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When is withdrawing care appropriate?

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Interesting editorial in the Canadian Medical Association Journal, read it here. One passage brought back memories of my ethics placement at the Montreal’s Children’s Hospital:

The case of Samuel Golubchuk, an elderly and very ill man at the threshold of multiple organ failure in a Winnipeg intensive care unit, illustrates this problem. The doctors wanted to withdraw care, and they met with the family on several occasions to seek consent; however, a religious impasse was reached, and Mr. Golubchuk’s son and daughter would not give consent.

 The doctors wanted to withdraw care. One day during morning rounds, we were discussing withdrawal of treatment for a dying infant. A resident used these very words “withdraw care” and was immediately corrected by the attending neonatologist who said: “We never withdraw care…” and a chorus of students completed her sentence: “we withdraw treatment!”

Without referring to the particulars of the Golubchuk case, I wonder to what extent “religious impasses” are not reached when families are given the impression that “care” is withdrawn along with treatment. After all, no religion contends that physical life should never end. But most religions – at least those I know – advocate death with dignity. By this, I do not mean the so-called dignity brandished by euthanasia and assisted suicide supporters. I mean respecting the intrinsic dignity of every human being, regardless of their physical and mental condition. Faced with the imminent death of a loved one, families shouldn’t be made to feel like they are a burden to the system or that health care professionals are giving up on them. If health care professionals can’t or won’t respect the dignity of their dying patients, they are only inviting resistance from those who do. The Golubchuk case is not an invitation to draft more stringent end-of-life clinical guidelines – as was so sensitively done by the Manitoba College of physicians and surgeons, read my previous post on the topic here – but rather an invitation to review how we can effectively extend care where treatment is no longer appropriate.

Health care workers and the right to choose

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Sakatchewan-Wanuskewin MP Maurice Vellacott has reintroduced a bill that would protect the conscience rights of healthcare workers. Read about it here.

I like the fact that he framed his bill in freedom of choice although I strongly feel that the irony will be lost on self-proclaimed “choice” advocates – as the weeping and gnashing of teeth over bill C-484 reminds us daily. If choice is, as we are told by Ujjal Dosanjh, “paramount,” it depends for whom and in what circumstances. As with everything abortion, the supremacy of choice is so relative it becomes absolute.

Re-introducing his bill in the Commons, Vellacott declared:

Mr. Speaker, the bill would prohibit coercion in medical procedures that offend a person’s religion or belief that human life is inviolable. The bill seeks to ensure that health care providers will never be forced to participate against their will in procedures such as abortions or acts of euthanasia.

This is a good thing. I have argued before that the right to have a conscience was but an empty shell without the right to act on it. And unlike what abortion advocates would have you believe, the abortion debate is everything but settled. In the absence of consensus on the morality and health benefits of abortion, it stands to reason that individual health care professionals should be the arbitrators of what they are about to perform.

I have not yet read Vellacott’s proposed bill but here are some hurdles I expect it to face. To begin, Vellacott’s bill will face the same accusations of back-doorism as bill C-484. But where Vellacott’s proposed bill notoriously parts from C-484 is that it might de facto prevent some women from getting abortions. Maybe not in large urban centers; but faced with a conscientious objector in a rural area, women might not have another choice but to pursue the pregnancy. Don’t shoot me for pointing The Other Side to their choice argument; they are well aware of it already.

So what does it all mean for any law that would protect conscience rights at the risk of limiting access? It will be the object of a Charter challenge pitting women’s rights and freedoms against those of health care practitioners. “But”, you tell me, “abortion is not a right in Canada.” Nope, but you can bet the farm that a bill such as Vellacott’s will push abortion advocates into the debate they don’t want to have. The only way to tear down Vellacott’s kind of bill will be to argue that it limits women’s rights and freedoms in a way that is neither reasonable nor justifiable in a free and democratic society.

Hopefully, we will be ready for that challenge when it knocks at our door. Because if abortion is enshrined as a constitutional right, there is no telling where that train will take us.

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Rebecca asks: Maybe someone can clear this up for me. It should be pretty straightforward for most doctors to avoid ever performing an abortion once they’re finished their schooling. I’ve heard that it can be a lot harder to get through medical school without carrying one out, and some people have argued to me that since a D&C (the procedure by which most abortions in Canada are carried out) is often necessary for things other than aborting a pregnancy (primarily removing tissue after a miscarriage) it’s legitimate for medical schools to require that graduates know how to do a D&C.

