Hospice and Palliative Care Medicine (HPM) is a field of clinical expertise recognized by the American Board of Medical Specialties since 2006. We treat patients experiencing distress due to diseases that may threaten their lives and certainly burden them with symptoms which cause suffering. While most hospice patients face death within six months to a year, most palliative care patients have chronic life-threatening diseases, but still have viable treatment options offering them many more years of life.
Different Approaches for Very Different Patients
Unfortunately, many bioethicists have framed both palliative care and hospice care as ‘end-of-life’ care. HPM’s name and current practice reinforce this commonly accepted view of a single approach to the treatment of two very different kinds of patients. This is misleading and dangerous, especially today when hospice care and palliative care both are liable to be misused to limit treatment and/or hasten death to help rein in healthcare costs.
In palliative care, the HPM specialist’s approach is to help the patient live well as their disease is being treated. Patients with newly diagnosed cancer, heart failure, or early dementia are excellent candidates for palliative care. Here, we focus on easing the patient’s symptoms—pain, depression, constipation, loss of appetite, etc.—caused both by their disease and by the treatment they are receiving. Cancer treatment, for example, may extend the life of a patient and, with expert palliative care, their general well-being is vastly improved. This is clearly not ‘end-of-life’ care.
The goal of hospice care is to alleviate the painful and bothersome symptoms of patients who are dying from progressive, untreatable diseases. Hospice patients choose to forgo further treatment for their underlying diseases. They have determined to live out the remainder of their lives focusing on important relationships with family and friends, yet desire to be comfortable. Hospice is a holistic approach that expertly treats symptoms which cause patients and families distress. Hospice care focuses not on the disease, but on the dis-ease causedby pain and suffering—physical, spiritual, psychological, and even intellectual. It involves a team of care givers trained in these domains. Dying is recognized as a communal event involving family, care givers, and community. Good hospice care prepares the person for death and allows it to occur naturally, never hastening it nor proposing death as a treatment for the suffering person.
The Physician’s Traditional Ethics
Physicians, until more recent times, have been guided by their twofold oath to “do good” and “never to do harm” to individuals in their care. In this way, the public’s trust in doctors and the medical profession was justly earned. Life, itself, was viewed as a great good, even life plagued by difficulties. Taking a life, for any reason, was taboo. Profound respect for the sanctity of life has always been the core principle of medicine. Is Hospice and Palliative Care Medicine losing its soul?
The New Bioethics: A Seismic Shift from the Sanctity of Life Ethic
There are changes being wrought by many elite academicians, including physicians, philosophers and lawyers, who profess that only certain lives are worth saving. What doctors once were trained to think of as an unassailable good—protection of every human life entrusted to their care—is being rejected.
In a clear rejection of the sanctity of life ethic, this new viewpoint—utilitarian bioethics—presents a quality of life approach that divides human life into two categories: “wanted” and “unwanted.” Like their brothers and sisters who are aborted at the beginning of their lives, the chronically ill, disabled, elderly, and mentally ill are seen as nuisances, sometimes even to themselves. The new bioethics has convinced many that the real kindness is to kill.
According to the new bioethics, when applied to certain people, “do no harm” implies further life is harmful and, therefore, killing them is beneficent. In hospice and palliative care settings, the administration of intentionally larger doses of analgesia, beyond what is necessary to diminish pain, is sometimes done to intentionally end patients’ lives. This is not a secret within the medical profession.
In September of 2000, the World Federation of Right to Die Societies (an association of organizations which promote euthanasia throughout the world) issued a declaration, stating in part:
We wish to draw public attention to the practice of “terminal sedation” or “slow euthanasia” which is performed extensively today…A physician may lawfully administer increasing dosages of regular analgesic and sedating drugs that can hasten someone’s death as long as the declared intention is to ease pain and suffering…Compassionate physicians, without publicly declaring the true intention of their actions, often speed up the dying process in this way.
The arguments employed to justify killing patients encompass a seismic shift in medical ethics. Notice what is happening here: the medical profession (and society, too) is slowly turning away from the traditional sanctity of life ethic toward an arbitrary quality of life ethic.
Guardrails for Good Medical Care in Hospice and Palliative Care
The guardrails for good medical care begin and end with physicians’ commitment to treat individual patients according to their needs and the refusal to become agents of the government or other third parties interested in cutting costs and preserving resources. Physicians should be committed to doing the very best for each patient they encounter and directing patient care in cooperation with their patients. This traditional approach was and is based on recognizing the equal moral worth of every human life.
By Ralph A. Capone, MD, FACP. Dr. Capone is board-certified in Hospice and Palliative Care Medicine and Internal Medicine. He also teaches Catholic Bioethics at St Vincent College in Latrobe, PA.
Catholic Hospice of Pittsburgh, Cristen Krebs, RN, DNP, ANP-BC, founder/director—working to create new pro-life hospices around the country: 724-933-6222