Thursday, April 23, 2009

The elder daughter has a question...

...We were discussing Terri Schiavo last time she was here and got onto the question of whether someone is obligated to receive treatment - ever. For example, you're diagnosed with, say, some kind of fatal cancer. You're given two years to live. There will of course come a time when the end is in sight, at which point you might decline further intervention. But at the beginning of the two years: are you morally obligated to take treatment (some of which might be fairly unpleasant), or are you free to say 'no'?

15 comments:

zippy said...

Well, it is a prudential judgement; which, as we know, is not code for "there is never a right or wrong answer". So the answer to your daughter's question is that yes, there is, sometimes under some circumstances, most definitely an obligation to receive/pursue treatment. We might even be able to construct a theoretical "just treatment" guideline similar to the just war doctrine -- similar, that is, in the sense of providing some of the objective criteria which would apply to making that kind of decision.

Bill in NC said...

No legal obligation exists assuming a competent adult.

Moral depends on your moral basis.

Witnesses would not accept most blood products, for example.

Lydia McGrew said...

Well, since you were talking about Terri Schiavo, I feel that I simply must stick my oar in to say that the question in the post is unrelated to Terri, because mere food and water are not treatment.

Okay, now that I got that off my chest, sure, there are times when treatment of some sort is obligatory. For example, suppose you were feeling unhappy and miserable and came down with pneumonia. It would obviously be wrong to say, "Oh, no, don't give me the antibiotics, because then (goody) I might die of this pneumonia and get out of this miserable life."

But it's going to be very hard to construct generic rules that are going to crank out the answers to every question. One of the major problems with cancer treatment is that the treatment itself is generally harmful to at least some extent. That changes the whole complexion of the case, to my mind. The term "side effects" can begin to sound like a euphemism if we're talking about chemo with a very high level of toxicity. More like, "Am I obligated to take poison--real poison--in the hope that it will kill the disease before it kills me?" I can think of plenty of cases where the answer would be clearly, no, though it might not be wrong to accept the highly toxic treatment, either.

wl said...

Well, to dispense with Bill in NC:

We're not discussing a legal obligation but a moral one, the kind imposed by God, not Greer. That which is merely legal in this country can get you killed.

Morality is not determined by one's "moral basis", but by the truth, with which your moral basis may or may not be in contact. Jehovah's Witnesses who refuse life-saving blood transfusions (especially on behalf of their own children) are perfect examples.

Lydia says "the question in the post is unrelated to Terri..." Well of course it's related. All those in favor of pulling the tube thought it an act of withdrawing "life-sustaining treatment." The fact that they were wrong doesn't make it unrelated. My daughter's in no doubt as to the obligatory nature of food and water, and was horrified at what was done to Terri. It was in moving from that to other scenarios in which genuine treatment might be refused that I had trouble convincing her that, short of an immediate death sentence, refusing to fight (within reason) would amount to a form of suicide.

But it's going to be very hard to construct generic rules that are going to crank out the answers to every question.Yes. There will be lines that are hard to draw, and judgements of which we are not sure, i.e., 'when is enough enough?' But I like Zippy's idea because there will also be obvious cases where the law allows too much and needs to be resisted. That death by dehydration is now a legal fact of life in this country makes that pretty clear. (And that awful apnea baby case you referred us to.) The thing is, I think the "just treatment doctrine" already exists, even if it hasn't been encoded. Most health professionals who have been around for any length of time know what it is; a lot of them just don't happen to like it.

For example, suppose you were feeling unhappy and miserable and came down with pneumonia. It would obviously be wrong to say, "Oh, no, don't give me the antibiotics, because then (goody) I might die of this pneumonia and get out of this miserable life."Let's try it this way: should I have those antibiotics forced upon me, even if it requires putting me in restraints?

I'll be gone for a couple days. Further contributions, and elaboration of those already given will be welcome. I'll read them soon's I get back to this computer. And thanks to Lydia and Zippy.

Lydia McGrew said...

"It was in moving from that to other scenarios in which genuine treatment might be refused that I had trouble convincing her that, short of an immediate death sentence, refusing to fight (within reason) would amount to a form of suicide."

My own inclination is to say rather that the treatment/non-treatment distinction is more crucial than this would imply, particularly when the treatment involved is itself physically harmful. It's important to remind people, too, that doctors are sometimes mistaken about how best to treat diseases and often do more harm than good with their treatments. So if you take a "you have to fight or you're committing suicide" perspective, you are in some danger of accepting uncritically the medical community's present take on whether a) a given treatment actually works and b) whether the objective, manifest, and immediate harm it does to your body is worth the possibility (sometimes at rather long odds) that it will help you physically longer-term. Since medical treatment is supposed to make you healthier, medical treatment that comes within an ace of killing you first in the hope that in the long run it will save your life is, to my mind, questionably obligatory. (An example here would be destroying all your bone marrow and transplanting somebody else's to you in the hope of getting rid of cancer. This is a very risky treatment in itself.)

