Friday, July 12, 2019

Of Vincent Lambert and Ethical Rubicons

This article was published by National Review online on July 12, 2019.

Wesley Smith
By Wesley J Smith

Vincent Lambert is dead.

The forty-two-year-old Frenchman, who breathed his last yesterday in Reims, didn’t die by accident. It wasn’t “his time.” He died slowly, over nine days, by forced dehydration—a demise that causes radical drying of tissues, cracking membranes, potential seizures, and slow organ failure.

This was not a case of euthanasia, per se—even though taking away a person's sustenance can only have one outcome. Rather, Lambert’s forced dehydration was deemed simply a matter of bioethics carried out in law, an emotionally difficult but routine matter of removing the “medical treatment” of “artificial nutrition and hydration”—because his wife wanted it and the courts judged it to be in his best interests.

How was this in his best interests? Lambert was profoundly disabled with a catastrophic brain injury that left him diagnosed as permanently unconscious (although his parents insisted that he was minimally aware). But he did not require mechanical breathing assistance or kidney dialysis. All the poor man needed to survive was what every human requires: food and water.

Lambert’s case made huge news in Europe because it was the subject of a bitter court fight between his wife and his parents (both his mother and father wanted Lambert to live). The story was less discussed in the United States, partly because of distance, but also because we crossed the dehydration Rubicon in 2005 with the death of Terri Schiavo, when courts ordered her tube-feeding halted.

Lambert's case closely paralleled Schiavo's. Both were profoundly disabled with a severe brain injury. Neither had left formal written instructions about their desires if they became seriously incapacitated. Both deaths were preceded by bitter intra-family legal disputes. Schiavo’s two siblings opposed her dehydration; Lambert’s full-siblings supported it, but his half-siblings sided with his parents. Both Schiavo and Lambert were Catholic patients, and in both cases pro-dehydrators accused family members opposed to dehydration of being motivated merely by religion, and not by true concern for the patients.

Some argue that these cases demonstrate a bias against the equal worth of cognitively disabled patients. That argument went nowhere in the Schiavo case. But in the Lambert case, the Committee on the Rights of Persons with Disabilities at the United Nations intervened, requesting that his dehydration be delayed while it investigated whether removing his food and water would be a discriminatory act. That request gave Lambert a temporary reprieve when a French Court of Appeals reversed a trial court’s approval of the dehydration. But the victory was short-lived, as the French Supreme Court later reversed the decision.

I hope the U.N. Committee continues its investigation. Lambert (and Schiavo) were not terminally ill. They only died because those with the power to decide deemed their lives not worth living. Is it not discrimination based on disability to decide that death is in a patient’s best interests because a patient is cognitively incapacitated? Is it discrimination based on disability to remove food and water from people because they are cognitively incapacitated, when we would not (yet) starve incompetent patients who willingly eat?

In the U.S., popular support for Schiavo’s dehydration was a Rubicon. Before the national imbroglio about her dehydration, many Americans were unaware that the cognitively disabled could die in this way. Post-Schiavo, polls showed that most Americans supported the approach, and that settled the “food and fluid” issue. Today, unconscious and minimally conscious patients are dehydrated in all fifty states as a matter of medical routine, usually with the family's acquiescence. If there is a family dispute, the law will usually give the benefit of doubt to death instead of life, unless the patient made it abundantly clear before injury or illness that they wanted care to continue. I suspect that Lambert will be such a Rubicon throughout much of Europe.

But that will not be the end of it. Bioethics is never static. The mainstream movement’s utilitarian reasoning is based on a “quality of life” ethic, instead of a “sanctity/equality of life” approach. That philosophy, embraced by the medical establishment, will lead the country to view induced death as the proper response to serious illness and injury. Prepare for the following trends:

  • Advocacy to withhold spoon feeding from people with advanced dementia: The euthanasia movement wants the law to allow advance medical directives to instruct caregivers to starve the signer—even if they willingly eat and drink—once their dementia reaches a predetermined level of decline. If adopted, it would force nursing homes and family members to starve and dehydrate these patients to death—perhaps even if they ask for food. 
  • Increase in “futile care” laws: Texas, Virginia, and other states permit doctors and/or hospital bioethics committees to refuse wanted life-sustaining treatment based on their views about the quality of the patient’s life and/or costs of care. In the future, such laws could permit doctors to order tube-feeding withheld over the objections of family.  
  • Healthcare rationing: With the increased crisis in medical costs, we could one day see laws placing time limits on coverage for the cost of care of profoundly disabled patients like Lambert and Schiavo.  
  • Lethal injection instead of dehydration: If euthanasia/assisted suicide spreads, at some point people will conclude that lethally injecting these patients is more humane than dehydration—which it undoubtedly would be. One of the advocacy points behind these dehydration cases has been to acclimate us to eliminating suffering by eliminating the sufferer. Once that premise is accepted, lethal injection becomes the logical choice.  
  • Harvesting the organs of profoundly disabled patients: Dehydrating patients to death renders their organs unusable for transplantation. But if we ever allow their euthanasia killings, that paradigm would change. Belgium, Netherlands, and Canada already conjoin euthanasia with organ harvesting and some bioethicists have opined in professional journals that the cognitively disabled (and others) should be organ harvested as the means of euthanasia.
As Fr. Richard John Neuhaus once wrote, bioethicists “professionally guide the unthinkable on its passage through the debatable on its way to becoming the justifiable until it is established as unexceptional.” With the Schiavo and Lambert dehydrations, removing sustenance from the cognitively disabled has been “established as unexceptional.” Futile care is at the “justifiable” stage. Organ harvesting conjoined with euthanasia, as the means of killing patients, has become “debatable.”

Unless society collectively rejects the logic and moral premises of the “quality of life” ethic, I see few impediments—other than the weak reed of emotional revulsion—to keep us from following a dark bioethical path.

Wesley J. Smith is a senior fellow at the Discovery Institute. His latest book is Culture of Death: The Age of “Do Harm” Medicine.

1 comment:

Morten Andreas Horn said...

Wesley Smith,
I agree that it's possible to regard the Vincent Lambert (and possibly even the Terri Schiavo case) as examples of discrimination against and devaluation of people with cognitive disabilities. Indeed, there may be people who argue for the appropriateness of witholding fluid and nutrition to patients such as these, exactly based on prejudices against them, and on the concept of "lives not worth living". We should be mindful of the risks of such attitudes, even more so in the event that assisted death is legalized.

One reason I'm a strong opponent of legalizing assisted death in my country (where witholding fluid and nutrition to a patient like Vincent Lambert would be "the right thing to do", and juridically, medically and ethically sound) is that we may then cross that Rubicon, embark on a process of sliding values, that might lead us to practices that even those liberal-minded today would not endorse.

However, there is a limit to being principled, or to being single-minded on just one principle. One other principle is the respect for the value and integrity of the human being. A patient like Vincent Lambert, or Terri Schiavo, isn't simply 'cognitively disabled', like any other cognitively disabled patient. Their disability is so profound, so complete, there is hardly any ability left. Terri Schiavo's brain, reportedly, weighed less than half its normal weight when she died. Vincent Lambert has been in a state of unresponsive wakefulness (UWS) for >10 years. There was no convincing (in the eyes of experts) evidence that he was aware of himself or anything else, or that he had any capacity of enjoying any aspect of life - even realizing that he was alive.

Two pillars of medical ethics are beneficence and non-maleficence; to do good, and to not harm. Vincent Lambert was beyond his point of normal death for more than 10 years; for a decade he was actively kept alive - not by any action of his own, not even instinctive ones, but rather as the result of deliberate feeding of fluid and nutrition into his gastrostomy. Without these actions - made possible by the intervention of the gastrosurgeon, and by the day-by-day repeated action of nurses, he was kept alive a decade beyond the time of natural death.

There was no indication that this procedure, this chain of procedures, was ever of any benefit for him. He left life after 10 years of maintenance, without achieving or experiencing anything that could be expected to be of value to him. How can this treatment be said to have been beneficent to him - except from the slow accumuaccumulation of chronological life?

We cannot know whether he sensed anything in that state. If he did, it would be just as likely that would be pain or discomfort related to paralysis, bedridden state, inability to communicate. It's hard to rule out that keeping him alive caused him harm.

Patients in the UWS and minimally conscious state (MCS) are rare, and readily distinguished from other patients with cognitive disabilities. There is little reason to fear that respecting the principles of beneficence (more than simply the prolongation in time of life) and non-maleficence in these cases, will lead to euthanasia or other discriminatory acts towards the mentally disabled.

Especially we, who oppose assisted death, should be eager to point out the fundamental difference between taking someone's life, and letting die a natural death.

Morten Horn, MD, PhD
Consultant in neurology
Member of the Medical Ethics Council, Norwegian Medical Association