I’ve always wondered, though – precisely since many D&Cs are done for reasons other than abortion, why couldn’t pro-life medical students train by doing those (non-elective, non-aborting) procedures? There is a big difference between the ability to perform a procedure (which is identical whether it’s removing a viable living fetus from the uterus or removing dead tissue) and the circumstances under which it’s done. In practice, how hard is it to be pro-life in medical schools these days?

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Véronique says: Your reasoning is right in theory. My experience talking with pro-life med students is that this is more about power than about D&Cs.

I should maybe share the experience of a brilliant young man I met some years ago. He was invited for a med school interview following the selection of a written essay. The essay topic was “An Event that Changed Your Life.” Innocent, he wrote about attending World Youth Day in Toronto. During his interview he was grilled on his position on abortion. The interviewers asked about nothing else. When he was turned down for med school, his interview report said that the committee believed that his religious convictions would prevent him from offering optimal medical care to women. He appealed this decision to the University’s human rights board for religious discrimination and the University upheld the committee’s decision. He applied to another University, kept quiet about his religion and was admitted.

But I think you ask a great question: how hard is it to be pro-life in medical schools these days? I would love to hear our readers’ input.

Ladies, do you know what your bodies can do?

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I have the great privilege of living a life of leisure these days, recuperating from a minor surgery on a generous dose of Tylenol 3. As if looking and talking like a boxer who had one fight too many wasn’t annoying enough, we’ve added uselessness to nuisance by moving the TV in my bedroom where I can indulge in endless re-runs of A Baby Story on TLC . I have a love-hate relationship with A Baby Story. It portrays a very one-dimensional image of labour and delivery: Woman goes into labour, woman gets epidural, woman naps while man paces around the room, woman gets pitocin, woman turns beet red as she pushes with her face instead of her lower body (which she can no longer feel), MD thinks “baby never gonna get out” and orders life-saving c-section. The End.

Today however, I found myself watching an unusual episode of natural labour on TLC. And by “natural” I don’t mean the kind where the mother isn’t wearing any make-up. I mean the drug-free, noisy, sweaty but oh-how-elating kind of labour. I don’t know if it was the codeine or the sleep deprivation but I found myself huffing and puffing and cheering the mother on. When the baby was finally born, I started to cry. It was so intense and powerful; I could not believe I had also done it. Me? That strong? Five times??? No way!

What would happen if we started seeing childbearing and childbirth as empowering rather than debilitating? If a woman’s ability to bear and deliver children was seen as a capital instead of a liability? If childbirth was seen as an integral part of women’s dignity rather than an obstacle to the realization of their full potential?

I wonder.

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Tanya adds: You know, I have to agree that the most powerful moment of my life was the hour’s worth of pushes it took to deliver my daughter. Despite the epidural (I opted to look up to women who delivered naturally rather than be one of them), a woman often becomes acutely aware of her reproductive power at the climax of the labour process. Women really are amazing, as cliché as that may sound.

China: Are we there yet?

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In recent news, not so much abortion but morality, particularly the kind or morality — or lack thereof — found in today’s movies. The artistic community has its nose out of joint in light of a new bill that would give the federal Heritage Department the power to deny funding for films or tv shows it considers offensive. At least, that’s what the CBC tells us. Driving with the radio on, I was treated to much weeping and gnashing of teeth from concerned artists promising a descent into China-styled censorship and the end of audacious, creative movies — by which they must mean movies that cannot get a message across without repeated appeals to sexually graphic images, gratuitous violence and other delicious morsels of entertainment.

When they say “deny funding” what they mean is deny a tax credit. A tax credit worth 11% of salaries paid to Canadian employees in the making of the movie. What this means, really, is that offensive movies will still be created, produced and distributed in Canada, only that offensive movie-makers will have to do it on their own dime. Which they already did, strictly speaking, since a credit reimburses money already spent on salaries.

China is not around the corner. Not because of this bill, in any case. 

