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article imageDoctor Argues We Should Ration End-of-Life-Care

By Carol Forsloff     Jan 22, 2010 in Politics
While Sarah Palin, former U.S. Vice-Presidential candidate, used issues about end of life to target President Barack Obama's health care plan, some doctors say rationing is a good idea. But what are the issues and are there easy answers?
In this month's Journal of Medical Ethics John Freeman, M.D., Lederer, Professor Emeritus of Pediatric Neurology and a faculty member of the Johns Hopkins Berman Institute of Bioethics, recommends to the Obama administration that end-of-life care be rationed. Dr. Freeman considers this a good step in reforming health care.
Dr. Freeman's article is entitled, “Rights, Respect For Dignity And End-Of-Life Care: Time For A Change In The Concept Of Informed Consent.” He begins by saying that it is costly to try to save lives when it is futile to do so and there is an unlikelihood that the patient will be able to live. He maintains that the expensive end of life care is widespread and contributes significantly to the high cost of health care. These high costs, Doctor Freeman maintains, is part of why it is difficult to provide equitable health care for everyone.
A living will should be respected, according to Dr. Freeman, as what he calls an "ethical imperative" for patient autonomy; but he also maintains this should be examined against the social impact and costs of medical care. Doing good might mean doing good for the greatest good for the whole of society. He suggests the family should be encouraged to examine comfort care only and goes on to say,
“There must be few situations more undignified, more dehumanizing or more humiliating than lying in bed, incontinent, tube fed, with or without a respirator, unable to speak or to relate to individuals or the environment,” Freeman says, factors that more surrogates may want to give more weight.
Rationing and providing only comfort care should be considered not just at the end of life for adults, Freeman maintains, but also in instances of extremely premature births. He cites studies showing that intensive care for infants born at 22-23 weeks resulted in more than 1,700 extra days in intensive care, with less than 20 percent surviving. Of those 20 percent, less than 3 percent survived without profound impairment that required expensive interventions.
The University of Minnesota Bioethics Department has reviewed some of the specific issues on end of life care, revealing the complexity of the issue and why the arguments about it have entered the political landscape. First they label what is considered to be a "good death" so that the foundation is set for a discussion of the ethical issues:
Adequate pain and symptom management.
Avoiding a prolonged dying process.
Clear communication about decisions by patient, family, and physician
Adequate preparation for death, for both patient and loved ones by patient, family.
Feeling a sense of control.
Finding a spiritual or emotional sense of completion.
Affirming the patient as a unique and worthy person
To reach the goal of the "good death" involves examining a set of issues surrounding it to include, according to experts in bioethics, the patient's access to care, prognosis, pain management, when to withhold and withdraw medical treatment, what types of treatments to use, terminal sedation, and the existence or non existence of advance directives. The issues are complicated and include some special topics as physician-assisted suicide, how to deal with children who are dying, homelessness of a dying patient, the lack of family support and finally the ethical issues involved after the death of the patient.
Christians look at end-of-life issues from a Biblical perspective with the precept that life is a gift from God, the belief that after death there is an afterlife, and that God is in control of the universe and ultimate life-and-death issues. From the Apologetics Press comes a synopsis of the Christian view:
"The laws of man are of little use, since what is legal may not be what is right in the eyes of God. Similarly, our instincts and insights may be of no use, since they often are clouded by pain or emotion. Therefore, we must prayerfully request the wisdom that God has promised to give to those who ask (James 1:5). Mature Christians understand that even in suffering, there can be reward. Sometimes, our own suffering permits us to comfort others who find themselves in a similar situation. And, sometimes, others are afforded the same blessing as a result of our suffering. When we come to end-of-life decisions—as many of us will—our decisions must be based, first and foremost, on God’s Word."
Lewis presents arguments that examine some of the ethics involved in the economics of end-of-life deabate. Most ethacists observe that everyone has a decision to make at the end of life and individually, and for loved ones, have to make critical decisions. This is why they consider the debate about it important so that people make the right decisions to experience "the good death." Politics and good medicine can be at loggerheads in making this possible, as Lewis' argument and political arguments reveal.
More about End life care, Physician-assisted suicide, Rationing health care
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