumstances.2 To further push the argument, the unpredictability of dying itself introduces a type of suffering that cannot be relieved except by allowing the dying person to take control of the process in situations where death is certain to be the outcome in any case.3
Arguments in favor of hastening death are bolstered by a strong commitment to individual autonomy, whereby each person should have a right to decide his or her means of death when a terminal illness is diagnosed. This argument is further supported by impressing the importance of advance directives whereby individuals, some of whom are healthy, independent, and not yet suffering any physical or cognitive challenges, are encouraged to imagine what dying will be like and to make their desires for end-of-life care known, either in writing or in discussion with the individual chosen as the durable power of attorney for healthcare. Making one’s future desires known is proposed as a means to ensure the individual that he or she will retain autonomy and, were hastening death an option, retain the right to choose the means and timing of dying.
The idea that relatively healthy individuals have the ability to make reasonable medical treatment decisions for an imagined future self, or even that they should have a right to do so, has been drawn into question in interesting and compelling ways.4,5 Although I will not entertain an in-depth discussion of the subject here, the ability to decide in advance the means and timing of one’s own dying in such an imagined future is similarly questionable. This line of argument further draws into question healthcare providers’ tendency to rely on autonomy defined in terms of individual choice as an overriding principle that can be actualized in the advance directive.
Conclusion: Let’s Not Forget We Ever Had Questions
The palliative care approach requires humility, restraint, and attentiveness on the part of healthcare providers, which in turn requires that time and space be open to the process. In a critical care setting, it is difficult to afford this kind of attention to dying when so much effort is directed toward saving and prolonging life. Hastening death, as long as it is what the individual has chosen voluntarily, is likely to be seen as the best action based on utilitarian calculation and on a balancing of the principles of autonomy, beneficence, and justice. My fear is that if hastening death becomes established in the minds of healthcare providers and the public at large as the only sure way to avoid suffering in dying and, thus, as the best approach to end-of-life care, intervening to rush the dying process will come to be seen as the only appropriate choice when death is certain. Reliance on the individual patient’s preference to prevent the entrenchment of hastening death as the overriding form of end-of-life care does not account for the influence of public discourse on the development of personal preference and the way that each individual’s choice is influenced by what becomes the status quo. Nor does it account for the influence on critically ill patients and their families of what choices are offered in the context of end-of-life care and how those choices are presented.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