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Rebecca adds: … but why expect Canada’s chattering classes to grasp this rather unsubtle difference? After all, the suggestion that we not use taxpayer dollars to fund elective abortions inevitably results in protests that evil conservatives want to create a world of back alley abortions, in which doctors and women in desperate straits are thrown in jail. Just as the body politic increasingly wants everything undesirable to be criminalized, so it wants everything legally permitted to be federally funded.

Autism linked to premature birth

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Read the news release here. Then revisit our post on previous abortions and the risk of preterm birth.

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Rebecca adds: Tsk tsk, Véronique. Don’t you know that sharing scientifically established facts is just another way of imposing patriarchal values on women, to scare them out of exercising their right to choose?

Seriously – it bears repeating that if any other necessary surgery, let alone an elective procedure like an abortion, were done exclusively on women, and more often on minority women, without studying its long term consequences, or without sharing the facts about those consequences that are known, feminists and all sane people would be up in arms. Consider the work that’s been done on unnecessary hysterectomies, for instance, or on the virtues of radical mastectomy compared to lumpectomy for cancer. A great deal of thought has gone into considering these procedures not only in terms of their short term medical consequences but also their longer term effect on women’s physical and mental health, and sexual health. None of this discussion has yet taken place about abortion.

 

Index that

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This article from last Saturday’s National Post must be one of the most shallow analyses of parenthood and reproduction I’ve ever read. And I’ve read a lot. One notable excerpt made me laugh out loud:

Why are people choosing to have fewer children? After all, voluntary childlessness seems to violate the Darwinian premise that our genes predispose us, like all other creatures, to try to reproduce.

I don’t think we can be faulted for failing to try to reproduce. As the mother of inquisitive children, I can tell you that copulation is everywhere. Our problem is not the trying. The actual reproduction that results from all the trying, well, uh, that’s another story.

That being said, this article made me take stock of my own happiness index. Being five times a mother, I figured I should know. Maybe this made me reflect because I was particularly grouchy that day. Because reward, when it comes to parenting, is something we feel more than something we know. It is both inanely obvious and impossible to describe. It chews us up and spits us out and makes us grateful for the ride. It is like nothing else, which probably explains why conventional happiness indexes miss it all together.

The contentment that comes from being a parent is not physical – although those newborns sure smell good – nor is it emotional. In fact, the emotions it triggers can be downright negative: may the person who has never felt exasperation after repeating the same simple instruction a gazillion time – don’t jump on the couch, leave your brother alone, when the baby cries it means he doesn’t like it, the cat is not supposed to make that noise – cast the first stone, but it sure won’t be me! The contentment that comes from being a parent is a contentment of the heart, a sense that we are partakers in something much bigger than ourselves, a feeling that we are given a mission we can’t refuse. It also pushes us to limits we didn’t know we had. Limits of patience, yes. But also limits of self-sacrifice, love and tolerance. When my first child was born, I thought I could never love anyone else that much. Until the second one came along. And the third. By the fourth, I had learned one of life’s most valuable lessons: each additional child doesn’t take away from the mother love-pie, it’s the pie that gets bigger.

And this is my unscientific observation: Parenthood makes me happy because I love. And the more I parent, the more I love. But the more I love, the more I suffer because loving children is not the same as loving ice cream. When they cry, I cry. When they fear, I fear. When they stumble and fall, I stumble and fall and then have nightmares about it. And as they grow and become more independent, I am torn between beaming with pride and collapsing in a heap because each step they take away from me is a step that separates me from a piece of my own heart. The heightened sensitivity that comes from being a parent has made me more aware of forms of happiness I would have otherwise ignored. And while each additional child makes me cry, fear and stumble more, children also make me more sensitive, loving and patient. Happier.

Happy-index that!

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Tanya is picturing Véronique breaking into song:

 

[youtube:http://www.youtube.com/watch?v=o6P2w5GkXmU]

 

Lowering the bar

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Brigitte posted recently on U.K.’s bid to lower the gestational age limit on abortion from 24 to 20 weeks in light of improved outcomes for extremely premature infants. An accompanying piece to the Telegraph’s article featured a toddler born at 23 weeks gestation and his mother commenting on the proposed revised guidelines.