Lydia McGrew said...

By the way, I certainly don't mean to attribute malice to the medical profession here. But doctors who bled people were also not malicious. That was what they believed you had to do to "fight" disease. The fact that it actually killed people was a genuine tragedy and accident. But a person who said, "Look, I know this will weaken me and might kill me. You _say_ it will help or might help, but that is just a hope or a chance, and I'm not sure you're right, so I'm not going to consent to something that I know is harmful on the chance that it might also be helpful," would have been exercising common sense and, as we now know, giving himself a better chance of surviving whatever underlying disease he actually had.

If a treatment has a very real chance of killing the patient sooner than he would die of the disease (not to mention in more misery), he can certainly be morally justified in turning it down. I suspect this insight may lie behind the position I've heard attributed to Aquinas, that a person is not obligated to have a gangrenous limb removed. At the time, the blood loss might very well have killed the person, and further infection might have set in from the wound caused by the amputation. That is not to mention the horrible pain of amputation without anesthetics. In our own time, rejecting amputation of a gangrenous limb is far more morally questionable, because it is highly unlikely that the person will die of the amputation and because anesthetic will be used.

Elena said...

For me, frankly, it depends on how much the treatment is going to cost. If it is expensive cancer treatment that is going to leave my husband tens of thousands of dollars in debt - then no. I don't think so. Give me the pain meds though!

wl said...

I'll get back to you guys tonight. I am very tired.

wl said...

Lydia, I'm talking about "normal" scenarios, not those in which "the treatment might kill you" or be as bad as the disease itself. In other words, you'll have maybe a year and a half of a decent quality of life interspersed with a few rough patches due to treatment. Is there a problem with just giving up from the beginning? And if so, should such a person have treatment forced upon him?

Elena, I'm dubious of the expense argument. If someone can refuse treatment only because it's expensive, then I don't see why hospitals couldn't refuse to treat people for the same reason, or, if the sick person couldn't speak for himself, why a family member might not legitimately decide to spare his pocketbook at your expense.

Lydia McGrew said...

I would certainly say that the person should _not_ have such treatment forced upon him. There are lots of reasons for this. One of the reasons is that I'm probably far less sanguine than you are, Bill, about determining "normal" situations of the sort you describe or about the probability that a person who chooses to fight, fight, fight cancer will have a year and a half of a decent quality of life interspersed with a few rough patches! I've known of far, far too many people who have been absolutely ravaged by chemo to think that this is a description of the most common result of deciding to fight cancer good and hard. Moreover, I think you are assuming that we can just tell that we are in a "normal" situation where it is highly unlikely that the treatment will cause death. But again, especially with drug treatments, it isn't nearly that cut and dried. Chemo patients are very susceptible to pneumonia and may well die of pneumonia, in which case it can be hard to tell whether they died of the cancer (esp. if they have a form of cancer that compromises the immune system) or of the treatment (which compromises the immune system). Those risks definitely ought to be left to the patient to decide whether or not to take.

More generally, I'm not of the opinion that anything that, upon considering all the factors (both prudential and moral), is the correct decision automatically becomes something that should be forced upon the patient. To permit that sort of power to others would both be highly imprudent as granting them a dangerous amount of power and also, it seems to me, would be simply wrong. Even where there is a right answer, the right answer is not blazoned in the sky in such a way that only someone wicked or vastly morally confused could fail to see it. In other words, even in the case you give, and even if (which seems to me unlikely) one could know with confidence that one was in that situation, reasonable, Christian people can understandably disagree about the right thing to do. And where that is the case, I sure-n-certain don't want the doctors to be able to tie me down and treat me!

wl said...

I'm probably far less sanguine than you are, Bill, about determining "normal" situations of the sort you describe... apparently because you've known of far, far too many people who have been absolutely ravaged by chemo...etc.Please. I've had a number of family members ravaged by both cancer and chemo and in every case the diagnosis, course of the disease, prediction of longevity and quality of life were uncannily accurate. A friend of mine just finished going through radiation and chemo for a "treatable" cancer (treatable means you might live, or that the odds are in your favor, if you take the treatment) and he still suffers from the after effects: wasting, loss of appetite, severe diminution of his energy levels. Life was not, and still is not, very much fun for him, yet his wife and kid are glad to have him around, and no doubt would have screamed their outrage had he chosen not to be treated.

So what are we going to do? Compare the number of people we know who have gone through these situations? I don't see any answers in that direction.

You've already given me this case: It would obviously be wrong to say, "Oh, no, don't give me the antibiotics, because then (goody) I might die of this pneumonia and get out of this miserable life." But I don't find it helpful because the "goody" frontloads it with an obviously suicidal patient whose affliction isn't necessarily fatal.

