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Ethics in Medicine
Written and researched by Bob Murray, PhD
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More Controversy in the Euthanasia Debate
September 1, 2004
The very definition of euthanasia is complicated as an article in the current journal Annals of Internal Medicine highlights.
Dutch doctors are "sedating many terminally ill patients until death," in some cases without artificial feeding or hydration. However this is not called euthanasia or mercy killing. Researchers estimate that terminal sedation occurred in about 10% of the total 14 000 deaths in 2001.
As sedation is considered normal medical treatment, doctors are not legally obliged to report their actions as they must in euthanasia. But terminal sedation is now seen as an alternative to euthanasia for many Dutch patients.
In most cases, the doctors' first aim was to alleviate symptoms, but in 17% of cases was an explicit intention to hasten death. The study was funded by the Dutch government and led by Paul van der Maas, professor at the public health department of the Erasmus University Medical Centre, Rotterdam.
The study looked specifically at terminal sedation in detail, analysing data from last year's national study into medical decisions at the end of life. That study included interviews with 410 doctors from a range of specialties. More than half had practised terminal sedation (defined as "the administration of drugs to keep the patient in deep sedation or coma until death without giving artificial nutrition or hydration").
In the most recent 211 cases, doctors intended to alleviate severe pain in half, reduce agitation in slightly more than a third, and help shortness of breath in slightly more than a third. Nearly 80% of patients who received sedation were aged 65 years or more, and more than half had cancer. The researchers estimated that sedation had shortened patients' lives by less than a week.
Doctors almost always discussed treatment with relatives but not always with patients, who were often no longer able to communicate. In a third of cases, patients themselves requested deep sedation. Euthanasia, in which drugs are given to specifically end the patient's life, was discussed with the patient in more than a third of cases but rejected.
One reason patients preferred terminal sedation was because they considered it to be less disturbing to the natural process of dying. Professor Van der Maas said that ensuring that a dying patient remains asleep until death--mostly by giving benzodiazepines or combining these with morphine--had more or less become established medical practice. For some patients who were "suffering unbearably" it was a "relevant alternative" to euthanasia. He emphasized that the primary intention in most cases was alleviating symptoms not shortening life.
According to a report in the latest British Medical Journal, last year the Netherlands' attorney general, Joan De Wijkerslooth, called for the legal controls on euthanasia to be extended to cover terminal sedation. The Dutch Medical Association, however, instead emphasized the need for clear professional guidelines to define terminal sedation and how doctors should act. It argued the involvement of the legal profession in a normal medical practice was a frightening prospect.
Read more in Annals of Internal Medicine
Read more in British Medical Journal
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Preparing for Armageddon in South Asia
June 24, 2002
An article by Zulfiqar Ahmed Bhutta, Husein Lalji Dewraj professor of paediatrics and child health at the Aga Khan University in Karachi and his Indian colleague Samiran Nundy, consultant gastrointestinal surgeon at the Sir Ganga Ram Hospital, New Delhi published in the British Medical Journal makes very disturbing reading. According to them, the unthinkable has actually happened. Over a span of barely four years, the subcontinent and its military and political leadership seem to have moved seamlessly from an obtuse nuclear capability and a doctrine of nuclear deterrence to the present state of nuclear weaponization.
As a million soldiers face each other across the volatile line of control and the border between India and Pakistan, the arguments have shifted from no use of nuclear weapons to their potential use in the event of conventional war, to the current state of actual deployment. To a large extent the numerical superiority of the Indian army and air force translates into a no win situation for Pakistan in the event of a conventional conflict. Faced with the potential of humiliation and dismemberment in such a scenario, the authors believe, a nuclear first strike becomes a frighteningly real possibility.
What really worries the professors is that the threat is being met with apathy on both sides: "The debate and outcry on this reckless brinkmanship in South Asia has remained confined to the peace groups, and the vernacular press has largely been jingoistic and indifferent to the disastrous consequences of nuclear war. While one can understand that the illiterate masses in both countries may have no concept of the awesome power of nuclear weapons, the apparent resignation of the educated elite and intelligentsia to their fate and a possible nuclear conflagration is most surprising. Most of the medical associations on both sides of the border have maintained an ominous silence."
This apparent apathy, they write, can be interpreted in one of several ways: one that there is widespread disbelief that a conflict will take place, the other that no level of preparedness can mitigate a nuclear conflagration. A third and more plausible explanation is that few among the health professionals are even remotely aware of the true meaning and consequences of a nuclear conflict.
In fact the only estimates of casualties has come from Western, specifically American, sources. The authors state that it is entirely plausible that a nuclear exchange between these volatile neighbours will be neither surgical nor contained. They quote a secret Pentagon study which reveals that the immediate death toll in the case of a nuclear exchange can be as high as 12 million, with almost 7 million injuries. The widespread destruction of property, nuclear fallout, and environmental costs are almost impossible to compute, and may involve the entire south and central Asian region. The humanitarian crisis in the region and the impact on the global economy will be devastating.