Now, I want to be very careful in critiquing an effort that would no doubt reduce the number of abortions performed. That being said, my area of specialty in bioethics is neonatal ethics. I’ve seen enough infants born at 23 weeks gestation to last me a lifetime and while I support making every reasonable effort to support them medically while they grow enough lung and brain tissue to make it in the big wide world, I’m not sure I understand why abortion should be prevented with more gusto when it targets a viable fetus. My objection is philosophical: abortion cannot be half-right or half-wrong. Either the fetus is human or it’s not. You have to take the life of a viable fetus just as much as a non-viable one. That being said, I can grasp – if I don’t completely buy it – the moral basis of this partial ban on abortion. Infants who are completely dependant on their mothers for survival can be dispatched by the mother. When they become independently viable they should no longer be considered the property of their mother.

But let’s not fool ourselves here, “viability” when applied to a 23-weeker is a loaded term. Infants that young are not viable without the help of a truck-load of expensive equipment, 1-on-1 nursing care and a team of highly trained pediatricians. In many cases, this is not enough to save very premature infants and in another many cases, life-saving treatments can themselves cause severe impairments.

I think that what makes me so uneasy with this initiative, despite its positive aspects, is its potential to “de-dramatize” the abortion of non-viable fetuses, particularly in the eyes of the silent majority who oppose abortion but abhor judging those who get one even more. It seems that by lowering the gestational limit on abortion, we have found a way to make abortion both right and wrong. By making the buck stop at an arbitrarily set date, we numb ourselves to the reality of abortion with the balm of feeling like we actually did something about it.

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Brigitte feels like quibbling: Point nicely made and taken about the danger of de-dramatizing early abortion. Though in this country it could hardly be less dramatized… The thing about arbitrary limits is that there is a point after which the state will not tolerate so-called lifestyle abortions because these are considered worse by public opinion than those performed at, say, 8 weeks, when the embryo looks like something out of a sci-fi movie. Likewise, why is it that sentences are more severe for someone convicted of first-degree murder than they are for any other form of homicide? Because the law, reflecting public opinion, considers first-degree murder worse. It’s far from perfect, as a system. But it has the virtue of being legitimate.

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Andrea adds: I started this group because public opinion must and indeed can change. There is nothing better or worse about an abortion at 23 weeks than at eight weeks–that small person only now looks more like he or she will when born. The law is not effective here and surely the law in the UK is worse than no law at all. Sure, it reflects public opinion and therefore the gruesome dismembering limb from limb of babies at 23 weeks is more repugnant to many than an early term abortion. But not to me, it isn’t.

When I was little, I loved going on frog and toad hunts. There was something amazing to me about these tiny creatures in the woods. There still is. I would (most unfortunately) go to any length to catch one, so I could look at it in my hand. (This changed at least a little when I fell into a stinky swamp.)

If we cared about people in the same manner as we do about small toads in the environment… if we held the developing embryo in awe, as I do these tiny toads–we would all oppose abortion fully at any time after those cells began rapidly multiplying, knowing that all genetic material is in place from conception onwards for a whole new person to live and thrive.

I believe we can make people care about embryos and should strive for nothing less.

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Rebecca adds: I’m not sure I agree that the law in the UK is worse than no law at all. While I don’t see the law as the best way to stop abortion, laws (especially those with popular support) express the collective opinion of the people. I would rather Canadians express the opinion that abortions after 24 weeks, or 20 weeks, are unacceptable, than our current iteration, which is that anything goes if you can find a doctor willing to do it.

I also find it surprising how few Canadians are aware of how extreme our legal position on abortion is – the thoroughly secularized western European states are all much less permissive than we are. Then again, given that there are literally no restrictions on abortion in Canada, that’s not saying much.

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Andrea clarifies: I worry about that portion of the population that looks to the law as a teacher. And then says: If abortion is legal before XX weeks, it is right. But agreed on your point: I too would rather live in a world where we can all agree that late term abortion is wrong. That sentiment already exists in Canada; we see it expressed in polls. I want to cause people to reconsider their views on how/when life begins: A little respect and sympathy for the poor embattled embryo. 

Basement-inspired thoughts

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I had heard about Earth Hour but didn’t quite remember when it was. On Sunday morning, the power went out in my neighborhood for about three hours: I thought Hydro was enforcing Earth Hour by shutting off the grid. In the end, my husband drove our 12-seater van to the nearest McDonald’s for coffee and breakfast. How ironic. We burned fossil fuel to buy non-fair trade coffee at McDonald’s of all places, but didn’t turn on a single light bulb. We felt quite righteous.