But what about Elena's example of someone who could have a couple of decent years left yet refuses the treatment because of expense and that alone? Or the Jehovah's Witness who refuses a lifesaving blood transfusion, an irrational decision in its presumption on God's beneficence, and in its conscription of medical personnel into the service of evil by forcing them to aid and abet a suicide by omission? Based on what you've said, I'm getting that there's nothing we can do about it, and nothing we ought to do.

Lydia McGrew said...

The reason I brought that up about the nature of cancer treatment was because of your reference to a "normal" case where "you'll have maybe a year and a half of a decent quality of life interspersed with a few rough patches due to treatment." I mean, what you just said tends to show that that's not really the "normal" case in the sense of "usual." And your friends were _undoubtedly_ at risk of dying of the treatment through its effects on the immune system. Don't you think they should have been allowed to decide whether to go through what they went through and risk what they risked from the treatment alone?

I'm pointing out that this often isn't just a matter of things' being "not fun." It's a matter of concrete, serious, damage to the body. If there were a treatment that would make someone blind but would give him one month more of life, are you implying that he should be forced to have it? If a woman is at risk for breast cancer for genetic reasons and it becomes a new medical fad to remove a person's breasts even before any diagnosis for prevention purposes (some people really have chosen to have this done voluntarily), should she be able to be forced to have this done?

Moreover, the medical profession can be _wrong_, empirically _wrong_, and sometimes has been, about what is best for the person even physically and about whether the treatment is an improvement over non-treatment. There was a supposed "epidemic" in Japan of a diarrhea disease, and it turned out that the medicine they were prescribing was _causing_ the worse symptoms (and I believe deaths as well). There are women walking around today who have had what are now recognized to be unnecessary hysterectomies because of benign cysts and other problems, because aggressive hysterectomy for people with those symptoms was at the time believed to be the best thing to prevent cancer. It's bad enough that they are sorry they followed that medical advice. It would be even worse if their wombs had been _forcibly_ removed. At a minimum, people have to be able to make their own judgments about the empirical facts of the case, which may differ from the judgments of their doctor and where the patient is sometimes right and the doctor wrong.

You must realize that we would have forced abortions (for example, for a woman with cancer or various other illnesses) if the norms and standards of the medical profession determined treatment which was then forced upon the patient.

Presently it's all the rage to have 11-year-old girls have a vaccination for a sexually transmitted disease. There are known side effects, and the only reason it's even considered is because they are expected to start being sexually active thereafter. Otherwise they could wait and, if they were in the end virgins marrying virgins, never even have to bother having it. There are moral considerations involved here, and parents of some girls are _quite right_ to think it not worth it for them to be vaccinated at age 11. Do we want the government to be able to force it on us? No way.

I'm inclined not to force the man to have antibiotics or the J.W. to have a blood transfusion for the many prudential reasons involving not wanting to give this power to the government and medical profession. But I think the people are wrong--either morally or rationally--in these cases. Therefore, if there were some way for a family member to administer these indisputably medically valuable, not harmful, and moral treatments quietly and privately without the person's knowledge and hence get around the person's irrationality without setting a precedent or giving that power of force to an overarching authority, that would probably be the best solution, but unfortunately in the case of the blood transfusion that is not going to be possible.

wl said...

I mean, what you just said tends to show that that's not really the "normal" case in the sense of "usual."I don't know how you came to this.

And your friends were _undoubtedly_ at risk of dying of the treatment through its effects on the immune system.No they weren't. I can't get you to stipulate to any scenario I present, so that'll do for now. My daughter will be glad,though, that you took her side.

Lydia McGrew said...

I'm sorry to have left the impression of being dodgy. I didn't think I was being dodgy. In fact, I answered the question about antibiotics and even J.W.'s absolutely straight-up. In case there's something I've left out...

No, even if it were true that the person would have "rough patches from treatment [meaning that the treatment does cause physical harm]" but a "basically good quality of life" for a year and a half, and even if the patient knew this and agreed with this empirical claim and the doctors knew it, it would not be right to tie him to the bed and put the chemo through the IV. Is that a straight enough answer to the question? I don't usually get accused of dodging questions, and it's not my intention to do so.

In fact, honestly, the very suggestion of forced chemotherapy absolutely horrifies me and strikes me as a caricature of the pro-life position with which we should not cooperate, and if I've been speaking in a low-key way (as well as trying as I go to explain some of the reasons behind my position), it is not out of a desire to be evasive but out of a desire to avoid saying, "What in the world? No, of course not! That's crazy!"

wl said...

the very suggestion of forced chemotherapy absolutely horrifies meMe too, under certain, perhaps most, circumstances. But if my daughter, say, became a JW and refused a transfusion, I'd pursue every legal means at my disposal to have it forced upon her, and I'd do the same if she refused antibiotics. I don't see how that's a caricature of the pro-life position, let alone crazy.