Even in the US the state of readiness for a limited terrorist nuclear attack is appallingly low. A recent review of hospitals there revealed that 73% were unprepared for a nuclear accident or attack. In India and Pakistan the situation is much worse. "Poor disaster preparedness and health system performance in the subcontinent," they write "means that the number of late deaths due to burns, radiation, and infections will be considerably greater. To those potentially relying on the effectiveness of a limited nuclear strike over military targets, the unpredictability of wind directions and contiguous heavily populated border areas make containment almost impossible. The development and use of nuclear shelters by a select few only serves to highlight the abject lunacy surrounding nuclear weaponization in the subcontinent."
They argue that the current nuclear imbroglio in India and Pakistan is a direct consequence of a lack of human and social development in the region. Malnutrition rates in the region are among the highest in the world, and successive generations have been fed a daily gruel of intolerance, jingoism, and religious fervor by political and military governments. "The current military standoff must also be viewed in the context of the growth of religious intolerance and lack of social development in both countries. A conservative estimate of the costs of nuclear weaponization in India placed it at well over US$10bn and although modest by comparison, it is sobering to note that Pakistan's recent ballistic missile tests alone could have funded the entire health budget of several districts."
They conclude that the current crisis also highlights why the doctrine of nuclear deterrence is a myth.
Read more in the British Medical Journal
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Research Claims Exaggerated
June 10, 2002
One of the problems health writers experience is having to rely for their information on press releases put out by universities or medical journals. Mostly they just do a re-write of the press release without checking further. Most journalists have don't have the time to go back to the original article or research and check the facts, as we do in this web site.
This leads to a lot of mis-information being spread regarding health issues. Researchers from the Dartmouth Medical School in New Hampshire, US, examined the quality of information put out by leading medical journals and news copy produced by journalists covering scientific meetings.
They found that press releases put out by some medical journals may exaggerate the perceived importance of findings, and do not always highlight the limitations of the research.
The researchers examined the medical press release process at several high-profile medical journals. They found that while medical journals strive to ensure accuracy and the acknowledgment of limitations in articles, press releases may not reflect these efforts. The study focussed on 127 press releases produced by nine highly respected journals. These were:
- Annals of Internal Medicine
- British Medical Journal (BMJ)
- Circulation
- Journal of the American Medical Association (JAMA)
- Journal of the US National Cancer Institute (JNCI)
- The Lancet
- Pediatrics
The researchers found that many of the releases did not give full statistical information with which to put the findings of the study into full context. Just 23% of the releases noted study limitations. And industry funding was acknowledged in only 22% of the studies that had received it.
Writing in JAMA, lead researchers Dr Steven Woloshin and Dr Lisa Schwartz said: "A number of authors have criticized the accuracy and balance of the news media in reporting on medical science. As a direct means of communication between medical journals and the media, press releases provide an opportunity for journals to influence how the research is translated into news. Our findings suggest journals could make more of this opportunity."
Editor's note: the stories reported in Uplift news are never taken just from press releases or from the popular press unless there is no other source available. When available we read all of the original articles cited. BM
Read more in Journal of the American Medical Association
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Big Step Backwards for Euthanasia Lobby
June 10, 2002
The furore over the "suicide" of great-grandmother Nancy Crick has made the front pages of the major Australian newspapers and the lead story in the evening TV news. At the time it was claimed by the euthanasia supporters that she had taken her life because she could no longer bear the pain of stomach cancer.
It turns out that this was a lie. The 21 people who gathered around her to watch her die were aware that she suffered from nothing more than an operable intestinal problem. Voluntary Euthanasia campaigner Doctor Nitschke now admits that Crick's exact state of health should have been stressed.
Meanwhile, the Queensland Premier has condemned Dr Philip Nitschke for failing to tell the truth over Mrs Crick's illness. Peter Beattie claims Dr Nitschke has done a great deal of damage to the euthanasia debate. "The reality is that Queenslanders and Australians were misled and I don't find that a terribly pleasing set of circumstances, I find that very sad," Mr Beattie said.
According to her doctors Mrs Crick had at one time suffered from cancer, but her treatment had been entirely successful. They had told her that her GI problem could also be cured with either drugs or a relatively simple operation, but the widowed Mrs Crick, who had been suffering from depression since the death of her husband, refused treatment.
Before her death Nancy Crick had received a lot of media attention from her highly-publicised wish to die and kept supporters up to date with a web site. A postmortem after her death revealed that the weight she listed on her site was substantially less than her real weight and that she had been gaining rather than losing weight.
Psychologists speculate that Nancy had become so committed to the fame her "right to die" campaign had brought her that she felt unable to back out.
Meanwhile Queensland police are considering charges against the Voluntary Euthanasia campaigners who were aware of her true state of health and yet stood around and let her die.
Read more in ABC Online
Read more in the Australian Daily Telegraph
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About the Author
Dr Bob Murray is a widely published psychologist and expert on emotional health and optimal relationships. Together with his wife and long-term collaborator Alicia Fortinberry, he is founder of the highly successful Uplift Program, and author of Raising an Optimistic Child (McGraw-Hill, 2006) and Creating Optimism (McGraw-Hill, 2004).
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