In any case, I have been reflecting on whether or not we should all live like Ethiopians and the difficult issue of taking the so-called moral high ground in matters of environment when our excesses ruined it for developing nations. I just feel squirmy when I hear gainfully employed urban-dwellers complain about everything that made their enviable situation possible. But I digress.

My husband and I are in the process of having our basement finished. It wouldn’t be worth a blog entry but for the combined occurrence of Earth Hour and the spilling of our basement’s content into our family room. All I will say about that is “Man, that’s a lot of Stuff!” Still, we manage, through regular purges and careful spending, to keep our Stuff within the square-footage of our suburban family home. Meanwhile, in a nearby business park, a monstrous self-storage facility is emerging. With drive-through capabilities. I can’t help but shake my head in disbelief when I think of the Earth Hour gushing I heard today – “… saved enough power to take Ottawa and Guelph off the grid!” – while our ever growing urban-sprawl boxes are no longer big enough to contain all the Stuff required by the Good Life. We now need to build storage facilities on what used to be prime agricultural land, drive our Stuff there and pay good money so our Stuff will have a decent place to call home. In the meantime, we turn off the energy-efficient light bulbs in our McMansions for an hour and get to feel like a Friend of the Earth.

I don’t know. It just doesn’t do it for me. (It didn’t do it for this guy, either.)

Sex-ed in the 21st Century

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My children Liesl, Kurt, Martha and Brigitta are sitting silently in the dentist’s waiting room, filling-out their health questionnaire. Kurt glances up and asks the million dollar question every parent dreams of being asked in public:

“Mommy, what are Cialis and Viagra?”

Me, clearing my throat, thinking very fast: “Drugs. You aren’t taking any.”

Kurt: “What kind of drugs?”

Me, thinking very fast at a G-rated explanation of erectile dysfunction: “They’re for adult males who have sexual problems.”

Liesl: “Gross…”

Martha: “What are adult males? What sexual problems?”

Me: “Males about the age of Daddy?”

Brigitta: “Daddy has sexual problems?”

Liesl: “Oh, look at the time…”

Me, looking at the receptionist in despair: “Isn’t one of the kids due for a cleaning right about NOW?”

Sex-ed in the 21st century: it’s all about opportunities. They are literally everywhere.

Watch your language, part II

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I am a bit of a stickler for how we use words, especially in the context of hot-button issues like euthanasia and assisted suicide. We can’t settle these issues without debating them and we can’t debate them if we are not talking about the same thing. In an otherwise excellent article in this morning’s Ottawa Citizen, Naomi Lakritz writes:

The killing of Tracy Latimer was not euthanasia. It was murder. Euthanasia is also known as assisted suicide. Tracy did not commit suicide, let alone ask for assistance in doing so.

True, but euthanasia is not also known as assisted suicide, at least not in today’s academic literature in bioethics. With assisted suicide, a physician provides the means or information necessary for a person to end his or her own life. Physician-assisted suicide (PAS) also describes situations like Sue Rodriguez’ where the patient is able to express a desire to end his or her own life but unable to perform the required actions. Suicide is no longer criminal in Canada and the sticky issue with PAS is whether or not physicians should be allowed to facilitate it. Another sticky issue with PAS lies in the validity of someone’s desire to die. Is it a desire to die or a fear of suffering?

Euthanasia refers to the termination of someone’s life by another for the purpose of ending that person’s suffering. Accordingly, if PAS is technically suicide, euthanasia is technically murder and both should be debated as such.  Suicide is legal in Canada but assisted suicide is not. Accordingly, we oppose PAS by arguing that the presence of a third party no longer makes it a private decision. Since euthanasia is murder (or at least should be), we oppose it by arguing that disabled life in any way, shape or form, is as valuable as another. One of the sticky issues with euthanasia is precisely the lack of active involvement in the decision by the person whose life is to be ended. That person may have expressed a desire to be “euthanized” in the past, but the actual life-or-death decision is made by an external party. This is in great part why the Latimer debacle is so worrying for disabled Canadians: once you let able-bodied people decide what a life worth living is, you eliminate the experience of disability from the decision-making picture.

All this to say, both are wrong for similar reasons. But that doesn’t make them synonymous.

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